"C^^i. Y\i<^ dalis^s af ^hijatrians anb Bar^anB Srfj^r^nrF Ktbrarg Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons (for the Medical Heritage Library project) http://www.archive.org/details/surgerypracticalOOmans SURGERY A PRACTICAL TREATISE Press Notices of First Edition OF MOULLIN'S SURGERY. From THE AMERICAN JOURNAL OF MEDICAL SCIENCES, Philadelphia. " The aim to make this valuable treatise practical by giving special attention to 'questions of treatment has been admirably carried out. Many a reader will consult the work with a feeling of satisfaction that his wants have been understood, and that they have been intelligently met. He w-ill not look in vain for details, without proper attention to which he well knows that the highest success is impossible." MEDICAL RECORD, New York. " From such a standpoint it goes without saying that the writer's attitude is a conservative one. He is, however, free from hesitancy, and shows a keen appreciation of the rapid strides of surgical art in the last decade. No less than two hundred of the illustrations were drawn expressly for this work. It has all the conciseness of Druitt's well-known work, and the ad- vantage of a somewhat more extensive description of certain conditions occurring in practical work. The book is creditable alike to author, assist- ants, and publishers." THE PHYSICIAN AND SURGEON, Ann Arbor, Mich. "The spirit of the work is eminently clinical and practical, and the author, in avoiding controversial matters, has endeavored to direct special attention to treatment. The work is profusely illustrated and appears well up to date in recording the achievements of modern surgery. This is well shown in the chapter dealing with intestinal surgery." From THE LANCET CLINIC, Cincinnati. " We have carefully examined this work, and can truthfully say that it is the best of the condensed works on surgery in the English language. It is based upon modern ideas, it teaches modern surgery, and gives a very intelligent description of the subjects treated. The title of the book calls attention to the fact that the subject of treatment has been made of primary importance, and the book fully justifies the announcement. * * * * " In conclusion, we feel that strict justice compels us to say that we know of no work on surgery that can be as highly recommended to students as the volume before us. For practitioners (surgical) the book forms a valuable condensation of modern surgical thought, and should be in their possession as a book to be consulted frequently." Handsome Cloth, $7.00; Leather, Raised Bands, $8.00; Half Russia, Crushed, Marble Edges, $9.00. (These prices are absolutely 7iet.) P. BLAKISTON, SON & CO., Philadelphia. SURGERY A PRACTICAL TREATISE WITH SPECIAL REFERENCE TO TREATMENT BY C. W. MANSELL MOULLIN, MA, M.D. OXON. FELLOW OF THE ROYAL COLLEGE OF SURGEONS; SURGEON AND LECTURER ON PHYSIOLOGY TO THE LONDON HOSPITAL; FORMERLY RADCLIFFE TRAVELING FELLOW AND FELLOW OF PEMBROKE COLLEGE, OXFORD, ENGLAND ASSISTED BY VARIOUS WRITERS ON SPECIAL SUBJECTS WITH SIX HUNDRED ILLUSTRATIONS MANY OF WHICH ARE PRINTED IN COLORS, ABOUT TWO HUNDRED HAVING BEEN MADE FROM SPECIAL DRAWINGS SECOND AMERICAN EDITION REVISED AND EDITED BY JOHN B. HAMILTON, M.D., LL.D. PROFESSOR OF THE PRINCIPLES OF SURGERY AND CLINICAL SURGERY, RUSH MEDICAL COLLEGE, CHICAGO; PROFESSOR OF SURGERY, CHICAGO POLYCLINIC; SURGEON, FORMERLY SUPER- VISING SURGEON-GENERAL, U. S. MARINE HOSPITAL SERVICE; SURGEON TO PRESBY- TERIAN HOSPITAL; CONSULTING SURGEON TO ST. JOSRPH'S HOSPITAL AND CENTRAL FREE DISPENSARY, CHICAGO; SECRETARY-GENERAL OF THE NINTH INTERNATIONAL MEDICAL CONGRESS, ETC. PHILADELPHIA P. BLAKISTON, SON & CO I0I2 WALNUT STREET 1893 Copyright, 1S93, p.y P. Blakistox, Son &; Co. Press cf V/m F. Feu. & Co 1220-24 SiNSOM St., PHII-AOELPHIA. AUTHOR'S PREFACE TO FIRST EDITION. Modern Surgery has advanced with such rapid strides, and in so many differ- ent directions, that it is ahiiost impossible, within the space of a single volume, to give more than an epitome of its main principles. I have heretofore touched but lightly upon controversial matters, and have endeavored to make this book a practical one, in the hope that it may be of greater service to students and gen- eral practitioners. With this object, I have given special attention to the question of Treatment; and I have included under the head of each organ a brief descrip- tion of the malformations to which it is liable, and the various operations that may be performed upon it, instead of relegating them to chapters by themselves. The General Pathology of Surgical Diseases is dealt with in Part I ; that of Inju- ries in Part II. In Part III the Diseases and Injuries of Special Structures and Organs are considered more fully. Throughout, I have endeavored to enforce the idea that the chief aim and object of Surgery at the present day is to assist the tissues in every possible way in their struggle against disease. Through the kindness of the publishers, I have been enabled to make use of many illustrations from Bryant's " Practice of Surgery," Fergusson's " Surgery," and Astley Cooper's work on "Fractures and Dislocations." I am indebted to the Clinical Society and to Mr. Morrant Baker for Figs. 245, 246, 247, illus- trating Charcot's disease ; to Mr. Bowlby for Figs. 50 and 54; to Mr. Greig Smith for several illustrations of the various methods of suturing the intestine; and to Mr. Nettleship for others in connection with ophthalmic surgery. Messrs. Krohne and Sesemann, Arnold, Weiss, Maw, and Schall have also kindly allowed me to make use of various cuts from their catalogues. The rest V vi AUTHOR'S PREFACE TO FIRST EDITION. of the illustrations, nearly two hundred in number, were (with four exceptions) drawn from original specimens by my brother, Dr. J. A. Maxsell Moullix (to whom I am indebted for the article on Diseases of the Female Generative Organs) or myself. I have also to express my thanks to Mr. J- Hutchixsox, junior, for his chap- ters on Diseases of the Skin and Eye ; to Mr. T. Mark Hovell, for that on Diseases of the Ear and Larynx ; and to Mr. F. S. Eve for that on Tumors. C. W. MANSELL MOULLIX. EDITOR'S PREFACE. Moullin's Text-book on Surgery was introduced into this country two years ago, and its favorable reception by the Profession soon caused the exhaustion of the edition. Its wide scope, its clear expression, and its excellent illustrations made it a favorite ; and these characteristics have been preserved in the American edition now offered. The work has undergone thorough revision wherever necessary, and many new illustrations from the most recent Foreign and Domestic Monographs have been added, and such changes in the text have been made as recent changes in Theory and Practice required. Some rearrangement has been made of the text, and a brief chapter on the outlines of Military Surgery has been added. To make room for the new matter and new illustrations, without materially in- creasing the bulk of the book, certain portions of the former chapters on diseases of the skin, diseases of the eye, diseases of the ear and larynx as were not strictly Surgical, have been omitted. Among other additions, the chapter on amputations has been enlarged by the addition of a number of new illustrations, and Surgical Bacteriology has been newly illustrated by colored engravings from recent monographs. The additions made by the Editor are enclosed in brackets. The Editor feels sure that this excellent work of Moullin in its American dress will continue to enjoy the popularity in this country which the first edition so well merited and received. Thanks are due Passed Assistant Surgeon Wertenbaker, M. H. S., and Dr. D. Bevan, of Jefferson Medical College, Philadelphia, for a number of carefully made drawings that increase the value of the book ; and to Drs. W. A. Wells and W. M. Barton for assistance in preparing the index. JOHN B. HAMILTON. Rush Medical College, Chicago, III., April, i8gj. Vll CONTENTS. PART GENERAL PATHOLOGY OF SURGICAL DISEASES. CHAPTER I. PAGE INJURY AND REPAIR .... 25 Injlani m a/ion — Sympttjms of Inflammation 30 Varieties of Inflammation 34 Treatment of Inflammation . • ... 35 Chronic Inflammation 38 CHAPTER II. DISEASES DUE TO NON-INFECTIVE ORGANISMS. Septic Fever 42 Sapraemia 43 CHAPTER III. DISEASES DUE TO INFECTIVE ORGANISMS. Non-specific — Suppuration 45 Abscess 46 Varieties of 49 Treatment of 51 Hectic 55 Albuminoid degeneration 55 Sinus and fistula 56 Ulceration 58 Gangrene 59 Phagedena 69 Hospital gangrene 69 Phlegmonous inflammation 70 Treatment 73 Pyaemia 74 Treatment 77 CHAPTER IV. DISEASES DUE TO INFECTIVE ORGANISMS. 2. Specific — Erysipelas 79 Treatment 81 PAGE Septic infection or true septicemia . . 82 Anthrax 84 Treatment 86 Glanders 87 Treatment 89 Actinomycosis 89 Treatment , ... 90 Tuberculosis 91 Treatment 95 Syphilis, chancroid, or soft chancre, etc. 95 Treatment 97 Acquired syphilis 98 Secondary period I.02 Tertiary syphilis 103 Congenital syphilis 109 Treatment 1 1 1 Leprosy 116 Treatment 117 Tetanus 118 Treatment I2i Rabies 121 Treatment 123 CHAPTER V. TUMORS. By Frederick S. Eve, f.r.c.s. Cysts 125 Fibromata 130 I-ipomata 132 Myxomata 1 33 Enchondromata 134 Osteomata 135 Myoma 136 Myo-fibromata 137 Angeioma 137 Lymphangeiomata 138 Neuroma 138 Sarcomata 138 Papillomata 143 Adenomata 144 Carcinoma 144 CONTENTS. PART II. GENERAL PATHOLOGY OF INJURIES. CHAPTER I. THE GENERAL EFFECTS OF INJURY. PAGE Shock 149 Treatment '5' Delirium tremens ^S^ Treatment 152 Traumatic delirium I53 Traumatic fever '54 CHAPTER H. THE LOCAL EFFECTS OF INJURY. Subcutaneous injuries '55 Signs of contusion ^S" Wounds '57 Repair of wounds '5^ Cicatrization '59 Skin-grafting '60 Complications of repair '62 Treatment of wounds '64 Special kinds of wounds J 74 Cicatrices '75 CHAPTER HI. Burns and Scalds i79 Constitutional symptoms 180 Treatment l8l CHAPTER IV. Minor Surgery — Sterilization of the hands, clothing, in- struments, etc 184 The patient 185 The anaesthetic 185 Local anaesthesia 185 General anaesthesia 186 Bandaging '88 PART III. DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER I. surgical diseases of the skin. PAGE Lupus 189 Treatment '9' Lupus erythematosus '9^ Boils and carbuncles '9^ Treatment '93 Ulcers, syphilitic, chronic, tubercular, trau- matic, maligant ^93 Nisvi 197 Warts '98 Corns 198 Horns '99 Diseases of the Nails, treatment I99 CHAPTER II. injuries and diseases OF blood-vessels. 1. Injuries of vessels, Symptojtis, Trealment, etc 201 Injuries of arteries, hemorrhage, aneu- rism, treatment, etc 205 Injuries of veins 218 2. Diseases of vessels 220 Angeioma 220 Haemophilia 222 Diseases of arteries ■ ■ 222 " veins 227 Thrombosis 229 Embolism 232 Phlebitis 233 Aneurysm 235 Idiopathic or spontaneous aneurysm . 235 Treatment 241 Traumatic aneurysm 248 Special aneurysms with treatment , . 248 Opei-ations on arteries 261 General rules for ligature 261 Special ligatures . 262 CHAPTER III. injuries and diseases of lymphatics. Injuries of lymphatics 281 Diseases of lymphatics with treatment . .281 Lymphangitis 281 Lymphadenitis 282 Lymphatic glandular tumors .... 286 Lymphangeiectasis 289 Lymphangeioma ....•.••• 289 CONTENTS. CHAPTER IV. INJURIKS AND DISEASES OF NERVES. PAGE Injuries of nerves, -ivith treatmenf, .... 292 Dise(jses of nerves, " " .... 299 Neuritis 299 Neuraiijia 301 Operations on nerves 302 Nerve stretching 302 Neurectomy 304 Neuromata 305 CHAPTER V. INJURIES AND DISEASES OF MUSCLES, TENDONS, ETC. Injuries of muscles, etc. Sprains and contusions 306 Rupture 307 Dislocations 308 Diseases of muscles, etc., with treatment Atrophy 309 Functional disorders 310 Contracture 311 Myositis 311 Teno-synovitis 312 Ganglion 315 Dupuylren's contraction 317 Bursa; 319 CHAPTER VI. INJURIES AND DISEASES OF BONES AND JOINTS. 1. Malformations and deformities, with treat- ment. Disproportionate growth 322 Congenital dislocations 322 Club-hand 324 Webbed fingers and toes 324 Talipes 325 Flat foot 336 Deformities of the toes 338 Genu valgum . 341 Rickety deformities 342 2. Injuries of bones, with treatment. Fractures 345 Repair of fractures 349 Imperfect repair 354 Symptoms and diagnosis 361 Complications of fractures 363 Treatment of fractures 369 Fracture of the bones of the face . . . 381 " clavicle 385 •' scapula 390 " humerus 392 " radius 403 " ulna 408 " carpus and hand . . 410 " pelvis 411 " femur 413 " patella 429 " tibia and fibula . . . 435 " bones of foot .... 443 PAGE Diseases of bone, with treatment. Atrophy 444 Hypertrophy 444 Intiammation 444 Acute 445 Chronic 446 Caries 448 Simple traumatic 450 Phosphorus necrosis 432 Mercurial necrosis 453 Acute suppurative osteitis .... 453 Acute epiphysitis 462 Septic osteomyelitis 462 Exanthematous necrosis .... 464 Syphilitic osteitis 464 Rheumatic osteitis 471 Tubercular osteitis 472 Rickets 474 Acute rickets 479 Osteitis deformans 480 Osteomalacia 483 Tumors of bone 484 Osteoma 484 Enchondroma 486 Fibroma 487 Sarcoma 487 Central sarcomata 488 Periosteal sarcomata 489 Cysts 491 Carcinoma 491 Injuries of joints, with treatment. Wounds of joints 492 Subcutaneous injuries, sprains and contusions 495 Dislocations, general pathology, symp- toms, diagnosis, treatment .... 497 Dislocation of the lower jaw .... 504 " clavicle 506 " scapula 508 " humerus 508 " elbow joint . . . .519 " wrist joint .... 524 " thumb 525 " hip joint 527 patella 535 " knee 536 " semilunar cartilages. 537 " ankle 540 " astragalus .... 543 Subastragalar dislocation 544 Diseases of joints, with treatment. Pathology 545 Etiology • • • 547 Mode of examination 548 Synovitis, acute and chronic .... 549 Arthritis 554 Suppurative arthritis 559 Pysemic arthritis 563 Puerperal arthritis 564 Exanthematic arthritis 564 Urethral arthritis 564 Gouty arthritis 566 Rheumatic arthritis 5^9 Osteo arthritis 569 Charcot's disea'^e 577 Tubercular arthritis 580 Senile tuberculosis 585 Diseases of special joints with treat- ment 588 Diseases of the hip joint 588 CONTENTS. PAGE Diseases of the sacro-iliac joint . . 603 " knee joint .... 605 " ankle 61 1 " shoulder 612 " elbow 612 " wrist 613 Foreign bodies in joints 614 Ankylosis 616 6. Excision of joints 619 Excision of joints of the upper ex- tremity 620 Excision of joints of the lower ex- tremity 625 CHAPTER VII. INJURIES AND DISEASES OF THE HEAD. Malformations 630 Injuries of the head Injuries of the scalp 631 Fracture of the skull 634 Injuries of the brain 640 Intracranial hemorrhage 648 Injuries of nerves 650 Traumatic epilepsy . . .... 654 " insanity 654 Diseases of the head. Diseases of the scalp 655 Erysipelas 655 Suppuration 655 Tumors and horns 656 Diseases of the skull 657 Hypertrophy 657 Rickets 657 Inflammation 658 Tumors 659 Diseases of the brain and meninges . . 660 Inflammation 660 Suppuration 664 Hernia cerebri 672 Tumors 673 Trephining 677 Cerebral localization 678 CHAPTER VIII. INJURIES AND DISEASES OF THE HACK. 1. Malformations, with treatment. Spina bifida 680 Congenital sacral tumors 684 2. Injuries of the back, wit It treatment. Sprains and wrenches 685 Fractures and dislocations 687 Injuries of the spinal cord 697 3. Diseases of the back. Disease of the spinal column . . . .701 Osteitis 701 Tubercular osteitis 701 Suppuration and spinal caries . . 709 Curvature of the spine 710 Inflammation of the spinal cord and meninges 71S Tumors of the cord 720 Trephining 721 CHAPTER IX. INJURIES AND DISEASES OF THE EYE, By Jonathan Hutchinson, Jun., f.k.c.s. PAGB Methods of examination 722 Injuries of the eye 726 Diseases of the eye. Diseases of the conjunctiva 728 " cornea 729 " iris 729 Cataract 731 Glaucoma 733 Diseases of the choroid 734 Diseases of the eyelids, etc 735 Operations on the eye 738 CH.APTER X. INJURIES AND DISEASES OF THE FACE AND NOSE. Malformations : Harelip, etc 742 Injuries of the face 745 Wounds 745 Fracture 745 Foreign bodies in nose 745 Division of parotid duct 745 Diseases of the face. Inflammatory affections 746 Tumors of the face 748 Diseases of the nose, malformations, and deformities 751 Epistaxis 751 Inflammatory affections 753 Tumors 755 CHAPTER XI. INJURIES AND DISEASES OF THE MOUTH AND JAWS. Alalformations : Cleft palate, etc 759 Injuries of the mouth and fauces .... 762 Diseases of the mouth and fauces. Inflammatory affections 762 Periostitis and osteitis 765 Diseases of the antrum 767 Closure of the jaws . , 768 Tumors of the mouth and jaws . . . 770 Operations upon the jaws 774 CHAPTER XII. INJURIES AND DISEASES OF THE TONGUE, SALIVARY GLANDS .\ND TONSILS, WITH TREATMENT. Malformations : Congenital affections, ma- croglossia, etc 778 Diseases of the tongue : Glossitis 779 Leukoplakia 781 Tumors of the tongue 784 Operations on the tongue 787 Operations on the lingual nerve . . . 790 Diseases of the tonsils 79^ Diseases of the saliva fy glands 794 CONTENTS. xiu CHAPTER XIII. SURGICAL DISEASES OF THE EAR AND LARYNX, WITH TREATMENT. By T. Mark Hovell, m. d. PAGE Diseases of the ear : Examination of the ear 797 Diseases of the external ear 799 " middle ear 8oi " internal ear 802 Syphilitic affections 803 Diseases of the larynx : Examination of the larynx 803 Inflammation of the larynx 804 Tumors of the larynx 809 Disorders of sensation 811 Muscular paralysis and spasm . . 811-813 CHAPTER XIV. INJURIES AND DISEASES OF THE NECK AND THROAT. MaIfortnatio7ts : Branchial fistula, etc. . .814 Injuries of the neck : Wounds 814 Fracture of hyoid bone, and cartilages of larynx 817 Foreign bodies in air passages .... 818 Scald of the glottis 821 Diseases of the neck : Inflammatory affections 823 Torticollis 824 Tumors of the neck 826 General operations on the air passages . 828 Intubation of larynx 833 Excision of larynx 835 CHAPTER XV. DISEASES OF THE THYROID. Inflammation of the thyroid 838 Simple enlargement, or goitre .... 839 Malignant disease 844 CHAPTER XVI. INJURIES AND DISEASES OF THE PHARYNX AND (ESOPHAGUS. Malformations 845 Injuries of the oesophagus 845 Foreign bodies in the oesophagus .... 846 Diseases of the cesophagus 847 Tumors 848 Stricture 849 CHAPTER XVII. INJURIES AND DISEASES OF THE CHEST. Injuries of the chest wall 853 Fracture of the ribs 853 Injuries of the sternum 855 Non- penetrating wounds 855 Injuries of the thoracic viscera 856 Diseases of the chest wall 864 Operations upon the thorax 864 CHAPTER XVIII. INJURIES AND DISEASES OF THE ABDOMEN, WITH TREATMENT. 1. Injuries of the abdomen. pace Contusions 870 Wounds 872 2. Surgical affections of the stomach : Operations on the stomach 874 3. Hernia 877 Anatomy 878 Trusses 8S0 Irreducible hernia 882 Obstructed hernia 883 Inflamed hernia 884 Strangulated hernia 884 Special hernicTe : Inguinal hernia 896 Femoral hernia 905 Umbilical hernia 907 Ventral hernia 909 Obturator hernia 9°9 4. Intestinal obstruction : Acute intestinal obstruction 91 1 Chronic intestinal obstruction . . . .922 5. Perityphlitis and peritonitis 931 6 Operations on the intestines. Enterostomy 93^ Colo'.omy 937 Lumbar colotomy 937) 94° Inguinal or laparo-colotomy 939 Enterectomy 941 Colectomy 945 Cfficectomy 946 Intestinal anastomosis 946 Artificial anus and frecal fistula . . . 947 7. Surgical affections of the liver and pancreas. Abscess of the liver, 949 Hydatid disease 95° Diseases of gall bladder 951 Operations on gall bladder . . . 953 Diseases of the pancreas 954 CHAPTER XIX. INJURIES AND DISEASES OF THE RECTUM, WITH TREATMENT. Malformations 955 Exaviination of the rectum 956 Diseases and injuries of the rectum. Hemorrhoids 95^ Prolapse 9^6 Polypus 969 Pruritus 97° Proctitis 970 Periproctitis 973 Fissure 974 Fistula 976 Stricture 980 Malignant disease 983 Villous tumor 9^^ CHAPTER XX. INJURIES AND DISEASES OF THE KIDNEY, WITH TREATMENT. Malformations 988 Movable and floating kidney 989 Injuries of the kidney. Contusions and lacerations 990 CONTENTS. Diseases of the kidney. Suppression of urine 992 Hydronephrosis 994 Tumors of the kidney . .... 996 Renal calculus 998 Nephritis 1003 Pyelitis and pyelonephritis 1006 Perinephritis loio Renal fistula 101 1 Methods for differentiating the secre- tion of the kidneys ...... loii Operations upon the kidneys. Puncture 1012 Nephrotomy 1012 Nephrolithotomy 1012 Nephrectomy 1014 Surgical aspect of the mine 1015 CHAPTER XXI. INJURIES AND DISEASES OF THE BLADDER, WITH TREATMENT. Malformations 1024 Injuries of the bladder 1026 Diseases of the bladder. Atony 1029 Irritability 1030 Incontinence 1031 Retention 1032 Tapping the bladdi r lojS Cystitis 1036 Calculus 1041 Table of general characters of calculi . 1043 Lithotrity 1047 Lithotomy 1052 Tumors . 1064 Electrical illumination of bladder . . 1067 Foreign bodies 107 1 CHAPTER XXII. DISEASES OF THE PROSTATE, WITH TREATMENT. Enlargement 1072 Malignant disease 1083 Inflammation 1083 Pfostatic calculi 1087 CHAPTER XXIII. INJURIES AND DISEASES OF THE URETHRA, WITH TREATMENT. Injuries of the urethra : Rupture 1088 Calculus 1090 The passage of catheters and general effect of operations 1091 Diseases of the urethra ; Inflammation I095 Stricture 1102 Extravasation of urine 1 118 Urinary abscess I120 " fistula . . 1121 The female urethra 1 122 CHAPTER XXIV. INJURIES AND DISEASES OK THE MALE ORGANS, WITH TREATMENT. Malformations and diseases of the penis Diseases of the scrotum Malformations of the testes Diseases of the testes. Neuralgia Atrophy Inflammation Tubercular disease Hernia Tumors Castration Varicocele . . Hydrocele Haematocele PAGE 124 125 127 128 129 129 '34 135 137 138 139 143 CHAPTER XXV. DISEASES OF THE FEMALE GENERATIVE ORGANS, WITH TREATMENT. By J A. Mansell Moullin, m.d , m. r. c. p. Inflammation of the ovaries and Fallopian tubes 1 1 45 Ectopic gestation 1146 Tumors of the ovary and broad ligament . 1 148 Tumors of the uterus II59 Operations about the vulva and vagina . . I168 CHAPTER XXVI. DISEASES OF THE BREAST, WITH TREATMENT. Malformations I171 Diseases of the nipple I171 Diseases of the gland. Inflammation ii73 Tumors 1176 The male breast 1185 Excision of the breast 11 85 CHAPTER XXVII. AMPUTATIONS. Amputation of limbs and special amputa- tions 1188 Hip-joint operations (including Senn's new method) 1193 Amputation through femur, 1196 Amputation of knee-joint, leg, ankle, foot, toe 1 197 Diseases of stumps 1203 CHAPTER XXVIII. THE PRINCIPLES OF MILITARY SURGERY. By the Editor, John B Hamilton. First aid to the wounded, transportation, etc 1204 Gunshot wounds 1209 I Gunshot fractures 121 2 I Index 1213 LIST OF ILLUSTRATIONS, Platks. Intestinal Anastomosis, Senn's Method, Frontispiece. Bandaging. Two jilates, showing twenty-seven of the principal forms, . Placing pages i86 and 1 88 Lumbar Hernia, Facing page 876 The Handkerchief Bandages, Facing page 1204 FIG. PAGE 1. A Group of Fibroblasts, Bryatti 30 2. Diapedesis, ■ Original, 31 3. Storaata of the Capillaries, Dtiplay and Rectus, ... 32 4. Dilatation of Capillaries, Original, 32 5. Pus from Acute Abscess, After Woodhead, .... 47 6. Streptococcus Erysipelatous, Baumgarten, 79 7. Blood of Mouse after Inoculation, with Bacillus of Septi- caemia, After Woodhead, .... 83 8. Bacillus Anthracis, " " .... 85 9. Fibrous Nodule from a Case of Actinomycosis, " " .... 88 10. Actinomycosis, " ♦' .... 89 11. Tubercle Bacilli, " " .... 91 12. Hereditary Syphilis, Face in, Bryant, no 13. Lipoma of Arm, *' 132 14. Diffused Lipoma of Neck, '* 132 15. Myxoma (microscopic appearance), " 133 16. Fibroma, Osteoma, and Enchondroma, (microscopic ap- pearance, " 135 17. Non-striped Myoma, After Woodhead, .... 136 18. Sarcoma (microscopic appearance), Bryant, 139 19. Adenoma " " " ........ I43 20. Carcinoma, " '* " 145 21. Epithelioma of Stump, " 146 22. 23. Cicatrization by Skin-Grafting, " 161 24. Irrigating Can, — 165 25. Button Suture, Bryant, 169 26. Quilled " " 169 27. Twisted " " 169 28. Interrupted Suture, " 170 29. Glover's " '« 170 30. Quilt " Greig Smith, 170 31. Cicatrix of Burn on Face, Bryant, 175 32. " " Arm, Fergusson, 175 33. The Same after Incision, " 176 34. Epithelioma Growing from a Cicatrix, Hamilton, 177 35. Lupus (microscopic section), Hutchinson, 190 36. Chronic Onychia, Bryant, 199 XV LIST OF ILLUSTRATIONS. FIG. 37- 38. 39- 40. 41. 42. 43- 44. 45. 47- 48. 49. 50. 51- 52. 53- 54- 55- 56. 57- 58. 59- 60. 61. 62. Onychia Maligna, Laceration of Internal Coats of Artery, Petit's Tourniquet, " " Applied to the Brachial Artery, « u i< « Femoral " Signoroni's Tourniquet, , Acupressure, Effect of Torsion on an Artery, 46. Aneurysmal Varix, Arterio-venous Aneurysm The same laid open, Cirsoid Aneurysm of Scalp, Syphilitic Arteritis, Varicose Veins, Section through Popliteal Aneurysm, Diagrams of Operations on Aneurysms, Femoral Artery Laid Open after Ligature, . . . . Method of Applying Ligature to Artery, Aneurysm Needle, Ligature of Common Carotid and Facial Arteries, Fergusson, Bryant, . Fergusson, Bryant, Fergusson Bryant, Fergusson Bowlby, Bryant, Bowlby, Bryant, " Subclavian and Lingual Arteries, . . . " Axillary Artery, " Brachial Artery, " " " at Bend of Elbow, . Lines of Incision for Brachial and Radial Arteries, 63. Ligature of Radial Artery, 64. 65- 66. 67. 68. 69. 70. 71- 72. 73- 74- 75- 76. 77- 78. 79- 80. 81. 82, 84. 85. 86. 87. 88, 90. 91. " Radial and Ulnar at the Wrist, . . . . . Incision for Ligature of Common Iliac Artery, Ligature of the External Iliac and Femoral Arteries, . . Line of Incision for Ligature of the Femoral Artery, . . . " " " Posterior Tibial Artery, Adapted from Sedillot by \ Bryant. i Fergussoti, j" Adapted frotn Sedillot by \ I Bryant. Fergusson, Ligature of the Posterior Tibial Artery, " " " at Ankle, . . . Line of Incision for Ligature of Anterior Tibial Artery, Ligature of the Anterior Tibial Artery, " Dorsalis Pedis Artery, . . . Treves' Cervical Splint Lymphoma (microscopic), Serous Cyst of Neck, False Neuroma, Rider's Bone, Avulsed Thumb, Ruptured Biceps, Nussbaum's Appliance for Writer's Cramp, 83. Sterno-mastoid Induration (microscopic). Compound Palmar Ganglion, Dupuytren's Contraction, Semi-solid Bursa, laid open, Supernumerary Thumb, 89. Congenital Displacement of 1 lip, . . . Webbed Fingers, Congenital Talipes Varus r Adapted from Sedillot by \ I Bryant. i Original, Fergusson, ( Adapted from Sedillot by \ I Bryant. i Krohne and Sesemann, . Bryant, Holmes, Bryant, Bryant, Fergusson, Bryant, . Fergusson, Bryant, . Feigussou , Bryant, . PAGB 200 205 208 208 208 209 211 212 217 218 218 221 224 227 239 243 244 262 262 264 267 270 270 271 272 272 273 274 275 276 278 278 279 279 279 280 286 287 289 305 306 307 307 3" 312 316 317 320 322 323 325 326 LIST OF ILLUSTRATIONS. PIG 92. Congenital Talipes Valgus, Bryant, 93. Barwell's Adhesive Straps, Sayre, . 94. Morton's Club-Foot Stretcher, Bradford, 95. Bradford's " " " 96. Tin Splint for Slight Varus — 97. Little's Shoe, — 98. Little's Modification of Scarpa's Shoe, Bryant, 99. Talipes Equinus Fergusson, icx>. " Calcaneus, " 101. Harwell's Shoe " 102. Walsham's Shoe, — 103. Lever for Great Toe, — 104. Osteoclast of Rizzoli, — 105. Transverse Fracture of Femur, Original, 106. Greenstick Fracture of Radius " 107. Comminuted Fracture of Clavicle, " 108. T-shaped Fracture of Humerus, ■ '* 109. Badly-United Fracture Laid Open, " ;io. Ununited F"racture of Ulna, Fergusson, [II. " " Tibia [12. Pseudarthrosis of Tibia, .... " 113. The Limb in the same case, Fergusson. [14. Gutta-percha Splint for Lower Jaw, Original, [15. Wire " " " [16. Thomas's ^lethod of Wiring Jaw, " [1 7. Displacement of Broken Clavicle, Fergusson, 18. Triangular Bandage Applied, Original, [I9. Bandage for Fracture of Clavicle, " 120, 121, 122. Sayre's Bandage for Fracture of Clavicle, ... — [23. Pick's Bandage, Original, [24. Fracture of Neck of Scapula, Fergusson, [25. " Surgical Neck of Humerus, " [26. Bandage for Fractured Neck of Humerus, Original, 127. Line of Upper Epiphysis of Humerus, " [28. Splint for Fracture of Shaft of Humerus, " [29. Fracture of Lower end of Humerus, Fergusson, [30. Badly-united Fracture of Humenis, " [31, Fracture of Inner Condyle of Humerus, " [32. Epiphysis (lower) of Humerus, Original, [33. Separation of Upper Epiphysis of Radius, " 134. Diagram of Colles' Fracture, " [35. Section through Colles' Fracture, Bryant, 136. Hand in Colles' Fracture, Fergusson, 137. Gordon's Splint, Original, [38. Carr's Splint, .... Bryant, 139. Fibrous Union of Olecranon, Fergusson, 140. Fracture of Pelvis, " 141. Bryant's Triangle, Bryant, [42. Intra-articular Fracture of Neck of Femur, Original, [43. Section through Neck of Femur, " 144. " " (horizontal) '' 145. Impacted Fracture through Base of Neck, " 146. " " inlra-articular, " 147. Separation of Great Trochanter, ... Bryant, 148. Liston's Splint — 149. Desault's Splint, — PAGE 326 328 330 330 331 333 334 335 338 340 344 345 346 346 346 352 355 355 355 356 Z^o 384 385 386 387 388 389 390 391 392 393 394 397 399 400 402 402 403 404 405 406 407 407 409 413 414 415 415 417 419 419 420 422 422 xviii LIST OF ILLUSTRATIONS. P'G- PAGE 150. Mode of Applying Stirrup, Original, 423 151. Listen's Splint Applied, " 423 152. Thomas's Knee-splint, " 424 153. Badly-united Fracture of Femur, Fergusson, 424 154. Mclntyre Splint Applied, Original, 425 155. Hodgen's Splint Applied, Bryant, 425 156. Fracture of Femur in Infancy, Original, 425 157. Vertical Separation of Lower Epiphysis of Femur with Bony Union, " 426 158. Fracture of Lower End of Femur, " 426 159. 160. Fractured Patella, Fergusson, 429 161. Section through Knee after Fracture of Patella, .... Original, 429 162. Outline of Knee in Fracture of Patella, Fergusson, 429 163. Bony Union of Fractured Patella, Original, ........ 430 164. Fibrous Union of Fractured Patella, " 430 165. Splint for Fracture of Patella, " 431 166. Malgaigne's Hooks, — 432 167. Leather Splint for Knee, — 433 168. Stocking Splint for Leg, Original, 437 169. Bavarian Splint, " 438 170. Section through Foot showing effect of Eversion, .... " 440 171. " " " Inversion, ... " 440 172. Vertical Splitting of Tibia, " 441 173. Dupuytren's Splint, Fergusson, 441 174. Compound and Comminuted Fracture of Leg, — . . . * 442 175. Atrophy of Bone, Original, 444 176. Chronic Traumatic Osteitis, , " 446 177. Inequality of Growth Consecutive to Inflammation and Necrosis, " 447 178. Chronic Abscess of Bone, " 449 179. Chronic Osteomyelitis, " 452 180. Phosphorus Necrosis of Jaw, " 453 181. Acute Suppurative Osteomyelitis of Tibia, " 455 182. Chronic Osteomyelitis of Lower End of Femur, .... " 456 183. Section through Bone after Amputation and Osteomyelitis, " 463 184. Tubular Sequestrum " 463 185. Syphilitic Caries of Skull, " 466 186. " Osteosclerosis of skull, " 467 187. Parrot's Nodes, " 468 188. Tubercular Caries of Radius, " 473 189. Section through an Epiphysis in a Case of Rickets, ... " 475 190. 191. Rickety Femur and Tibia " 476 192. Skull from a Case of Osteitis Deformans, " 480 193. Femur from a Case of Osteitis Deformans, " 480 194. Attitude in Osteitis Deformans, Bryant, 481 195. Exostosis of Frontal Sinus, " 484 196. Exostosis from Frontal Sinus, " 484 197. Sub-ungual Exostosis, " 485 198. Enchondroma of Finger, Original, 486 199. " Hand, Bryant, 486 20Q. Central Sarcoma of Tibia, Original, 488 201. " Fibula, " 488 202. Periosteal Sarcoma of Femur, " 489 203. Old Subcoracoid dislocation — glenoid fossa, " 499 204. 205. New Sockets in Old Dislocations of Hip, Astley Cooper, 500 206. Dislocation of Lower Jaw, Fergusson, 505 LIST OF ILLUSTRATIONS. xix FIG. _ PAGE 207. Old Dislocation of Humerus, Original, 510 208. Subcoracoid Dislocation " 511 209. " " Capsule Laid ()|ien, " 512 210. ■ " " Showing Effect of rotation out- ward and abduction " 513 211. Rotation Outward of Arm ill Reduction of Dislocation, . " 513 212. Circumduction of Arm, " 514 213. Forced Rotation Inward of Humerus, " 515 214. Reduction of Dislocation by Heel in Axilla, Fergusson, 515 215. Clove-hitch, " 516 216. Reduction of Dislocation by Upward Traction, " 517 217. Dislocation of Bones of Arm Backward Modified from Astley Cooper, 519 218. Unreduced Dislocation of Elbow, Fergusson, 522 219. Subluxation of Radius in an Infant, Original, 524 220. Thumlj Forceps, Fergusson, 525 221. Dislocation of Proximal Phalanx of Thumb, Original, 526 222. Complete Dislocation of Proximal Phalanx of Thumb, . " 526 223. Complex Dislocation of Proximal Phalanx of Thumb, . Original, 526 224. Dislocation of Finger, Fergusson, 527 225. Dorsal Dislocation of Hip, Aslley Cooper 529 226. Sciatic Dislocation of Hip, . - .- " 529 227. Thyroid Dislocation of Hip, " 529 228. Pubic Dislocation of Hip, " . ... 529 229. Dislocation on the Dorsum above the Tendon, Original, 530 230. " " " below the Tendon, " 530 231. View of Pelvis from below in Sciatic Dislocation, ... " 532 232. Method of Applying Pulleys in Reduction of Dislocations', Fergusson, 535 233. Pott's Fracture, " 540 234. Dislocation of Foot Backward, " 541 235. Subastragalar Dislocation, Original, 544 236. Absorption of Articular Cartilage by Granulations, ... " 547 237. Abscess in Upper Diaphysis of Tibia, " 559 238. Exfoliation of Cartilage, '' 560 239. Degeneration of Cartilage in Osteo-arthritis, " 569 240. Knee Joint, Showing Thickening of Synovial Fold, ... " 569 241. Elbow Joint in Advanced Osteo-arthritis, '' 57° 242. Absorption of Neck of Femur in Osteo-arthritis, .... •' 571 243. Papillary Synovitis, " 572 244. Rheumatoid Arthritis of Shoulder with Absorption of Biceps Tendon, " 572 245. Shoulder in Charcot's Disease, " 577 246. Hand in Charcot's Disease, " 578 247. Elbow in Charcot's Disease, " 578 248. 249. Knee Joint in Charcot's Disease, Clinical Society, 579 250. Incipient Tubercular Infiltration of Upper End of Femur, Original, 581 251. Incipient Tubercular Infiltration of Upper End of Tibia, " . 581 252. Sequestrum in Neck of Femur, Bryant, 588 253. Separation of Head of Femur, " 589 254. Destruction of Head of Femur, Original, 5^9 255. Diagnosis of Hip Disease, — 591 256. 257. Attitude in Early Hip Disease, Modified from IVright, . . 592 258, 259. Tilting of Pelvis and Abduction, Original, 593 260. Attitude in Advanced Hip Disease, Bryant, 59^ 261. Bryant's Splint, — 597 262. Abduction and Extension in Hip Disease, Original, 598 263. Adduction and Extension in Plip Disease, •' 59^ XX LIST OF ILLUSTRATIONS. FIG. 264. Section through Trunk and Limb to Show Position of Thomas's Splint, — egg 265. Measuring for Thomas's Splint, — jgg 266. Thomas's Wrenches, — 600 267. Method of Lifting Patient with Thomas's Splint Applied, . — 600 268. Thomas's Hip Splint Applied, — 601 269. Double Thomas's Splint, — 601 270. Chronic Disease of Knee Joint, Secondary to Osteitis, . Original, 606 271. Primary Tubercular Synovitis of Knee, " 607 272. Section through Knee Joint in a State ot Advanced Arthritis " 608 273. Thomas's Knee Splint with Patten, — 609 274. Thomas's Knee Splint Applied, — 609 275. Abscess in Head of Humerus, — 612 276. Disease of Elbow Joint, Fergusson, ....*... 613 277. Section through Anchylosed Elbow Joint, Original, 618 278. Excision of Elbow Joint — 622 279. Incisions for Excision of Wrist Joint, — 623 280. Lister's Splint for Excision of Wrist, — 624 281. Meningocele Bryant, 630 282. Encephalocele, " 631 283. Exfoliation of Skull after Injury, Original, 633 284. 285. Fracture of Vault of Skull, Inside and Outside, . . " 634 286. Punctured Fracture of Skull, " 636 287. Fracture of Base of Skull, " 638 288. Hemorrhage from Middle Meningeal Artery, " 649 289. Horn and Sebaceous Cysts of Scalp, Bryant, 656 290. Necrosis of Frontal Bone (Syphilitic), " 659 291. Section through Mastoid Process and Lateral Sinus, . . Original, 666 292. Hernia Cerebri Bryant 672 293. Osteoplastic Resection, Esmarch, 676 294. Trephining, Fergusson, 677 295. Localization of the Cerebral Convolutions, — 678 296. Wilson's Cyrtometer, in situ Bramwell, 679 297. Meningomyelocele Laid Open, Origitial, 681 298. Spina Bifida (Diagrammatic), " 682 299. Cicatrix from a Case of Spina Bifida, Bryant, 682 300. 301. Congenital Coccygeal Tumors, " 684 302. Fracture of Spine, Original, 688 303. Dislocation of Spine, Bryant 688 304. Ankylosis of Dorsal Vertebrte after Canes, Original, 702 305. Tubercular Osteitis of Spine, " 702 306. Atlo-axoid Disease, " 706 307. Sayre's Tripod, — 707 308. Double Thomas's Splint for Caries of Spine, — 707 309. Sayre's Jury-mast, Bryant, 708 310. Lateral Curvature of Spine Original, 712 311. Spine from a Case of Lateral Curvature, " 714 312. Transverse Section through Thorax from a similar case (advanced) " 714 313. Extreme Scoliosis, Bryant, 715 314. Barwell's Sling, Original, 717 315. Prolapse of Iris " 727 316. Beer's Cataract Knife, A'ettleskip 736 317. Melanotic Growth on Edge of Eyelid, Original, 737 318. 319. Iridectomy, A^ettleship, 739 LIST OF ILLUSTRATIONS. xxi FIG. PAGR 320. Double Harelip — 742 321. Operation for Single Harelip, — 743 322. " " Harelip with Unequal Sides, — 743 323. " " Double Harelip, — 743 324. Lipoma Nasi ' Fergtisson 749 325. Bellocq's Sound " 752 326. Nasal Speculum — 754 327. Method of Grasping Nasal Polypi, Fergusson 756 328. Incision for Removal of Upper Jaw, Esmarck, 758 329. Plan of Bone Section, for Removal of Upper Jaw, ... " 758 330. Smith's Gag, — 760 331. Coleman's Gag, — 760 332. Cleft of Soft Palate with Lines of Incision, Fergusson 760 333. Smith's Tubular Needle, — 760 334. Cleft of Palate with Lateral Incisions, Origmal, 761 335. Ranula, Bryant, 771 336. Incisions for Section of the Superior Maxilla, Esmarch 775 337. 338. Resection of Lower Half of Jaw, " 776 339. Macroglossia, Fergusson, 779 340. Chronic Superficial Glossitis, Original, 781 341. Epithelioma of the Tongue, . . ; " 7^5 342. Tonsillotome, — 793 343. Salivary Calculus, Bryant, 795 344. Submaxillary Tumor, " . 79^ 345. Allen's Air-pad, — 79^ 346. Air-bag for Politzer's Inflation, — 79^ 347. Brunton's Auriscope, — 799 348. Ear Forceps, — 801 349. Golding-Bird's Dilator, — 821 350. Oildematous Laryngitis, Original, 822 351. Trachea Dilator, — 829 352. Parker's Suction Tube, — 829 353. Durham's Cannula, — 830 354. Parker's Cannula, — 830 355. Hahn's Tampon, .... — 831 356. O'Dwyer's Intubation Tubes, Mouth Gag, etc., — 834 357. Gussenbauer's Artificial Larynx, — 837 358. Parenchymatous Goitre Original, 840 359. Cystic Bronchocele, " 841 360. Colloid Degeneration of Thyroid, " 842 361. Cystic " " " 843 362. Horsehair Probang, Bryant 846 363. Coin-catcher, — 846 364. Malignant Stricture of CEsophagus, Original, 849 365. Ribs United by Callus, " 854 366. Strapping for Chest, Bryant, 855 367. Diagram Showing Position of Viscera, " 871 368. Oblique Inguinal Hernia, " 878 369. Direct " " " 878 370. Femoral Hernia, " 879 371. Truss for Inguinal Hernia, — 880 372. Single Circular Truss for Scrotal Hernia, — 880 373. Double Femoral Truss, — 881 374. Pad for Irreducible Hernia, Bryant 883 375. Unstrangulated Hernia, " 885 376. Strangulated Hernia, " 885 LIST OF ILLUSTRATIONS. FIG. 577. Congestion and Hemorrhage into Intestine from Strangula- - tion, Bryant, 886 378. Reduction en masse, Original, 890 379, 380, 381. Varieties of Incomplete Reduction, " 891 382. Method of Dividing Stricture in Hernia Fergusson, 893 383. Stricture of Intestine After Strangulation Bryant, 896 384. Congenital Hernia Complete, Original, 897 385. " " Incomplete, " 897 3S6. Infantile Hernia, " 898 387. Incision for Inguinal Hernia, Fergtisson, 900 388. Pad Formed in MacEwen's Operation, Original, 902 389. Vah-ular Shape of Inguinal Canal, After Astley Cooper, . . 902 390. MacEwen's Operation for radical Cure, — 903 391. 392, 393. Radical Operation for Inguinal Hernia, .... After Bassini, 904 394. Femoral Hernia, Original, 905 395. Strangulation of Intestine by Band, " 911 396. Prolapse through Meckel's Diverticulum " 912 397. Intussusception, " 913 398. Malignant Disease of Intestine " 924 399. Malignant Stricture (Annular), " 924 400. Nelaton's Operation, Bryant, 936 401. Method of Securing Intestine in Lumbar Wound, .... Original, 938 402. Artificial Anus After Lumbar Colotomy, Bryant, . 939 403. Method of Securing Intestine in Inguinal Colotomy, . . . Original, 940 404. 405. Maydl's Operation for Artificial Anus, Esmarch, 941 406. Lembert's Suture, Greig Smith, 942 407. " " Tied, " 943 408. Greig Smith's Method of Intestinal Suture, " 944 409. Entero-anastomosis, After Senn, 947 410. Allingham's Speculum, — 957 411. Clamp for Cauterizing Hemorrhoids, — 963 412. " Crushing Hemorrhoids, — 964 413. Prolapse of Rectum, Bryant, 967 414. Probe Passed through Anal Fistula, " 978 415. Method of Dividing Fistula, Fergusson, 978 416. Single Median Kidney, Original, 988 417. Hydronephrosis, " 994 418. Calculus Encysted in Kidney " 1000 419. Calculous and Suppurative Pyelitis, " looi 420. Tubercular Pyehtis, " 1007 421. Unnary Deposits — Urates, Bryant, 1021 422. " " Uric Acid " 1022 423. " " Oxalate of Lime, " ........ 1022 424,425. " " Phosphates, " 1022 426. " " Epithelium, " 1022 427. " " Spermatozoa and Epithelium " 1022 428. " " Casts, " 1023 429. Ectopia Vesicae in the Male, " 1024 430. " " Female, " 1024 431. Methods of Tapping Bladder, Fergusson 1035 432. Tapping the Bladder through the Rectum, Bryant, 1036 433. Hypertrophied and Sacculated Bladder, Original, 1037 434. Uric Acid Calculus with Oxalate of Lime, Bryant, 1042 435. Oxalate of Lime Calculus, " I044 436. Cystin Calculus, " I044 437. Enlarged Prostate, with Sacculated Bladder, Original, 1044 LIST OF ILLUSTRATIONS. FIG. 438. Thompson's Sound, — '045 439. Bigelow's Lithotiite — '047 440. Thomson's Lithotrite, — 1047 441. Lithotrity, Method of Seizing Calculus, — 104S 442. " " " " — '049 443. Bigelow's Evacuator — I049 444. Evacuating Tubes, — 1050 445. Lithotomy Knives, — J052 446. Clover's Crutch — '°53 447. Lithotomy Staffs, — 1053 448. Incision for Lateral Lithotomy, Fergusson 1054 449. Lithotomy with Curved Staff, Bryant 1054 450. " Straight Staff, — 1055 451. Blunt Gorget — io55 452. Lithotomy P'orceps — 1055 453. Lithotomy Scoop and Director, — 1056 454. Buckston Browne's Tampon, — io57 455. Angular Staff, — 1058 456. Suprapubic Lithotrity, Bardenhauer, 1061 457. Fibro-papilloma of Bladder Original, 1065 458. Epithelioma of Bladder, . . " 1066 459. Leiter's Cystoscope, — 1067 460. Thompson's Bladder Forceps, — 1069 461. Dilator for Female Urethra, — 1070 462. Cystoscope in Position, Duplay and Recliis, . . . 1070 463. Small Polyp as seen by Cystoscope, " " ... 107 1 464,465. Enlargement of the Prostate, Original, 1073 466. Section of Hypertrophied Prostate, Duplay and Reclus, . . . 1075 467. Watson's Cannula in Position, Esmarch, 1080 468. Neck of Bladder Seen from Within in a Case of Enlarged Prostate, , Original, 1082 469. Prostato-vesical Calculus Bryant, 1086 470. Prostatic Calculi with Prolapse of Ureter, Original, 1086 471. Various Forms of Catheters, — 1091 472. Method of Tying in Catheter, Bryant, 1094 473. Instrument for Tying Catheter in, — 1095 474. Gonococcus, Senn, 1096 475. Leiter's Panelectroscope — \\o\ i^jd. Stricture of Urethra with Diseased Bladder, Original, 1104 477. Otis's Urethrameter, — 1106 478. Bulbous Sound, .... — no? 479. Holt's Dilator, — "12 480. Civiale's Urethrotome, — 11^3 481. Otis's Urethrotome, — m3 482. Tee van's Urethrotome, — 1114 483. Syme's Staff, — i"5 484. Wheelhouses Operation, Original, 11 16 485. Grooved Staff, Bryant 1116 486. Teale's Gorget, " "'7 487. Cock's Operation, " i"7 488. Division of Stricture in Paraphimosis, " • ■ 1125 489. Strapping Testicle " '^3' 490. Gummatous Disease of Testis, Original, 1132 491. Tubercular Epididymitis, " '^^1)1> 492. Hernia Testis, Bryant, ii34 493. Cystic Disease of Testis, " ^'35 LIST OF ILLUSTRATIONS. FIG. PAGE 494. Varicocele, Original, 1138 495. Encysted Hydrocele of Cord « 1141 496. Spermatocele, <« u^i 497. Tapping a Hydrocele, Bryant, 1142 498. Obliteration of Tunica Vaginalis, Original,. . 1142 499. Tapping the Hydrocele, y, Volkmann, 1142 500. Inflammation and Distention of Fallopian Tubes, . . . . Original, 1 145 501. Multilocular Ovarian Cyst, « n^g 502. Dermoid Cyst of Ovary, << i j^g 503. Papillary Cyst of Ovary, « 1 1^0 504. Uterine Fibroids, « 1160 505,506,507. Ruptured Perineum, Operation for, .... , " 1169,1170 508. Cystic Tumor of Breast, Bryant, 11 78 509. Colloid Scirrhus of Breast, Ori<^inal, 1 180 510. Excision of Breast, Estnarch 1186 511. Teale's Amputation, Bryant, 1189 512. Carden's Amputation, <« ii3q 513. Amputation at Shoulder Joint, Jacobson, 1191 514. Amputation at Shoulder Joint, Fergusson, 1191 515. Amputation at Elbow Joint, Jacobson, 1191 516. Amputation of Forearm, Bryant, 1 192 517. Amputation of Hand, Jacobson, I192 518. Amputation of Thumb, « 1102 519. Outline Diagram for Amputation of Thumb and Fingers, . Bryant 1193 520. Furneaux Jordan's Amputation at the Hip, " 1 194 521. Amputation at Hip, After Wyeth, 1194 522. Stephen Smith's Method of Amputating, Bryant, 1197 523. Stump after Stephen Smith's Amputation, <' 1 197 524. Amputation through Knee Joint, •. . Erichsen, 1197 525. Amputation of Leg by Mixed Method, Bryant, -. . .1198 526. Stump left after Amputation by Mixed Method, .... " II98 527. Syme's Amputation of Foot, Treves, II98 528. Roux's Amputation of Foot, " 1 198 529. Pirogoff's Amputation, Bryant, 1199 530. Stump after Pirogoff's Amputation, — 1199 531. Incisions for Amputation of Foot, Jacobson, 1200 532. Stump after Chopart's Amputation, Fergusson, 1200 533. Lines for Tripier's Amputation, Bryant, 1200 534. Stump after Hey's Amputation, Fergusson, 1201 535. Amputation of Great Toe, " 1202 536. Dubreuil's Operation for Removal of Toes, Treves, 1202 537. Removal of Metatarsal Bone of Great Toe, Fergusson, 1202 538. Stump Left after Excision of Metatarsal Bone of Great Toe, .< 1202 539. Esmarch's Triangular Bandage, Pilcher, 1205 540. Placing Wounded Man upon Stretcher, U. S. A. Drill Manual, .1205 541-544. Bearing the Wounded, <* . 1206 545. The Travois, «< _ 1207 546. The Gorgas Cot, " . 1207 547. The Gihon Cot for Transporting Wounded on Shipboard, . " .1207 548. The Walton Wills Cot, Beyer, 1 208 549. The McDonald Ambulance Lift, " 1208 550. Ancient Bullet Forceps, 9 Figures, 1210 551. The Nelaton Bullet Probe, 1211 552. Longmore's Electric Explorer, Porter, I2ii 553. American Bullet Forceps, 1212 PART I. GENERAL PATHOLOGY OF SURGICAL DISEASES. CHAPTER I. INJURY AND REPAIR.— INFLAMMATION. INJURY AND REPAIR. The immediate effect of an injury is to kill some of the structures upon which the brunt of the violence falls and impair the vitality of others, the extent and severity of the damage sustained depending partly upon the intensity of the agent, partly upon the condition of the tissues. As soon as the irritant ceases to act repair begins, provided the violence has not been so great as to destroy life altogether ; if it continues, or if, before its effects have died away, a second is inflicted, impairing vitality further still, what is known as inflammation follows. Two things, therefore, have to be considered in estimating the effect produced — the severity and persistence of the irritant, and the condition of nutrition of the tissues. Of the Various Causes of Injury. Irritants are divided into two classes, the organized or living, and the unorganized, which may be mechanical, physical, or chemical. The distinction is not a logical one, as the former act either mechanically, by blocking the blood- vessels, or chemically, by means of certain poisons they produce ; but it is con- venient for this reason, that the one is endowed with an independent existence, and the other is not. I. Organized Jrrifa/its. Certain animal parasites (such as the chigoe) are occasionally met with living in the tissues, but they are so rare as to be of comparatively little consequence ; the more important ones are microscopic, unicellular organisms belonging to the class Schizomycetes, multiplying by transverse division, and, in the case of the rod-like forms, by spores as well. a. Of these some can only live in dead material. They are constantly present in the bronchi and the alimentary canal, they enter freely with the food and the air ; but even if they are injected into the blood they are either killed [by phago- cytic action of the leucocytes] or eliminated with the urine ; they are non-patho- genic, they do not of themselves give rise to any disease. Such, for example, are the bacteria of putrefaction. These cannot exist in the tissues so long as they are alive ; but where they gain entrance to a collection of pus or of wound-dis- charges exposed to the air they thrive most vigorously and form a chemical poison which is the cause of some of the varieties of wound fever. [Rosenbach has cul- tivated a saprophytic spore-bearing bacillus, and Hauser has found several varie- ties of \he proteiis.'] b. Others can exist in the tissues or in the blood, but are unable to affect them injuriously unless their power of resistance has been lowered by other local 3 25 26 GENERAL PATHOLOGY OF SURGICAL DISEASES. or constitutional causes. Such are the organisms which give rise to the formation of pus (staphylococcus pyogenes aureus, albus, or citreus, streptococcus pyogenes, and several more) ; they do not cause specific diseases, but according to the cir- cumstances under which they enter, and their surroundings, they are followed by suppuration, gangrene, pyaemia, noma, phagedaena, and other acute inflammatory disorders. c. A third class again is specific, being followed invariably by the same defi- nite disorder. Some of these are attended by local inflammation (tubercle, syphilis, erysipelas, glanders, anthrax, etc.) ; others, such as tetanus and hydro- phobia, give rise to constitutional symptoms only. 2. Unorganized Irritants. Mechanical such as cuts, bruises, friction, or tension. A simple incised wound heals at once, without inflammation. Certain tissue-elements are killed ; a very slight amount of blood is extravasated between the cut edges, but if there is no further hurt or injury the natural process of repair begins at once. If the blood decomposes, if the wound" is repeatedly rubbed, or if a suture is put in so tightly as to cause tension, a fresh injury is inflicted, the vitality of the surrounding tissues is lowered, and inflammation sets in and continues until the irritant is removed. Physical. — Heat acts in the same way. A cautery plunged into a njevus leaves a hole with blackened, charred edges ; but if no fresh irritant is allowed to appear the wound is repaired without inflammation. A burn covered up thor- oughly from the air and protected from decomposition heals without further trouble, unless pyogenic or other organisms gain access to it in some way. In- tense local cold produces the same effect. How a general chill acts when it causes internal inflammation (pneumonia, for example) is not certain. Chemical. — The same may be said of these. Nitric acid applied to the skin forms a scab under which repair is completed without further destruction or loss of tissue. If, however, a continuous stream of poisonous compounds is poured into the blood, or allowed to act upon the tissues, the most intense fever and the most widespread destruction may follow. It is still open to question whether the nervous system can of itself excite inflammation. There is no doubt that a part of the body separated from the cen- tral organs is especially liable to become inflamed if it is injured in any way : but this is not the point. It seems probable that certain disorders — herpes zoster, acute bedsores, and some forms of arthritis — are the direct result of affections of distant portions of the nervous system, and that, therefore, nerve-irritation must be regarded as a direct exciting cause ; but in what way it can act must remain undefined until more is known of the influence of the nerves upon the nutrition of the tissues during health. Of the Ixfluenxe of the Coxditiox of the Tissue.s. The effect produced by an irritant depends not only upon the irritant itself, but upon the condition of the tissues. In old age, where the arteries are athero- matous and the circulation feeble, or after prolonged exposure to cold, a scratch or bruise so trivial that under other circumstances it would scarcely have attracted attention may lead to the death of the part it affects, and by the changes that follow prove the cause of extensive gangrene. I. The circulation may be defective. There may be a deficient supply of blood, or the part may be engorged and congested. Everything that tends to prevent a fair amount of blood flowing to a part — arterial atheroma, cold, strangu- lation, as in the case of a hernia or Esmarch's bandage, if too long applied — lowers its vitality and renders it less able to resist injury. In the same way, if there is any difficulty to the return of blood — if, for example, the veins are vari- INJURY AND REPAIR. 27 cose and the tissues congested and oedematoiis — the most reel)le irritant may cause a very extensive degree of inflammation. II. The ([uahty of the blood may l)e defective: leucocythoemia, Bright's disease, scurvy, or diabetes may l)e present. It is probable that gout, intemper- ance, starvation, and possibly rheumatism also act in this way. III. Interference with the nerves going to a part undoubtedly predisposes to inflammation, but whether this is a direct result, or indirect, due to the fact that no work is done and that, consecpiently, the nutrition of the ])art is carried on without energy, is uncertain. Besides these causes there are others, many of them hereditary, concerning which it is impossible to say more than that the tissues themselves are peculiarly susceptible, sometimes to every kind of irritant, sometimes only to certain special forms, such, for example, as tubercle. The Effect of a Single Injury. The immediate effect of an irritant of more than the slightest degree of inten- sity is to kill some of the tissue-elements and lower the vitality of the others. Unless the blood-vessels are ruptured, so that there is some extravasation, the change that actually takes place is, for the most part, beyond our power of obser- vation ; it is known that after powerful electric shocks the corneal corpuscles and wandering leucocytes cease their movements and become fixed in shape, and prob- ably the same result is produced by other irritants of equal degrees of intensity ; but even of this it is impossible to say more than that the living protoplasm has undergone a process of coagulation. The interchange of oxygen and carbonic acid comes to an end ; the plasma ceases to circulate in the interstices ; fibrin- ferment is set free ; coagulation takes place ; and the injured part is converted into a semi-solid mass of dead albuminous material, of itself perfectly inert. If the irritant is not sufficient to produce the full effect and kill the tissues, the changes are probably the same in direction, but not carried so far. The effect upon the blood-vessels is of exactly the same character. At first, unless the irritant is a very powerful one, there is a momentary contraction of the arterioles and capillaries, but this is not constant and is probably not important. As soon as its influence fairly reaches the muscular fibres and the endothelial cells that form the walls, the tonic contraction relaxes, the vessels dilate, and the part becomes loaded with blood. For the first few moments the speed of the stream is slightly increased, owing to the capillaries not dilating to the same extent as the arterioles, but this does not last long. Some of the living cells are killed or badly hurt ; the normal relations between the blood and the walls of the vessels no longer hold good ; the colorless corpuscles, which always have a tendency to lie on the outside of the current, accumulate in greater numbers and cling more closely to the damaged structures ; they stick for a time at one spot, and when they do move seem as if they were being dragged away ; and many of them pass through the wall and collect in the interstices around. Then the plasma becomes more viscid ; the stream becomes slower and slower ; the red corpuscles in the axis oscillate a little, and finally come to a standstill. In other words, stasis sets in. The circulation stops ; the part is full of blood, and after a time thrombosis occurs, coagulation taking place in the vessels as well as in the tissues. The injury has lowered the vitality of the cells that line the vessels and form their wall, and now they act toward the blood like any other dead or dying struc- ture. The changes are the same as in the tissues ; the blood ceases to circulate in the one, and the plasma in the other ; some of the cells are killed ; the ferment is set free ; coagulation takes place ; and fibrin is formed, only, owing to the pres- ence of red blood-corpuscles in the one, the appearance is much more striking and more easily recognized than in the other. Such an effect as this may be produced by any simple kind of injury, mechan- ical, physical, or chemical. A bruise kills some of the subcutaneous tissues and 28 GENERAL PATHOLOGY OF SURGLCAL DISEASES. causes a slight extravasation of blood ; a clean, incised wound, the edges of which are at once brought together again, does the same. The actual cautery, plunged, for example, into a noevus chars some of the tissues round, and for the time impairs the vitality of those farther off. A ligature tied tightly round the stump of an ovarian tumor stops the circulation through it mechanically and leads to the same result ; and, on a larger scale, the same thing occurs in one form of senile gangrene ; the tissues are slowly starved to death, and the part gradually becomes hard and mummified. The subsequent changes, always provided no other irritant is allowed to appear, are equally simple. I. The tissues that are killed either undergo fatty degeneration, or are dried up, according to their position. In the former case they gradually disappear, being absorbed by the living structures around ; in the latter the deeper part may be absorbed, but all the hardened structures are thrown off, a new layer of epi- dermis being slowly developed beneath them, so that the surface is once more restored. II. Those around that are only slightly injured recover by degrees and begin the process of repair. For this, however, the general nutrition must be fairly good ; if their vitality is already low, not only is the extent of the original injury far greater than it otherwise would be, but they may not have sufficient power to rally, and then the area of destruction spreads. Repair. — Repair is merely an expansion of the natural process of nutrition. All the interstices of the tissues are everywhere filled with plasma, which pours out through the walls of the blood-vessels and drains off by the lymphatics. Each living cell draws from the general stock around it what it requires for itself, and gives up that for which it has no further need. When it is worn out, or when, from injury or any other cause, it is brought to an untimely end, it is removed and replaced, either by the development of fresh ones from the survivors near, or by the agency of the leucocytes which wander freel}' through the channels. The rapidity of the current is regulated by the amount of work to be done. Where the activity is unusually great, and the amount of work exceptional, as after an injury, the plasma pours through more freely, the blood-vessels dilate, the blood circulates more rapidly, more food is brought, and the waste is removed more quickly. If, on the other hand, a part of the body is kept at rest and does no work, whatever the cause may be, the plasma remains stagnant and the tissues starve. If the injury has been a slight one, not sufficient to kill any of the ti.ssues, perfect restoration is the rule. The red blood-corpuscles separate from each other and fall off into the circulation, almost, if not quite, unchanged ; the endothelial cells recover their natural tone ; the vessels regain their calibre ; the plasma loses its viscid character, just as incipient rigor mortis may pass off, and the colorless corpuscles cease to collect against the wall- or pass through in excessive numbers. If it has been more severe, so that some of the tissue-elements and of the cells in the walls of the vessels are killed (with or without extravasation), and the plasma has coagulated, the process is not so simple ; a certain amount of new tissue must be formed, to replace that which is lost. The injured area now is transformed from a living part of the body into a mass of dead and dying cells, held together by a network of fibrin. The circulation has ceased, the capillaries are plugged, and sometimes, owing to the giving way of their walls, the interstices are filled with blood. Such a condition as this occurs after every bruise and on the surface of every wound, even if the edges are brought together at once, the lymph forming a soft but tenacious clot which helps to check the hemorrhage and glue the parts together until permanent repair is effected. This is carried out mainly, if not entirely, by the leucocytes. Normally, in all the tissues there is a certain proportion of free corpuscles -wandering in the plasmatic canals, removing what is broken down and perhaps INJURY AND REPAIR. 29 replacing it. After an injury, especially one of this severity, these increase immensely in number, pouring through the walls of the vessels and spreading into all the spaces round. In the centre of the injured area, where stasis has occurred, this is only possible to a slight extent ; but all round, where the tissues are only slightly hurt, and farther away, where they are not hurt at all, but only stimulated to increased exertion by the presence of injured structures near, these leucocytes jiour out in myriads, removing and replacing what is dead, and advan- cing (forcing their way in reality) farther and farther toward the centre, until the whole injured area is transferred into a mass of living corpuscles. In the ca.se of small extravasations, this transformation is most conspicuous. At first there is merely a dark-colored clot of fibrin entangling the red corpuscles and a few of the white ones in its meshes ; the serum drains away and is carried off by the lymphatics. Then the red corpuscles undergo disintegration ; the coloring matter soaks out of them and stains all the tissues near, the debris and the fibrin remain behind. Soon the outside of the clot is j^erforated by numbers of living leucocytes, many of which may be seen to contain fragments of colored ones in their interior. Gradually this change extends farther and farther toward the centre, until by degrees the whole mass is consumed, and nothing is left but the leucocytes which have replaced it. These changes are not without their effect upon the parts around. More work has to be done ; a greater amount of blood is required, and consequently all the neighboring vessels dilate, the temperature of the part is raised, the .skin is reddened if it lies near the surface, there is a certain amount of tenderness on pressure, and a certain degree of swelling, caused not only by the extravasation, but by the increase in the quantity of the blood and the circulating plasma that the part contains. Further, the quantity of waste and dead material to be absorbed is larger than usual, and, as a consequence, the temperature of the w^hole body is slightly raised, for there is evidence to show that the ferment set free when the tissues undergo disintegration acts upon all the heat-producing centres. All the nutritive changes, in short, are carried on with more than the usual degree of energy. The next step is the formation of fresh blood-ve.ssels. It is possible that when the injured area is exceedingly small, the leucocytes may derive sufficient nourishment from the circulating plasma : but if it is of more than the most minute dimensions, and new vessels are not formed, the young cells near the centre starve and undergo fatty degeneration. In all cases they develop from pre-existing capillaries. Conical processes spring from the walls, and grow out among the masses of leucocytes, until they join other processes or other vessels. At first they are solid, but even while they are growing a hollow makes its appear- ance at the ends, and gradually spreads farther and farther until there is a minute central canal down the whole length. This enlarges sufficiently to admit the red corpuscles ; then nuclei appear in the wall ; and a perfect capillary is formed, ready itself to become the starting-point for others, until the mass of growing leucocytes is supplied with loops of vessels, spreading into it from all sides and converging toward the centre. This is known as vascula?- gratmlation-tissue , from the peculiar appearance it presents when it is formed upon the surface of a wound expo.sed to the air ; by it all the broken-down tissue and extravasated blood are removed, and from it is developed the newly formed tissue which ij? to replace the old. Many of the corpuscles of which it is composed closely resemble pus-corpus- cles, and prol)ably, like them, are dead. They are round, motionless, slightly granular, with a bifid or trifid nucleus, which becomes more distinct on the addition of acetic acid. These disappear, very possibly consumed by those around. The living ones are larger, with clear oval vesicular nuclei, and. from the resemblance they bear to epithelial cells, are sometimes called epithelioid. Organization always begins near the normal tissue, where the effect ot the irritant is scarcely felt. The living cells enlarge, become spindle-shaped or 3° GENERAL PATHOLOGY OF SURGICAL DISEASES. branched, and range themselves in bundles alongside or round the vessels {fibro- blasts) ; then their borders and ends become fibrillated, other fibrils make their appearance in the matrix between them, many of the nuclei disajjpear, others persist as small oval corpuscles, and a little mass of fibrous cicatricial tissue is formed, abundantly supplied with vessels. A few multinuclear giant-cells may generally be found, formed either by the division of nuclei without proportionate partition of the cell-body, or by the blending and coalescence of contiguous corpuscles. When the process is very chronic and the vessels few in number, as. in the case of infection with tubercle, the tendency to their production is very much greater. The process of organization after a single injury gradually extends through the whole thickness, begin- ning at the circumference and converging toward the centre, until the whole area of granulation-tissue is transformed. If the injury was an open wound, mod- ifications naturally take place for the production of a protecting layer of epithelium, but this will be dealt with later. The newly formed tissue at first is highly vascular ; by degrees, however, the bundles of fibrils contract more and more, and obliterate the vessels to a great extent. In simple injuries the amount is always small — the minimum, in fact, required to re- p , r cu ui . ■ jf move and replace what is dead, and the degree of Fig. 1. — A group of fibroblasts in dil- \ _ ' o ferent stages of growth, a, embryo contraction is never serious. When, on the other ing ^^^^^^ ^j^g tissues have been extensively destroyed by suppuration, the quantity may be so great, and the tendency to contract so inveterate, as to cause the most serious deformity. cell wandering. Bird.) Thk Effect of Continued Irritation. A transient irritant, not sufficiently severe to kill the tissues, after its first effect has subsided, acts as a stimulus on all the structures round ; they begin at once to act with greater energy, and strive their 'utmost to repair the damage that has been done. The same thing occurs when the irritant is a persistent one — the tissues throughout keep doing their best to repair the injury inflicted on them ; but there is this great difference, that in this case the irritant, instead of being a thing of the past, is hard at work the whole time, sapping the vitality of all the structures near, and diminishing their power of resistance. The whole time the irritant continues there is a contest between it, on the one hand, and the tissues on the other. These, by increasing the amount of the exudation that pours out through the walls of their vessels, keep striving to repair the damage already done, and to check the progress of the injurious agent, whatever it may be ; while this, so long as its power lasts, is engaged in destroying the exudation, weakening the tissues, and impairing their vitality. The sum of the changes produced in the conflict is known as inflammation ; as soon as the irritant ceases to act inflamma- tion ceases and repair begins. Symptoms of Inflammation. These are the same as those already described, but they are very different in degree. Redness, swelling, heat, and pain are present, as before, to a greater or less extent; the functional power of the part is lowered, and the temperature of the blood is raised ; but this is no longer Avithin physiological limits : now the changes are pathological, kept up by an irritant which is all the while at work, either impairing the vitality of the tissues, and causing inflammation, or killing them. In inflammation of a superficial part all these signs are usually present and JNFLAMMA TION. 3 1 eiiually well-marked, and the diagnosis is clear ; in other cases, however, especially when the part is deejjly seated and the irritant of low intensity, there may be only one, and then the ditificulty is very great. In such, a diagnosis can often be made only by a process of exclusion, or by actual exploration. Redness. — The color may be brilliant, returning instantaneously if driven away by pressure, or livid and almost purple, as round the margin of old sinuses. In severe ca.ses the blood-vessels give way, leaving ecchymoses, which after a time (especially if they are rei)eated) turn a dull red-brown. A pigment-stain produced in this way lasts for years, ])articularly when it is upon the legs. If, as in perios- titis of the femur, the inflamed ]>art is deeply seated, the color of the skin remains unaltered, or is even whiter than natural, from being stretched by the effusion beneath. Swelling is never al)sent, although if the part is thickly covered in, it may not be detected. At first it is due simply to the distention of the vessels ; but this is insignifi- cant in comparison with the exudation that follows. The rapidity with which it forms and the degree of firmness it presents to the touch, depend upon the anatomical arrangement of the tissues and the character of the exudation. The more open the tissue, the more quickly it takes place and the softer it feels. Structures, there- fore, like the eyelids or scrotum, easily assume enor- mous dimensions. On the other hand, when the exudation is bound down beneath a layer of dense and close fibrous tissue, such as the periosteum or the deep cervical fascia, it may be, for a time at least, as dense and resistant as bone, although if firm pressure is used, it wall always yield a little, forming a sharply defined pit which slowly fills up ic 2.— lape esis. again. The character of the exudation varies with the nature and intensity of the irritant. It may be serous, with but few leucocytes and little tendency to form fibrin — almost the same, in short, as that which is present in health ; this is chiefly met with when the cause is a distant one — round the extreme margin of an ab- scess, for example. It may be sero-fibrinous ox fibrinous, consisting of little but a meshwork of fibrin formed from the plasma and enclosing the leucocytes in its meshes. Or it may he sero-purulent ox purulent, when, owing to the peptic action of pyogenic micro-organisms, no fibrin at all is formed, but only a mass of albu- minous liquid, with dead and dying pus-corpuscles floating in it. Distinct exam- ples of all of these are seen in serous and synovial cavities, but they are of frequent occurrence elsewhere, especially in the meshes of connective tissue. When the irritant is very intense, the walls of the capillaries perish, and the exudation becomes hemorrhagic. When, on the other hand, it is slight but per- sistent, as in the case of tubercle and syphilis, masses of granuiafion-tissue, with giant and epithelioid cells, are developed. Sometimes, after lasting a considerable time, this becomes absorbed ; more frequently, according to the cause, it either becomes organized, undergoes degeneration and caseation, or breaks down into pus. From this peculiarity these diseases are sometimes known as infective granulomata, granulation-tissue being ])roduced in masses of such size that they reseml)le tumors. Heat. — The temperature of an inflamed part is nearly always raised ; the only exceptions are the very chronic cases (and in these it is probable that a ther- mopile would detect some slight variation at one time or another) ; and some of the very acute, in which, owing to the early occurrence of stasis, the current of blood flowing to the part is greatly reduced — in short, in incipient gangrene. It is stated to be due, not to the increased local production of heat, but to the in- creased supply of arterial blood raising the temperature of the part almost to that 32 GENERAL PATHOLOGY OF SURGICAL DISEASES. of the interior of the body. Of course this may be far above the normah Care must be taken, when estimating the temperature of any part, to compare it, not with the normal temperature of the l)ody, but with the actual temj^erature of the corresponding part, placed under exactly the same conditions of clothing and exposure. Pain. — The severity depends upon the degree of tension. In acute inflam- mation of tough, fibrous structures, or where, as when bone is concerned, there is great resistance to expansion, it is exceedingly severe, and is made infinitely worse by anything that increases the current of blood in the part — allowing it to hang down, for example, or using it in any way. Under these circumstances, especially when suppuration is imminent, it is often described as throbbing, each throb corresponding to a beat of the heart, and to a fresh amount of blood driven into the part. The character of the pain depends more upon the tissue concerned ; thus bones and ligaments ache \ the skin smarts and burns ; and the eyes become intolerant of light. In very severe cases the pain may cease altogether toward the end, owing to the failing power of the brain. Impairment of the function of the part is often one of the most valuable Fig. 3. — Stomata of the Capillaries. (After Duplay and Rectus.) Fig. 4.— Dilatation of Capillaries. signs ; an inflamed joint, for example, is held rigid by the muscles, and cannot be moved to its full extent in any direction. In the same way absorption and secre- tion cannot be carried out if the mucous membrane of the bowel is inflamed, and peristalsis is stopped if the serous and muscular coats are attacked. All work increases the amount of blood in the part, causes varying degrees of tension to fall upon the tissues, and makes the pain and inflammation more severe. Fever. — In addition to these local signs, inflammation is always attended by a certain degree of fever. The temperature of the body, w^hich normally ranges from 97.5° to 98° in the early morning, to 98.5° and even 99° of an evening, is raised; the pulse is quick and hard ; the respiration is hurried; the tongue and mouth are dry ; the appetite is lost, and all the secretions are dmiin- ished. The skin is hot and parched, the urine is .scanty and high-colored, and the bowels constipated. Sleep is disturbed ; headache is always present ; delirium is usual (especially at night) when the temperature is raised more than three or four degrees, and the loss of flesh and strength is rapid and extreme. The cause of this fever is mainly the increased production of heat ; in com- parison the diminished loss by the skin from the absence of evaporation is altogether insignificant, and this increase results from a greater degree of activity in the INFLAMMA TION. 33 metaliolism of the ])arenchymatons tissues of the body, the muscles and glands in ])arti(-ular. So much is clear from the rapid emaciation and loss of strength, and from the increase in the amount of carbonic acid and urea eliminated. The way in which this increased metabolism is brought about is not so defi- nite. In all i)robability the changes that take i)lace in the tissues are under the control of the nervous system ; it seems likely that the sujjreme centre is in the corte.x of the brain, probably in the parietal region; that there is another in the medulla oblongata ; and, as in the case of the vaso-motor system, others still — subsitliary ones — in the spinal cord. Possibly also, carrying the analogy further, the tissues themselves are not altogether devoid "of influence, at any rate when isolated from the main command. In fever it is believed that normal control over the metabolism is enfeebled, and that the tissue-changes are carried on at a much more rapid rate, with increased production of heat as a natural consequence. This undue activity of the metabolism is, in some cases, excited by peripheral stimuli ; tension, for example (even such an ajjparently trivial matter as a suture drawn too tightly), is undoubtedly a very powerful stimulus, although it must not be forgotten that it helps as well by promoting the al)sorption of fever-causing substances from the tissues. Mental emotion is another, and i)ossibly this ex])lains some of the mysterious cases of local hyperpyrexia. By far the most powerful cause, however, is the absorption, through the blood or through the lymphatic system, of certain products, which either weaken the control of the nerve-centres that preside over metabolism, 'or stimulate the tissues to increased change. In other words, pyrogenous agents, as they are called, act either directly or reflexly ui)on the heat-regulating centres in the central nervous system, impairing their power of control ; or upon the tissues themselves, stimulating them to increased activity. Of substances that possess this power there is no lack. Broken-down blood- clot, even when a wound is subcutaneous, is one, the active constituent being, so it is said, the fibrin-ferment. The products of putrefactive fermentation possess it in a very much higher degree, causing septic traumatic fever or sapraemia, accord- ing to the nature of the ptomaine produced, and the quantity that enters the cir- culation at once. Many varieties of infective germs are still more active, multi- plying in the tissues and the blood-stream, and forming substances which cause the most severe constitutional symptoms ; and in all likelihood the fever that accompanies simple inflammation (not due to putrefaction or to any infective germ) is mainly caused in the same way, partly by tension, but chiefly by absorp- tion through the lymph-stream of substances produced in the tissues under the action of various kinds of irritants. The character and severity of the fever depend upon the cause. Age is of some influence, as during childhood, when the metabolism of the tissues is most active, sudden and severe attacks are not uncommon after very slight causes. Sex, and what is known as temperament, may also have a certain effect. In the chronic forms of inflammation it is very slight ; in acute ones it may be sthenic, asthenic, or irritative. In the sthenic form the symptoms are acute, the temperature high, 104° or 105° F. , and the pulse full, strong, and bounding. The onset is usually sudden, and often marked by a shivering fit or rigor, or, in the case of children, by an attack of vomiting or convulsions. The asthenic may either succeed to this, or may commence as such, quietly anci insidiously. Sometimes it is attended with sloughing, but in many cases the local signs are very slightly marked. From the first, what are known as typhoid symptoms set in ; the patient lies overcome with stupor, or in a condition of low muttering delirium ; the .skin is hot and dry ; the face dusky and pinched, with sunken eyes ; there is sordes on the lips and teeth ; and the tongue is dry and brown, or red and cracked. Diarrhoea is often present, the motions being passed unconsciously ; and frequently there is albuminuria. The pulse is small and quick, and the respiration hurried and shallow, but the temperature is rarely very 34 GENERAL PATHOLOGY OF SURGLCAL DLSEASES. much raised, and it may even be sul)normal, especially toward the end. This variety is only met with where the patient's health is utterly broken down from intemperance or other causes, or where an irritant poison is absorbed in overpower- ing quantity, as in septic peritonitis following operation. Irritative fever is less well-marked ; one chief characteristic is the early occurrence of delirium, and the prominence of the nervous symptoms. The fever is said to be continuous when the daily variations do not exceed 2° F.; if it is greater than this it is called remittent. In the intermittent form there are periods (which may or may not be regular, and which vary greatly in dura- tion) during which the temperature does not rise above the normal. Varieties of Inflammation. These are the signs common to all forms of inflammation ; they are an indica- tion of the changes that take place in the living tissues while they are being irri- tated by some cause not sufficiently powerful to kill them, and they occur in all alike, so far as structural conditions allow. In part they are the direct effect of the injury lowering the vitality of the tissues upon which it is acting ; in part they are due to the efforts at repair made by the living (uninjured) elements around ; if the irritant is the stronger, destruction progresses more or less rapidly, and the fever is high, and the part red, swollen, and painful ; as its influence begins to wane and the tissues gain control, this diminishes, and when its action ceases, the fever and the other signs disappear altogether ; there is noth- ing then to hurt the tissues further, or prevent them regaining their former activity ; all pathological changes come to an end, and the natural process of repair removes all trace of morbidity so far as is possible. The extent of the changes in inflammation depends upon the condition of the tissues on the one hand, and the intensity of the cause on the other. The character depends upon the nature of the irritant. A very trivial injury, for example, may give rise to the most serious conse- quences if the nutrition of the tissues is enfeebled from disease or intemperance ; but mechanical irritants can only cause simple inflammation ; suppuration cannot occur without pyogenic organisms, and tubercle cannot appear without its specific bacillus. The tissues, in their endeavor to limit the action of the irritant, always produce the same exudation, but the changes this undergoes under the influence of different irritants, and under different conditions, naturally differ and give rise to different varieties of disease. A so-called croupous or diphtheritic exudation is occasionally met with upon the surface of granulating wounds. It forms a buff-colored rind which may be peeled off easily, leaving a raw surface, which usually heals readily if brushed over with nitrate of silver or iodine. Sometimes, however, it is reproduced again and again, and it may extend, to a serious degree, especially on burns. Probably it is due to coagulation-necrosis, caused by the action of certain germs, involving the exudation and, in the diphtheritic form, the tissues themselves sometimes to a consideraV)le depth. True diphtheria very rarely attacks wounds ; when it does it is usually caused by direct infection (though, curiously enough, tracheotomy- wounds are seldom contaminated), and the clinical symptoms and sequelae resemble those of the ordinary form, allowance being made for the difference in locality. [Summary. — Inflammation is due to irritation of the tissues by living organisms, chemicals, or mechanical violence ; its symptoms are redness and swelling with heat and pain (Celsus), and its pathological anatomy shows the stages of hyperccmia, stasis, and diapedesis.] INFLAMMA TION. Simple Inki.ammaiion. 35 The causes are nierhanical, physical, or chemical irritants, sufficiently severe to injure the tissues without killing them outright ; a suture, for example, drawn too tightly, a burn or scald exposed to the air, constant friction, or long-continued irritation by dust or smoke. I'he symptoms are those already described : red- ness, swelling, heat, and pain, with imjiairment of function and fever, varying according to the size and importance of the part involved, and the acuteness of the attack. They may be so intense as to endanger life, or so slight as to be scarcely perceptible. Simple inflammation may end fatally, or undergo resolution, or become chronic. The exudation may become absorbed, organized, or undergo fatty degeneration. Sui)puration is a complication due to the action of certain micrococci. (rt) Death may l)e caused by the intensity of the fever, by exhaustion, or by the organ that is attacked being essential to life, as in the case of the glottis or the heart. (J)) Resolution. — If the nutrition of the part is good, this begins as soon as the cause is removed. The pain and fever cease ; the temperature of the part, although still above that of the corresponding one, owing to the amount of blood it receives, is well below fever heat ; the swelling disappears, except so far as it is caused by the increased flow of blood and plasma necessary for repair ; and the redness loses its angry tint, although the blush persists for niany months if new vessels have been formed. The amount of granulation-tissue and .scar-formation depends upon the extent of the disease. It may be so little as to be practically imperceptible, as after a bruise or a simple incised wound, or it may be of any extent. (r) Persistenee. — If the cause is frequently repeated, or if, without being too severe, it continues to act, the inflammation persists and is very liable to become chronic. This is especially likely when constitutional predisposing causes, such as gout and rheumatism, are present ; the attack commences with some slight irritant, such as would not be noticed if the tissues were healthy, and the morbid state of the nutrition is sufficient to prevent resolution after the original irritant has ceased to act. General Principles of Treatment. Inflammation is the result of an injury sufificiently severe to impair the vitality of the tissues without killing them outright. The first thing, therefore, is to prevent, as far as possible, the access of any irritant (preventive, treatment), and the next to remove any source of injury that may be present, to strengthen and maintain the nutrition of the tissues, and to place them under the most favorable conditions for resisting and overcoming anything that affects them injuriously. I. Preventii'e. A single uncomplicated injury is not followed by inflammation ; the process of repair begins at once, and if there is no other irritant and the damage is not too extensive, is completed without the surrounding structures suffering in the least. Inflammation is the result of continued irritation — either local, such as that caused by the presence of foreign bodies, by tension, friction, want of rest, or putrefaction ; or constitutional, resulting from some morbid condition of the blood or tissues, as in gout. The preventive treatment, therefore, except in so far as it is possible to improve the nutrition of the tissues and place them in a more favorable condition, practically resolves itself into the treatment of wounds and other injuries. 2. Curative. I. Removal of the Cause. — Foreign bodies must be removed ; tension relieved by dividing sutures, making incisions, and providing the freest possible T,6 GENERAL PATHOLOGY OF SURGLCAL DISEASES. drainage ; and friction prevented by aljsolute rest. Pain must be allayed, and any irritant in contact with the surface, whether it is an over-powerful antiseptic or the products of putrefaction, either removed or rendered innocuous. Some- times, when the inflammation is due to the action of a powerful local irritant, as in phagedsena, the surface must be destroyed, and occasionally certain drugs are employed which may possibly act directly upon the cause — mercury, for example, in syphilis, and colchicum in acute gout. 2. Where the cause cannot be removed, the symjitoms must be treated. In other words, an attempt must be made to regulate the quantity and quality of blood flowing through the part, so that the nutrition of the affected tissue may be maintained as well as possible. The means at disposal are local and constitutional. Local Remedies. Rest. — The more the i)art is used, the greater the amount of blood flowing to it and the greater the tension. To be of any use, however, the rest must be complete. Position. — The effect of allowing an inflamed limli to hang down is well known. Raising it assists the venous and lymphatic circulation, and at the same time lessens the amount of blood entering it, by causing a vaso-motor constriction of the arteries. Pressure. — Uniform, gentle, and ela.stic pressure, such as that produced by investing the part with many thicknesses of cotton-wool, and then placing a band- age over the whole, is a most efficient method for diminishing pain and tension even in cases of phlegmonous inflammation. In a few instances pressure has been applied to the main artery of a limb with the same object, and the femoral has been ligatured in cases of acute inflammation of the knee-joint. Cold is a most powerful agent for checking the amount of blood flowing through a part. It may be applied either by means of an ice-bag, or by Leiter's coils of leaden tubing, arranged to fit closely round. In other cases, lead and spirit lotion is allowed to drip slowly over the part and evaporate, the surplus being carried off by means of properly arranged rubber sheets beneath. It checks protoplasmic movement, lowers the vascular tension by causing paralytic dilatation of the walls of the smaller vessels (at first there is a temporary constriction), and if applied continuously and with sufficient vigor, can stop the circulation alto- gether. In some cases, as for instance with tubercle-bacilli, it possesses the power of retarding development, but, at the same time, when carried far enough for this, there is great danger of its depressing the vitality of the tissues too. It may always be used in the early stages of inflammation, and very often throughout in the sthenic form, especially when the local symptoms are well-marked (as, for example, in quinsy) with a view of limiting the hyperaemia and, if suppuration occurs, reducing the size of the abscess ; but in the asthenic form it should always be avoided. An icebag laid along the course of the main artery at a distance from the seat of inflammation is sometimes of considerable value. Warmth acts in the opposite way ; it stimulates amceboid movements, causes the walls of the vessels to dilate, and gives freer passage to the blood. Applied to the spot itself it diminishes the tension in the tissues, and in the early stages may procure resolution ; but if suppuration is imminent it only encourages it. Advantage is taken of this when it is wished to make an abscess point. When used over a more extensive surface, it diverts a larger portion of the blood that would otherwise flow through the inflamed area, and, by relaxing the tissues, facili- tates the return through the veins and lymphatics. Whether heat or cold should be applied locally may be left, to some extent, to the patient's feelings, but not altogether. The former is usually selected, as it diminishes tension and pain more quickly ; but if the latter is continued for a little time, especially when the inflammation is acute and .sthenic, the relief is, INFLAMMA TION. 37 generally speaking, nnuh more complete. Whichever is chosen, the application must be continuous; any intermittence, especially in the case of cold, makes matters infinitely worse. [The late Professor Allen explained that either heat or cold, cotitimiously applied, is a sedative ; intermittently applied, a stimi//ant.'\ Astringents are chiefly used over the surface of mucous membranes. Lead, however, if ajjplied to the skin for any length of time, becomes absorbed (as shown by the discoloration) and acts directly u[)on the cajjillaries and small vessels. Local bleeding in acute inflammation is of the greatest service, although it is very difficult to explain why. It cannot be the amount withdrawn, for this is usually altogether insignificant. Leeches may be used (not, however, over any loose tissue, such as the eyelid or scrotum ; in orchitis they must be placed on the groin) ; superficial veins may be punctured ; or small incisions made here and there in the axis of the limb, taking care to avoid any important structure. The last method is especially useful in phlegmonous inflammation of the cellular tissue, when there is any danger of sloughing, to relieve the tension on the skin. The bleeding may be encouraged afterward, if necessary, by means of a warm bath. ^A^et-cupping is rarely practiced now ; but dry-cupping may be employed with benefit in inflammation of deep-seated organs such as the kidneys. The air in a cupping-glass is rarefied by holding it like a bell over a large spirit-lamp, or by burning a small quantity of spirit inside, and then the mouth is quickly pressed against the skin, taking care not to burn the patient. As the air condenses, the tissues rise up in a convex dome, partly filling the cup, the cutaneous vessels become distended, and many of the smaller ones rupture. Counter-irritants. — Rubefacients, blisters, Scott's dressing, and the actual cautery are chiefly of use in the chronic forms. Li all probability they act re- flexly upon the deeper vessels, as the mere local dilatation and exudation can have but little influence. Belladonna (the extract mixed in varying proportions with glycerine) is sometimes applied with benefit over very large areas. There is no fear of too great absorption through the skin, but abraded surfaces must be avoided. It cau.ses a slight temporary constriction, but this is soon succeeded by a more permanent dilatation, lowering the tension and relieving the pain. Constitutional Measures. Diet is of great importance. The waste in all forms of inflammation is very rapid, and at the same time the appetite and the power of digestion are very much impaired. Solid food is out of the question in acute cases. Light diet, milk, beef-tea, arrowroot, and other farinaceous foods, jelly, milk-puddings, and the like, are sufficient in cases of sthenic inflammation of short duration. If, however, the attack is of long duration, or if, as in erysipelas, the area involved is extensive, the strongest meat -jelly, eggs beaten up with milk, brandy, and tgg mixture, pep- tonized foods, and similar substances that are easily absorbed, must be given in small quantities at frequent intervals, even when the patient is young and was previously healthy. In older people, and those whose health is broken down, nourishment is still more imperative ; and it is then that stimulants are of value, enabling the patient to make the most of what is taken with the least exertion. Great care, however, is required not to overdo it. Fluids are given throughout as required. Fragments of ice may be sucked from time to time, to allay the parched condition of the mouth, but it must be remembered that a considerable quantity of water is swallowed in this way. Barley water, lemonade, and acid fruit drinks are often very grateful, and, in moderation, do no harm. In the more chronic cases — in tubercular inflammation of joints, for instance — a great deal may be done toward improving the quality of the blood, and the gen- 38 GENERAL PATHOLOGY OF SURGICAL DISEASES. eral nutrition, l)y means of good food, fresh air, tonics, and especially cod-liver oil. Sea-air in these cases is often of wonderful benefit, enabling the tissues to resist the action of the irritant until a less susceptible time of life is reached. Bleeding is rarely practiced, although in cases of acute suppurative arthritis, or in jjneumonia, when the other lung is becoming engorged, it is sometimes of great use, especially in young adults, the fever falling at once. In children or patients past middle life its ultimate value is very doubtful, although it may appear to help in tiding over a crisis. Purgatives. — In inflammation the bowels are nearly always constipated, and their action is followed by great relief. If the mucous membrane of any part of the alimentary canal is involved, this is different ; but in incipient peritonitis, with effusion, mild purgation has been strongly advocated. It must be remem- bered that the patient, as a rule, is taking only a small amount of food, and that of such a nature as to leave little residue, so that the constipation may be appa- rent rather than real. Aconite (one minim every five minutes until a distinct effect is produced upon the pulse) and antimony (given at fretpient intervals until it causes nausea) are sometimes given in young subjects at the commencement of an acute attack (when the heart is sound) with a view of producing general vascular depression. The latter drug is also used in smaller doses during the course of the fever, for the sake of its action upon the skin, and is frequently given for this purpose in conjunction with Dover's powder. Opium is often recpiired internally as well as locally, for the relief of pain or to procure sleep ; chloral, bromide of potassium, or strontium and sulphonal are chiefly of use as sedatives or hypnotics. If the tem- perature is very high, quinine, antipyrin, or salicylic acid is advisable, and the first named appears to possess the power of checking an incipient rigor. In hyperpyrexia cold-sponging, an ice-cap (Leiter's coils, arranged so as to fit the head, form the most convenient appliance, although a simple ice-bag made of thin rubber may be used) or even an ice-pack may be required ; but meanwhile, and for some time afterward, close watch must be kept upon the pulse, as sometimes, in these cases, the cardiac muscle fails rather suddenly. In some cases of high temperature alcohol has been given with considerable benefit. The condition of the pulse and of the heart is in general the best guide to its administration. It is not required in sthenic inflammation of short dura- tion in young subjects ; but in asthenic forms attended with sloughing and great depression, especially in old people, it must sometimes be given very freely to tide them over a critical period. In smaller quantities it is of great service in assisting digestion and enabling the patient to make the most of his food with the least expenditure, particularly during convalescence. Carbonate of ammonia in five- grain (.30) doses is especially useful when the tongue is dry and brown and the pulse is beginning to fail in strength and volume. Ether may be given at the same time. Mercury is used, and with benefit under many different conditions ; as a purgative at the commencement of an attack ; as an alterative, particularly in children, in the form of hyd. c. cret., or pulv. pil. hydrarg. ; in all stages of syphilis, more especially the early ones ; and locally, sometimes, as a counter- irritant. Colchicum, alkalies, iodide of potash, salicylate of soda, and other drugs are of benefit in special cases; and tonics, especially iron, quinine, and cod-liver oil, are usually required during the period of convalescence. Chronic Inflammation. Acute inflammation may become chronic merely from frecpient repetition, even when the tissues are healthy and without jtredisposition of any kind. Each time, for example, a loose cartilage is caught between the bones of the knee-joint, it gives rise to an attack of synovitis ; before the first one the tissues may have been perfectly healthy, and if it is the only one they may recover completely ; if, however, the injury is constantly being repeated, so that there is no time for INFLAMMATION. 39 jierfect rei)air, organir changes are left, nutrition is jjermanently impaired, and the synovitis becomes chronic. Constant friction acts in the same way ; the conjunctiva, for instance, l)e- comes roughened and granular ; the neck of a hernia hard and dense as cartilage ; and even the skin may be entirely altered in texture. In the same way the mucous membrane of the throat, instead of remaining soft and flexible, becomes covered with irregular elevations, and seamed with superficial cicatrices as a result of persistent chemical irritation of slight intensity. Chronic tension leads to a similar result. A leg in which the veins or lym- phatics are obstructed slowly increases in size, and becomes affected by what is known as solid (cdema, from the resistance it offers when pressed by the finger. The exudation becomes organized ; the amount of lowly developed fibrous tissue increases; the muscles waste; the skin is thickened, bound down, and hard, and at length a condition practically equivalent to elephantiasis is produced. Predisposing causes are of especial importance in connection with chronic inflammation. If they are strongly marked, an acute attack is almost sure to become chronic, whether the exciting cause is repeated or not. A single abrasion, for example, is sufficient in the case of a leg which is congested from long-stand- ing venous obstruction. The skin is badly nourished ; in certain places — ^just above the ankle, for example — it is scarcely able to hold its own ; if the cuticle is rubbed off, or a tiny vein gives way, or, in short, if there is the least injury, such as in any other part of the body- would not attract attention, inflammation sets in, the already weakened cells and fibres perish, and then, because of the presence of these dead structures, or the friction of the clothes, or the tension due to the very slight addition of blood to the part, it becomes chronic. The least cause is suffi- cient to depress the vitality of the tissues around and to prevent resolution. In gout and rheumatism, which are among the most common causes of chronic inflammation, the conditions are much the same. In each the nutrition of the tissues is so gravely involved that a very trivial cause gives rise to an acute attack, and sometimes the predisposition is so strong that an exciting cause is scarcely needed. At first the attacks subside and recovery is, to all intents and purposes, complete. ' After a time, however, the reparative power of the tissues becomes more and more impaired, the natural condition is never regained, and the inflammation becomes chronic. The predisposing causes have grown so strong that they are not only able to originate an attack with the very slightest assistance, but to maintain it, too. Symptoms. The general symptoms are the same as in acute inflammation, but much less severe. Increased heat is often scarcely to be detected ; the redness is always slight, although brown discoloration from long-standing hypersemia is often pres- ent, especially upon the legs, where gravity favors stasis ; and the pain more frequently takes the form of a continuous wearying aching, with every now and then a more severe spasm ; but even when suppuration occurs, it never assumes a tense, throbbing character. In the same way the fever is slight, and the loss of function much less noticeable, partly, no doubt, because other structures compen- sate for it, and the patient has had time to become accustomed to it. With swelling, however, the case is different. Exudation is always present, but only a small proportion of it is fluid ; nearly the whole is composed of organ- ized elements, many of them escaped leucocytes, but many more developed from the living cells in the tissues round. Whatever may be the case in acute inflam- mation, whether or no the tissue-elements take any share then in the production of the exudation, in the chronic form there is no doubt they do, and to a very considerable extent. Sometimes the part is greatly increased in size ; but not unfrequently, owing to retrogressive changes, its bulk is actually diminished ; either the exudation, after replacing the natural structures, itself undergoes degeneration and disappears, or it becomes organized into a lowly developed form 40 GENERAL PATHOLOGY OF SURGICAL DISEASES. of cicatricial tissue, which contracts, strangling the natural structures, and render- ing the organ it infiltrates hard, dense, irregular, and contracted. Organization is the prominent feature of the chronic inflammation that occurs in rheumatism. The articular ends of the bones are covered with dense irregular nodules \ the shafts in some cases are immensely thickened and hardened ; the fibrous tissue round the joints is toughened and rigid, and a similar change is met with in connection with the nerves, the walls of the arteries, and, in fact, any connective-tissue structure that is attacked. In chronic gout the ultimate effect upon the exudation is complicated by the addition of deposits of urate of soda. In some of these affections, in which the prominent feature is an immense overgrowth of the connective-tissue type, unaccompanied by pain, increased tem- perature, or fever, it is exceedingly difficult to draw a distinction between chronic inflammation and hyperplasia, especially as the remedies upon which reliance is usually placed here fail completely. Ostitis deformans is an example, and some of those cases in which the lymphatic glands are immensely enlarged without undergoing any definite alteration in structure. It is more than questionable, however, whether an attempt at such a refinement could succeed. In either case there is an impairment of nutrition, resulting generally in increased size, and always in imperfect development of the part, and caused by some morbid condi- tion of the tissues or of the blood. It is not possible to say whether this is to be regarded as the result of an irritant injuriously affecting one particular tis.sue, and acquired during life, or of some natural impairment born with the individual, and probably transmitted to him from his ancestors. Treatment. The principles of treatment in chronic inflammation are the same as in the acute form, but the details vary considerably. 1. Removal of the Cause. — In some few cases a definite exciting cau.se can be found and removed ; a sequestrum, for example, may be lying locked in the medullary canal of a bone, imable to escape ; or a band of lymph may be left tying down the margin of the iris. In the majority, however, the reason, if not for the outbreak, at least for its persistence, is to be found in the presence of some constitutional affection which does not admit of such speedy treatment. Mercury, given in small doses and for a sufficient length of time, may possibly act on the syphilitic virus as a specific, destroying it, or at least prevent it from having any further influence ; but very few other drugs possess this power. Potassium iodide, though it will remove the effects, certainly cannot stop recurrences, and the .same ma:y be said of colchicum in gout, and the .salicylates and alkalies in rheumatism. They relieve the symptoms for the time ; the exudation disappears and the pain diminishes ; but the cause is too deeply seated in the nutrition of the tissues to be removed in this way. 2. Improvement in Nutrition. General. — Many of the exciting causes are of very slight intensity ; and it often happens that if only the general nutri- tion can be a little improved, the tissues gain strength enough to deal with the irritant themselves. It is to this improvement, consequent upon the entire change of life and habits, that so many of the foreign bath resorts owe their reputation in gout and rheumatism ; and the effect produced does not subside at once. The i^articular line adopted varies, of course, with the complaint. With gout the diet should be sparing and light ; stimulants are better avoided, at any rate in the earlier periods of the disease ; the bowels should be kept fairly open, and any accumulation of uric acid in the blood prevented as far as po.ssible by abundance of fluid, combined with the moderate use of alkalies. Chronic rheumatism, on the other hand, is chiefly benefited by residence in warm, dry climates ; woolen clothing ; nutritive but unstimulating food, and the prolonged use of baths, especially sulphur ones, combined with internal administration. Tonics, particularly cod- INFLAMMA TION. 41 liver oil and iron, are often of use at the same time to combat the condition of ancemia which is frecjuently present. By measures of this kind not only is the immediate attack checked antl cureil, but the tissues are so built up that they are better able to resist injurious influences of the same character afterward, in spite of the general rule (which is especially true of this variety of inflammation) that one attack predis])oses to another. Local. — This must be guided very largely by the temperature of the part. Subacute attacks, in which the heat is considerable and the i)ain severe, should be treated as if they were acute ; but where the temjicrature is normal, or almost normal, those measures answer best which maintain an increased but uniform supply of blood. Warmth by itself is beneficial, but alternating with cold it produces a much greater effect. Pouring water down from a height, douche-jets, and needle-baths are exceedingly powerful, and are chiefly of use where the inflammation is past and only its effects remain. The same may be said of fric- tion, rubbing, and massage. Carried out efficiently these have immense influence upon the circulation ; the lymphatic spaces are emptied, the effete matter pressed out, the flow of plasma through the tissues quickened, and the nutrition greatly improved. Counter-irritants are of the greatest use in chronic inflammation, both for the relief of deep-seated pain and the diminution of tension by the absorption of the exudation. Rubefacients, vesicants, and even the actual cautery are employed, according to the depth of the structure it is desired to affect and the duration of the attack. How they act is uncertain, but that the effusion disap- pears, especially when they are repeated at frequent short intervals, there is no question. Setons, and other methods for causing continued suppuration, are rarely used now. Mercury and iodine are supposed to possess a special action in promoting the absorption of the products of chronic inflammation ; but, apart from the results they produce as counter-irritants, and in syphilitic affections, it is doubtful if they are not overrated. Potassium iodide, however, has a very considerable effect upon vascular tension. Superficial forms of inflammation — on mucous membranes, for example — ^are sometimes benefited by the action of local astringents ; and when there is a considerable degree of effusion, as in chronic synovitis, pressure, in con- junction with counter-irritation, may be applied with great advantage. 42 GENERAL PATHOLOGY OF SURGICAL DISEASES. CHAPTER II. DISEASES DUE TO NOX-IXFECTn'E ORGANISMS. Of these there are only two — septic fever and sapraemia. These diseases are caused by the absorption from the surface of a wound of certain poisons produced during the fermentation or decomposition of albuminous liquids. Probably they are ptomaines, analogous to the bodies formed in the alimentary canal. If they enter the blood, they act as virulent poisons, the sever- ity of the symptoms depending upon the amount of the dose : and they may cause a fatal result within a few hours. On the other hand, they do not multiply in the blood, which therefore is not infective if it is inoculated ; they are excreted slowly by the kidneys (ptomaines, probably formed in the alimentary canal, are found in the urine and saliva), and if the patient survives the iirst effect and the dose is not repeated, the constitutional symptoms gradually subside. There is no incubation period, and, other things being equal, a large wound, or one that exposes a large absorbent surface, such as the peritoneum, is much more likely to be attended with a .severe attack than a small one. Septic Fever. Subcutaneous injuries in which decomposition (in the sense of putrefaction) never takes place are often followed by a certain degree of fever, due either to tension or to absorption from the seat of injury of some of the products of tissue destruction, of which the " fibrin-ferment " is one, and, perhaps, the most import- ant. It sets in very shortly after the injury, attains its maximum within twenty- four hours, and then, unless some other irritant is present as well, begins to fall again. In addition to this, however, wounds that are exposed to the air are liable to be followed by another and more severe disorder caused by absorption from the surface of the products of decomposition. This does not commence for some days, generally two or three after the injury ; then it rapidly attains its maximum, persisting for three or four more, and at the end of the fifth or sixth, if the wound is thoroughly drained, the tissues healthy and well nourished, and no complication arises, begins to subside again. Naturally, septic fever rarely occurs by itself; in by far the majority of cases it follows the true traumatic fever before this has had time to disappear, and in its turn is followed by that which accompanies suppuration. At the commencement there is often a feeling of chilliness, but rarely a distinct rigor ; nausea and vomiting are not unusual ; there is headache, with extreme depression ; the temperature rises to 102° or 103° F.; the skin is hot and dry, the face flushed, the bowels confined, and the tongue thickly furred. The appetite is completely lost ; the pulse is full and rapid, and, especially in the case of children and people with an excitable temperament, there is often slight delirium at night. The edges of the wound are red and swollen ; the skin for some distance around is exceedingly tender and very hot ; while the surface, if it is visible, is probably covered over with grayish-yellow sloughs, and discharges a thin, turbid, and somewhat offensive fluid. Treatment. — The first thing is prevention. If it is too late for this, further decomposition must be stopped, either by irrigation with an antiseptic, or, better, by placing the part, if it can be done, in an antiseptic bath ; but I have known a sloughing wound of the hand remain for three days in a corrosive subli- mate bath (i in 5000, renewed every three hours) without the smell being over- come. SEPTIC FEVER— S APR ^ MIA. 43 In addition to this, the absorption must be stopped as soon as possible by the most thorough drainage and by encouraging the wound to secrete. Warm fomentations and warm baths are especially grateful ; the tension is relieved ; the throb])ing pain sul)sides ; the blood circulates more easily; the plasma and the leucocytes pour out more freely through the walls of the vessels ; the process of destruction ceases, and a barrier of vascular granulation-tissue is formed, to throw off dead cohering fragments and prevent the absorjjtion of any more of the poison. If the tension is completely relieved, the temperature falls to normal ; if, on the other hand, the discharge is retained, it rises regularly of an evening, assuming the remittent type as suppuration follows, and gradually passes into hectic. Constitutional treatment should not be neglected, but so long as the cause continues at work, it can give but a very small measure of relief. Sai'r.f.mia. Sapra;mia, or septic intoxication, is the name given to the most intense variety of septic fever. It occurs under the same conditions and is caused in the same way — by the absorption from the surface of a wound of some ptomaine formed during fermentation. Probably the particular variety is not always the same and certainly putrefaction, with the formation of offensive gases, is not necessary. Clinically, it is probably very rarely met with by itself; but, like the preceding, it is present as a complication in all extensive wounds, especially tho.se in which a large amount of blood is allowed to accumulate and undergo decomposition exposed to the air. Substances of a similar character are formed in the decomposition of pre- served meats, sausages, and the like, and when swallowed cause all the symptoms of violent irritant poisoning — vomiting, purging, etc., followed by profound col- lapse, coma, and, if the dose is sufficient, death within a very few hours. The constitutional symptoms resemble to some extent those of septic fever, but they are much more severe. In most cases, those especially in which putrefac- tion is present, the wound is acutely inflamed ; but I have known it, after an amputation through the knee-joint, progress, to all appearance, as well as could be wished, while the patient's temperature was gradually rising higher and higher and the pulse becoming weaker and more feeble. The only local sign to attract attention was the presence of a thin serous discharge in enormous quantities. Much more frequently, however, putrefaction is present, and various forms of infective germs as well. The pathological appearances present no distinctive feature of any kind. The blood either does not coagulate or else forms a loose, soft, black clot which readily breaks down. The lining of the vessels and the endocardium are often stained, and sometimes marked by actual ecchymoses, which also occur on the serous surface of the viscera, and at times in their interior. The spleen is enlarged and softened ; the liver and the lungs are congested ; the structure of the viscera, on section, is confused and blurred, especially in the case of the kidneys ; and the mucous membrane of the alimentary canal is frequently in a condition of acute inflammation, especially if the poisonous substance has been swallowed. When it is slowly absorbed from the surface of a wound, intestinal lesions are not usually present in man, though they are not uncommon in the case of animals. Decomposition after death, as in many other forms of sei)tic diseases, is unusually rapid. At the commencement there is usually a rigor or an attack of vomiting ; the temperature sometimes rises rapidly, without any apparent reason, to 104° or 105° F.; sometimes, on the other hand, especially in the more severe cases, it rises a little at the first, and then falls again, even becoming subnormal. The pulse is quick and feeble, the respiration hurried and shallow. The extremities are cold, while the trunk, perhaps, is burning hot ; the tongue is dry and brown, and the lips and teeth covered with sordes. Diarrhoea, with blood-stained stools, is usually 44 GENERAL PATHOLOGY OF SURGICAL DISEASES. present in artificially-produced saprcxmia, but is not frecpient in man. As the tem- perature rises the patient becomes delirious ; the prostration is extreme ; the pulse is almost imperceptible ; the forehead becomes covered with perspiration ; the face grows more and more dusky, and at length, if the dose is sufficient, or if it is repeated, the patient sinks into a state of collapse, and the heart fails com- pletely. Treatment. — The local treatment, as in the case of septic fever, consists simply in thorough drainage, combined with the use of antiseptics. If the wound is on one of the extremities, nothing is more successful than a corrosive sublimate bath (one part in 5000) ; if this is impracticable, it should be thoroughly irri- gated, great care being taken not to injure the surface. The object is to prevent further fermentation and absorption ; if this can be accomplished, and the patient's kidneys are sound, so that the poison is eliminated, the prognosis is good, in uncomplicated cases. Unhappily, sapraemia is usually merely an addi- tion to other even more serious affections. It has been suggested that where any definite nervous symptoms are present, which it is known can be counteracted by the action of other alkaloids^-dilata- tion of the pupil, for example — an attempt should be made in this direction ; but cases in which this would be practical must be very rare. After the acute symptoms have subsided, the anaemia and exhaustion left must be combated by iron, tonics, and a nutritious diet. Affections similar to septic fever and sapraemia are stated to have been caused by the injection into the blood of pepsin, trypsin, and other unorganized ferments. [Surgical (Traumatic) fever is the designation applied to the ephemeral fever which frequently appears after a wound or injury. It is due either to the absorp- tion of minute debris of tissue necrosis or to their oxidation. Intestinal Toxemia is a term used to designate a condition in which the ptomanies of putrefaction are absorbed from the intestinal walls, and thus enter the circulation. Metastatic abscesses may arise in this way. Intoxication from this source with pyrexia may be confused by the observer with sapraemic and septicaemic processes.] SUPPURATION. 45 CHAPTER III. DISEASES DUE TO INFECTIVE ORGANISMS. Pathogenic organisms are divided into two distinct classes, specific and non- specific. The former are always followed by the same di.sorder under whatever circumstances they occur, whether they cause local and constitutional symptoms (anthrax, syphilis, etc.), or constitutional ones only (hydrophobia and tetanus) ; the latter, the non-specific ones, according to the modes of infection and the condition of the tissues, give rise to a variety of diseases — suppuration with its consequences, hectic and albuminoid degeneration, ulceration, gangrene, phage- daena, pysemia, and many others. I. NON-SPECIFIC. SUPPURATION. It is still open to question whether suppuration can occur from merely mechanical or chemical irritants, however persistently they act. As a matter of fact, as Ogston was the first to show, certain forms of organisms — staphylococci or streptococci in the vast majority of cases — are invariably present in acute abscesses, whatever share they take in their cau.sation. They enter either through a wound or through the mucous membranes, and travel by means of the lymphatics or blood-vessels. Some (staphylococci for the most part) lead to circumscribed abscesses ; others (streptococci) spread by the lymphatics and are followed by diffuse suppuration. If the tissues are healthy they can do nothing — either they are killed or discharged in the urine. (It has been suggested that some are got rid of by the medium of the parotid, thus offer- ing an explanation of the extreme frequency of what has been called parotid bubo after operations and in the course of pyaemia ; but it is at least equally possible that the organisms enter the gland through the duct.) If, however, they are arrested in a part the nutrition of which is impaired by injury of any kind — mechanical, chemical, or physical — particularly if there is any extravasated blood ; or if, as in pyaemia, they are present in such numbers that whole districts of capillaries are simultaneously plugged, further changes take place in the surround- ing tissue and suppuration begins. The effect is most characteristic in cases of simple inflammation. The blood in the centre of the affected area has ceased to move ; in the rest of the vessels it is circulating very slowly ; the plasma round the injured cells has coagulated, and all round the tissues near are in a state of immense activity ; the vessels are dilated, the volume of plasma is increased, the number of free leucocytes is greater than ever, and every effort is being made by the developing granulation- tissue to absorb and replace the damaged structures. Suddenly a mass of staphy- lococci is brought to the part, either through a wound or the blood-stream. In the stagnant plasma and among the injured tissues they find a most favorable soil ; the structures among which they lie at once begin to lose their distinctness of outline, the fibres swell up, become homogeneous and almost translucent ; the leucocytes perish, and a ring of what is called coagulation-necrosis forms round the ma.ss of germs and spreads wider and Avider. After a time the centre becomes licjuid, and then a minute abscess is formed, lying in the middle of the inflamed tissues. Many of these small foci are usually situated close together, and, as they extend and widen, the intervening barriers soon break down. Meanwhile, the tissues farther away from the irritant strive to protect them- selves by throwing out a wall of lymph. At first, while the infection is still active, 46 GENERAL PATHOLOGY OF SURGICAL DISEASES. this melts away as rapidly as it is produced, the leucocytes perish and drop off as pus, and the debris of the tissues and the plasma (which is prevented from coagu- lating by the ptomaines) add to the amount. By degrees, however, the activity of the germs decreases, the wall of living leucocytes grows thicker, new vessels are developed from the dilated ones around, and at length a " pyogenic membrane " [limiting fibrine] is formed and the spread of the suppuration is checked. It rarely happens, however, that it is stayed altogether. Owing to the extreme hyperaemia in all the parts near, the tension of the fluid in the interior is unusually high, and, aided by this, the action of the germs remains sufficiently powerful to continue the destruction in the direction of least resistance. Sometimes, owing to the presence of dense sheets of fascia, the pus spreads laterally for immense distances among the tissues ; but sooner or later its course turns toward the surface, the skin or mucous membrane, as the case may be, gives way, and the abscess breaks and discharges its contents. [The law in regard to the " pointing " of an abscess is that pus is forced to the surface in the line of least resistance.] When the nutrition of the tissues is impaired by intemperance or prolonged residence in foul air, in pyjemia, and during convalescence from exhausting illness, suppuration sometimes occurs without local injury. The capillaries are plugged with micro-organisms at some small spot, and the walls of the vessels themselves are the first to perish and melt away. In such cases as these, or when the streptococcus pyogenes gains early access to the lymphatic spaces and spreads through them before the tissues can resist, a pyogenic membrane is never formed ; the suppuration is diffuse ; the strength of the tissues is so enfeebled that they disappear before the invading germs, unable to protect themselves by a barrier of any kind. Abscess, or Circumscribed Suppuration. Abscesses are acute or chronic, according to the intensity of the symptoms by which they are attended and the rapidity with which they spread. The latter are probably due to the same causes as the former, acting under less favor- able conditions. Those, however, that result from the softening and liquefaction of masses of caseous material must be distinguished ; they are al\\-ays associated with the presence of specific germs, and for a long time, at least so long as they are chronic, do not contain true pus. It must be admitted that it is not always easy to draw a definite line between them. Pus from an acute abscess in an otherwi.se healthy person is a thick, creamy, opaque, yellowish-white, or greenish fluid, with an alkaline reaction and a specific gravity of 1030 to 1035. ^^"^ color is due to the presence of small quantities of altered haemoglobin : when it is red and mixed with blood it is known zs sa?iious ; if it is thin and watery it is called ichorous, and curdy when mixed with flakes of caseous material. Sometimes, when it comes from a mucous membrane, it is known as muco-pus ; it may be i?ifective from the presence of micro-organisms, and sometimes specific when it conveys the germs that give rise to definite dis- eases. In the neighborhood of the alimentary canal it not unfrequently has a jjeculiarly offensive odor, although there is no direct communication, and the same thing is often noticed in connection with dead bone. In a few rare in- stances its color is blue, owing to the presence of a special organism {bacillus pyocyaneus). [This bacillus resembles the blue-milk bacillus {bacillus cyanogenus) and belongs to the semi -anaerobic species. According to Ernst, there are two varieties of this organism, the second having a green pigment.] Pus consists of pus-corpuscles mixed with germs, floating in a highly albuminous fluid. The corpuscles themselves are, some of them, identical with leucocytes, and these are alive, capable of amoeboid movements, but the vast majority are dead. They are round, slightly irregular on the surface, about ttsimj of an inch in diameter, and granular. The nucleus is generally bifid or trifid. and sometimes SUPPURA no N— ABSCESS. 47 actually di\ idcd into two or three. The granules are, many of them, soluble in acetic acid, so that when this is added the outline of the nucleus becomes more distinct ; but, after the i)us has been some time in existence, they chiefly consist of fat. In very old collections fatty degeneration is comjjlete, the corpuscles are entirely broken uj), and nothing is left but a thick, jnitty-like, caseous material mixed with cholesterin crystals. The germs, for the most part, are streptococci or staphylococci. The fluid, unlike plasma, has no power of coagulating ; it con- tains a large quantity of albumin and chloride of sodium, with small amounts of leucin, tyrosin, and other substances. Lime-salts and phosphates are present to a considerable extent, chiefly in the corjniscles. When suppuration is very acute, shreds and sloughs, composed of the denser tissues, such as fasciae and tendons, are usually found floating in the pus; their vitality naturally is low, and the inflammation around them has killed then en masse — in other words, they are examples of necrosis and inflammatory gangrene on a small scale. . Had they been of looser texture and more vascular they would jj^ 4^ Fig. 5. — Pus from an acute abscess at time of evacuation. Dried and treated with methyl violet. (X 700.) Pus corpuscles, between which may be seen the thin film of coagulated albuminoid material. Pair of micrococci. Diplococcus. Chains of micrococci. Streptococci. Sets of four. Tetrads. {^A/ter Woodhead.) have melted away, digested by the peptonizing action of the cocci, and helped to form the albuminous fluid. Symptoms. Local. — These at first are the same as those of inflammation, well marked in the acute form, very indistinct in the chronic ones. Then, as fluid begins to make its appearance, the character of the swellitig changes. At the commencement, if it is near the skin, it is bright red and firm to the touch ; the surface is shining and pits on pressure {inflammatory cedema) and the depression so formed is well defined and is slow in filling up again. By degrees, as the foci run together and the pus begins to collect, the centre becomes softer and more dusky, the abscess is pointing ; then the skin near the middle, where it is most undermined, bulges out a little, the cuticle peels off, suddenly a small, round opening makes its appearance, and the pus is discharged. In many cases, shortly before this happens, a soft circular spot with sharply defined edges, marking infal- libly the part through which the pus will appear, is felt on gently passing the finger over the surface. 48 GENERAL PATHOLOGY OF SURGICAL DISEASES. When the abscess is of any size, the existence of fluid is detected by what is termed fluctuation — the wave felt by the fingers of one hand when [pressure is made with the other upon a distant part. With large collections of fluid this can be made out at once, the amount of the displacement is so great ; but with small ones, especially when they are deep-seated or tied down by unyielding sheets of fascia, it is often a matter of extreme difficulty. At the same time it is impossible to overrate its importance. The further apart the fingers of the two hands can be placed the better. The pulps, not the tips, should rest upon the .skin ; two should be used if possible, but in many instances there is only room for one of each hand ; those of the one should maintain a slight but perfectly uniform pressure upon the skin, those of the other should be gently but firmly pu.shed down at short regular intervals, and before a definite opinion is formed the action should be reversed. Of course, fluctuation, even when the diagnosis is correct, can only be taken as a proof of the presence of fluid ; it is no ]jroof of its nature, which may or may not be inflammatory. In testing a part of the body in this way there are many sources of fallacy. An excellent imitation of fluctuation is obtained over a healthy muscle if the hands are placed side by side upon it, so that the wave is transverse. Soft, solid growths are so perfectly elastic that the .same sensation is produced over them, and, though the distinction is of less importance, as suppuration is almost sure to follow, areolar tissue infiltrated with inflammatory oedema often fluctuates dis- tinctly ; fluid is actually present, but instead of being confined in one central cav- ity, it is spread about in the loosely woven and softened network of fibres. In deep-seated abscesses, especially those which are tied down beneath dense sheets of fascia, as in acute periostitis, the oedematous swelling in the looser and more superficial tissue is so great that this false sense of fluctuation is all that can be felt. As, however, in itself it is almost diagnostic of the condition beneath, this is of less importance. In addition to this, the character of the pain changes as suppuration sets in. TJu-ohhing is met with under other conditions, but it is seldom or never absent when pus is forming rapidly, especially if it is tightly bound down, and tenderness too often becomes much more distinct and localized. Constitutional. — The fever that attends the formation and discharge of pus is in many respects highly characteristic. At the commencement this is very often a rigor or shivering fit. This begins with a sense of chilliness, or actual cold, which may last only a few minutes, or may continue half an hour. At the same time there is a feeling of extreme prostration. The skin is pale, livid, and rough ; the face is pinched ; the eyes are sombre and surrounded by dusky rings ; the respiration is hurried and shallow ; and the pulse small, frequent, and feeble. Even at this time the tem- perature is higher than normal ; the rise begins before the shivering, continues all through it (so that while the teeth are chattering the skin is scorching), and through the period of dry, burning heat afterward, until sometimes it reaches io6° F. As soon as it ceases, profuse perspiration sets in, the temperature begins to fall, the face becomes flushed, the involuntary muscular fibre in the skin relaxes, the natural texture returns, and there is a sensation of profound relief, although the weakness and exhaustion afterward are often extreme. Not unfre- quently a herpetic eruption makes its appearance around the lips the day after a rigor, and in some cases spreads over the lower j^art of the face. Typical rigors are by no means confined to the onset of suppuration. They occur at the commencement of many of the specific fevers, and in pneumonia and pyaemia. The first passage of an instrument down the urethra may cause one, or the first micturition after an operation. Those who sufter from ague are particu- larly susceptible to the urethral form, but nothing of the kind has been proved in reference to others. In children vomiting and convulsions occur instead, and in acute catarrhal inflammation, and sometimes in other forms, there is a succession of slight chills, la.sting for many hours, instead of one definite one. The ultimate SUFPURA T/ON— ABSCESS. 49 cause is unknown. No doubt, from the symi)tonis, they are due to the action of the nervous system, the medulla oblongata and the higher centres that control the production of heat in i)articular, but it is not known what the stimulus is nor how it acts. The suppurative rigor and that which heralds acute specific fevers may be caused by the absorjjtion of some poi.son into the blood ; and Harrison believes that this is true of urethral ones as well, the ptomaines present in the urine being al)S()rbetl through abrasions of the mucous mem])rane after micturition ; but it is more probable that these are due to reflex irritation, whatever ma)' be the cause of the others. The subsecpient course of the fever in acute suppuration dej^ends upon the amount of absorption. In deep-seated inflammation the temperature frequently continues to rise until the wall of granulation-ti.ssue is establi.shed ; then it usually drops slightly of a morning (rarely a degree), rising again to its former level of an evening. As soon as the abscess is opened and tension relieved, absorption ceases altogether, the temperature falls to the normal, and if the drainage is what it ought to be, and decomjwsition does not occur, it does not ri.se again. Suppurative fever must be distinguished from septic fever, although the two often occur together. If the sui)purative variety occurs alone, it pursues the course already described, the severity depending uj^on the tension. Sometimes, therefore, as in thecal abscess or whitlow, although the amount of pus is very small, the constitutional symptoms are exceedingly sever.e. If the two are present together they cause hectic, the temperature continues to rise of an evening (although it may be normal of a morning), and the strength of the patient fails until, if the cause is not removed, death ensues from ex- haustion. If sei)tic fever occurs, suppuration is sure to follow, unless the case proves fatal too soon. In a recent wound — a compound fracture, for example — in which the planes of cellular tissue up and down the limb are filled with extravasated blood, traumatic fever sets in first, with or without shock. Then, if decomposition takes place, septic fever follows, the limb becomes red and swollen, the tempera- ture rises, delirium sets in, and the patient may die from acute blood-poisoning before there is time for suppuration. If he escape this, the pyogenic organisms gain access to the part, the tissues, injured already by the action of the septic poison, melt away as pus, and in five or six days the fever begins to assume the suppurative type. After a time, unless the result is fatal in the meanwhile from exhaustion and hectic, the structural elements around regain their strength, a barrier of granulation-ti.ssue is thrown out, the temperature falls of a morning, although it still continues to rise in the evening ; and by degrees, if no further injury is inflicted, the suppurating area contracts, the absorption of the products of decomposing pus ceases, and the fever subsides. Varieties of Abscess. Acute or Phlegmonous Abscess. — This is usually taken as the type of an abscess. All the symptoms are present, constitutional as well as local, and they are severe in proportion to its size and the degree of tension. Throbbing pain, heat, swelling, redness, and fever are well-marked ; inflammatory oedema is always present over it, and fluctuation makes its appearance at an early period, varying, of course, according to the depth. If it is not opened it makes its way in the direction of least resistance, undermines the skin, and bursts ; the cavity contracts at once, and unless some cause, such as a foreign body or a piece of dead bone, keeps up the irritation, the granulations fall together as it collapses, and repair is completed in a very short time by their organization. Metastatic abscesses are a variety of the acute form occurring in connection with pyaemia. They are sometimes described separately because of their distinctly embolic origin ; but if the view^ that suppuration is due to the action of cocci, 50 GENERAL PATHOLOGY OF SURGICAL DISEASES. conveyed to a distant part of the body, sometimes, at least, by the blood-stream, is correct, the distinction does not appear a material one. Caseous abscesses are due to the breaking down of old, tubercular, syi)hilitic, or, in rare instances, epitheliomatous deposits. They are most common in con- nection with tubercular disease of the bone, especially of the spinal column ; but they often originate in the lymj)hatic glands or the subcutaneous tissues — in any place, in short, in which a caseous deposit is found. Cocci are never present so long as they are chronic ; and the material they are filled with, although it resem- bles pus in external appearance, contains very few pus-corpuscles, and consists chiefly of broken-down fatty debris mixed with fluid. [In America, in contra- distinction to acute abscesses, this form of abscess is generally termed "cold" abscess ; it is still an open question whether all these abscesses, without reserve, are tubercular, but that the majority are tubercular none dispute.] Abscesses of this description not unfrequently attain an enormous size without their existence being known. There is no pain in connection with them, nor any fever so long as they are chronic. They are too deep-seated in most cases to cause any redness of the skin or swelling ; and it is not until they have lasted, perhaps, for months, and have destroyed the tissues around them for immense distances, that they at length approach the surface. Even then the soft parts over them show no sign of active inflammation. The skin either rgmains entirely unchanged, or very slowly becomes thinned, reddened, and softened, until at length it gives way. The walls of these abscesses, especially the older parts, are usually dense and hard, containing few vessels, and lined with a layer of cheesy debris ; they do not collapse and cohere like those of acute ones, and this is one of the chief diffi- culties in treating them. The cavity, too, is often of the most irregular shape, with large offshoots running in all directions and crossed by bands and septa, many of which contain important vessels and nerves. In short, they are so altogether different from acute abscesses in their contents, character, and behavior, that, except as a matter of convenience, they should not be classed with them. Even their termination is different. It very rarely happens that acute abscesses dry up or disappear. With these this ending is not at all uncommon. The fluid is gradually absorbed ; the caseous material becomes more and more inspissated ; and at length it undergoes calcification, nothing being left but a dense, chalk-like substance, lying in the centre of a capsule of fibrous tissue. Unfortunately this termination cannot be relied upon. If left, caseous abscesses for the most part only grow larger and larger, destroying more and more, and becoming more complicated in shape, until either they break, or, from some accidental cause, the cocci of true suppuration gain access to them, and they become acute. Chronic abscesses that are not of tubercular origin are much more rare, but occasionally they are found — in the breast, for example, or locked in the interior of a bone. The irritant that has caused them has been of very slight intensity, and the tissue in which they lie has surrounded them with a capsule so hard and dense that escape is out of the question. Sometimes these, especially when they occur in bone, are the source of severe pain. Residual abscesses are akin to these, although many of them probably are tubercular. Typical ones are met with in old cases of joint-excision. Years after the operation an abscess, often of very large size, forms rather rapidly in the cicatrix. It may be due to an old tubercular focus which has been left behind suddenly waking up again after some slight injury ; or to the fact that extensive masses of cicatricial tissue are very poorly nourished, and very prone to break down from trivial causes. The prognosis is always good. Cold or congestive abscesses are usually met with in connection with the lymphatic glands, generally in the axilla or the groin. The patient has been out of health for some time, and has received some slight scratch or bruise. A few days afterward, perhaps, when the original injury is well and forgotten, a certain degree of stiffness is felt, and suddenly a huge swelling is discovered, very soft. SUP PUR A TION— ABSCESS. 51 lliictuatinn and jjainless, with but little siffii of fever or inflaminatioii. The con- tents are usually thin anil rather oily, and not unfre(|uently it takes a long time for the patient to recover. Tympanitic ahscesses, containing gas as well as pus, are occasionally met with in the neighborhood of the alimentary canal, not necessarily in connection with the intestine, though this is very commonly the case. Diffuse suppuration is only met with when the action of the poison is very intense, or the resistance of the tissues exceedingly feeble, and is usually as.sociated with streptococci, as well as staphylococci. The sym])toms of inflammation may be well-marked, but not unfrecpiently they are altogether concealed, the fever assuming a tyjjhoid or adynamic type, and the nervous system being so over- powered that pain is scarcely felt. Diagnosis. — If the part involved is superficial, and the signs of inflammation are distinct, there is little or no difticulty ; when the converse of this is the case it may be impossible. The occurrence of a rigor, the presence of throbbing pain and of inflammatory adema, a softer spot appearing in the middle of a mass of hardened tissue, and the sensation of fluctuation, are the mo.st important diagnostic signs ; but any of these may be absent, or even all of them, and it must always be remembered that fluctuation only indicates the presence of fluid, and of itself gives not the slightest clue as to its nature. In cases of doubt, and particularly where the diagnosis has to be made from cysts or soft solid growths (which may Ije attended by all the signs of inflammation — hectic, local heat, redness, swelling, and pain), it is advisable to make use of an exploring-needle (grooved .so that fluid can escape along it) or a long fine trocar and cannula. Very little harm can be done with either of these, if carefully used ; the liver, for example, may be punctured in all directions, almost with impunity ; and the result can be relied upon. Even in those cases in which a caseous mass prevents the exit of any fluid, evidence of its presence may generally be found at the end of the cannula when it is withdrawn. Treatment. — i. Acute abscesses. — Preventive measures may be tried first; but, as a rule, if there are fair grounds for suspecting suppuration, the sooner an incision is made the better. In cases in which pain is severe and tension high (as in whitlow, acute periostitis, and phlegmonous inflammation of the cellular tissue) it is certainly not advisable to wait. Free incision is the best prevention. Incision is the only method of treatment. If the abscess is i)ointing, or if, short of this, there is one spot more tender than another, or at which the skin is more adherent or oedematous, the question of locality is settled. Where there is no indication of this kind either the most dependent part is selected, or that which appears advisable for anatomical reasons. Superficial veins and nerves, for example, should be avoided ; natural folds of the skin selected as far as possible ; and, above all, especial attention paid to the depth, position, and direction of the more important structures, such as vessels and ducts. If an incision must be made in their neighborhood it should be parallel to them. No plunge should be made in opening an abscess. The spot is selected, and the scalpel or absce.ss-knife introduced perpendicularly until either the sense of resistance ceases or, when the blade is slightly rotated, the pus wells up round it. Sufficient length is obtained in cutting outward. Deep abscesses, lying among important structures, are opened either by dissection or by Hilton's method. If, for example, there is suppuration beneath the deep cervical fascia, and the position of the vessels is uncertain, an incision half or three-quarters of an inch in length is made through the superficial structures, and a steel director pushed into the most prominent part of the swelling. As soon as it reaches the fluid a little escapes along the groove. Then a pair of dressing-forceps, with the blades closed, is passed along the director, and the wall of the abscess, and the structures over it, torn as far as may be necessary by separating the handles. An abscess should never be scpieezed ; it only makes the granulations bleed. If the sac is small and the tension high the contents are soon forced out by the 52 GENERAL PATHOLOGY OF SURGICAL DISEASES. neighboring structures ; and if the incision is of proper size and in proper posi- tion the cavity is obliterated ahnost at once. All that is required is an absorbent dressing to take up the excess of fluid that is secreted at first, owing to the sudden removal of the tension from the vessels in the newly formed granulation-tissue. When the absce.ss is deep-seated or complicated in .shape this is not enough. If it lies beneath a layer of fa.scia, or if the surrounding structures have been much displaced by its pressure, the deep wound, when the tension is relieved, does not correspond to the superficial one. . The opening is valvular and the contents cannot escape freely. In this difficulty a drainage-tube must be used. The best are lengths of red rubber tubing kept ready in a five per cent, car- bolic solution. The size selected depends, to some extent, upon that of the abscess and the character of its contents, but, as a rule, the larger the better. Small ones soon become blocked and increase tenfold the danger they are intended to prevent. Nothing is more common than to see a gush of fluid when they are withdrawn. The walls must be flexible, but firm enough to maintain the patency of the interior, and openings must be made in them here and there. The deep end is passed by means of a probe or sinus-forceps quite to the farther limit of the sac ; the superficial one is just flush with the skin, and is provided with a liga- ture to secure it if required. The wall of an old abscess is thick and rigid ; the structures around have grown accustomed to its presence, and do not obliterate the cavity when the tension is relieved ; and for this reason, unless the freest possible exit is given to the contents by means of a dependent opening and a large drain- age-tube, some is sure to remain behind and decompose. In large abscesses it is advisable to make two openings and pass a drainage- tube through. After two or three days it may be withdrawn, and two, one at each opening, substituted for it. As the structures around recover themselves and become pressed together the middle portion of the sac is obliterated, and when the granulation-tissue begins to contract the tubes are gradually forced out. Wood-wool or moss, impregnated with corrosive sublimate, is a most efficient dressing, but any other substance that is sufficiently ab.sorbent and capable of preventing putrefaction may be u.sed instead. The dressing should be thick and cover some distance around ; the compression helps the abscess to contract, keeps the part at rest, and maintains an even temperature. The frequency with which it is changed depends upon the amount of discharge ; in many cases a single dressing is sufficient. The temperature, if the abscess is drained thoroughly, falls at once to normal ; if it rises above 99°, at any rate on more than one evening, it is almost certain that the exit is not free. Metastatic, residual, and cold or lymphatic abscesses present no peculiarities. Chronic ones, locked in bone, naturally require special treatment. If sui>puration is diffuse free drainage is even more imperative than when it is circumscribed ; it is just possible that relieving the ti.ssues of the additional irritation of tension may turn the scale in their favor, and enable them to throw out a protecting barrier ; but it must be remembered that in these cases there is, as a rule, progressive inflammation to deal with as well. 2. Caseous Abscesses. — The treatment of caseous or tubercular abscesses requires special mention. An acute abscess, unless there is some complication present, discharges itself of all its contents as soon as the tension is relieved, and organization begins at once. In these, on the other hand, the reparative power of the tissues is very feeble, the walls are dense and rigid, so that they do not collapse, and the caseous debris, especially the more solid part, has a great ]}ro- pensity for clinging to the interior. In other words, even when they are small, it is not easy to procure free and efficient drainage ; when they are of large size, as in the case of many spinal abscesses, and divided into a series of successive cham- bers by septa springing from the walls, or provided with offshoots spreading in all directions, the difficulty becomes a very serious one. Formerly it was the practice to leave abscesses of this kind alone as long as pcssible, more especially as, in a certain small proportion, the caseous material SUPPURATION— ABSCESS. 53 gradually dried up, and either became absorbed altogether or converted into a calcareous mass. Now, it is recognized that the earlier such an abscess is emjjtied the better the prospect of speedy recovery, and the less the risk of its proving ultimately a focus for tubercular dissemination. Many of them occur under conditions that necessitate special treatment. Such, for example, are the caseous foci found in tubercular epididymitis and in so-called strumous disease of joints. Others — those, for instance, that are met with in lymphatic glands, or in the cancellous tissue at the eijiphy.sial ends of the long bones — may be very briefly dismissed ; they should be opened as thoroughly as possible ; the lining of granulation tissue, covered with ca.seous material and infiltrated with tubercle, scraped out with a Volkman's spoon, and iodoform dusted over the interior. The difficulty is in dealing with the large ones, which cannot be treated in this fashion. Aspiration is harmless, and sometimes succeeds. The instrument ordinarily used is a modification of Dieulafoy's, consisting of an exhausting-syringe or glass receiver, and a trocar and cannula so contrived that the former can be withdrawn and the latter brought into connection with the receiver, without destroying the vacuum. Care must be taken that the instrument is absolutely clean (I prefer to have all cannula boiled in liquor potassae in a test-tube just before using ; no oil then is required) ; the opening should be valvular, and the trocar should reach well into the cavity before it is withdrawn, and the connection established. No attempt is made to empty the abscess ; as a matter of fact, it cannot be done ; a large amount of the caseous material clings obstinately to the wall, and if it is detached, blocks the cannula, and great care should be taken not to make the granulations bleed, either by bringing the end of the instrument into contact with them, or reducing the tension too rapidly. The vacuum should be maintained as the needle is withdrawn, for fear of its leaving some of the caseous debris in the wound. As the abscess is not emptied, the beneficial effect must be due to the relief of the tension ; sometimes absorption and condensation follow ; much more fre- quently the cavity slowly refills. If the aspirator is used more than two or three times, the openings fail to heal ; a little thin serum escapes from them, the mar- gins begin to ulcerate, and the contents slowly drain away. Small abscesses are sometimes emptied in this way, or with a trocar and can- nula, and then injected with an emulsion of iodoform in glycerine (one in ten), or a five per cent, solution of the same drug in ether. The former is especially recommended, as, owing to its high specific gravity, it sinks down through the caseous debris which collects upon the floor, and penetrates to the granulations ; but there is some risk of iodoform-poisoning. Large abscesses — those, for example, in connection with disease of the spine — must be opened and drained. Two incisions are always advisable — one at the most dependent part, the other as near the seat of disease as practicable. Some- times, when there are large outlying pouches, a third is required. The interior should be explored with the finger, to ascertain, as far as possible, its extent, and whether the disease which has given rise to it is within reach of treatment, but it should not be scraped out, for fear of hemorrhage, and of damaging important structures running in the wall, or across the cavity, or washed out with antiseptics ; then, a very large drainage-tube should be inserted, or, if necessary, more than one, and absorbent dressings applied. If the drainage is thorough, the caseous material that clings to the wall is thrown off by the granulations with the serum that exudes from them ; the amount of discharge is reduced to a few drachms of turbid fluid, and gradually, as the structures around collapse upon the cavity, all the outlying parts close up, leaving only one sinus, leading, by as straight a route as possible, down to the seat of disease. When this is not feasible, Hamilton's method of irrigation with chloride of zinc (one part in 200) may be adopted. A rubber tube, with a single opening in the side, is passed across the abscess-cavity ; one end is connected with an irri- gating can, the other wath a receiver, and the fluid (which is quite inert as a germi- 54 GENERAL PATHOLOGY OF SURGLCAL DISEASES. cide) is allowed to flow through, drop by drop, the rate being regulated by means of a stop-cock. After a week, the openings begin to leak, and then the continuous irrigation can be dispensed with ; the cavity throws off the inner lining in shreds, and gradually heals up. The object is to place the tissues under the most favorable conditions for getting rid of the noxious material that lines the cavity. When efficient drainage is impossible, so that there must be some residue of dead, putre.scible fluid in the cavity, or Hamilton's plan is unsuitable. Lister's method, or some modification of it, may be used. It aims at preventing the access of the germs of putrefaction, and if it is carried out at all, must be done thoroughly. These micro-organisms (unlike those of suppuration, which can be conveyed from one part of the body to another, and can enter through the alimentary or resj^ira- tory tract, and cause the formation of pus whenever they meet with tissues too feeble to resist them) are unable to act on living tissues ; they must have dead material at a certain temperature and with a certain amount of fluid — conditions whicq are perfectly fulfilled in ill-drained abscesses. The skin over and in the neighborhood of the wound is thoroughly cleansed with an antiseptic (carbolic acid, five percent., is the usual one), and, if neces.sary, shaved and purified from any fatty matter that may adhere to it, with ether or some strong alkali. The instruments, the hands of the operator, the sponges, and everything that can possibly come near the wound, are treated in the same way. After the abscess is opened, and the immediate discharge from it has ceased, a drainage-tube -is carried down to the bottom, and secured in the ordinary manner, and then special dressings are applied. The wound itself is covered with protective — oiled silk coated with copal vainish, and brushed over with dextrin. This is dipped in carbolic lotion first. In the case of a recent wound, it is just large enough to overlap the edges all round, and protect the healing surface from the irritating effect of carbolic acid. Over this is laid a dressing of specially^prepared gauze. As a rule, it consists of tarlatan impregnated with a mixture of one part of carbolic acid, four of resin, and four of paraffin ; but eucalyptus, salalembroth, and other substances are sometimes used instead. The dressing next to the protective is dipped in a solu- tion of carbolic acid (two and one-half per cent.), because, when dry, the dis- infectant is not given off" readily, and a particle of dust that had escaped the spray might come into contact with the drainage-tube. Over this, covering the skin for a long distance round, is the superficial dressing ; eight layers of gauze (dry, but prepared in the same way) with, beneath the outer layer, a piece of mackintosh cloth, so that the discharge may diffuse itself over the whole without coming into contact with the air at any one spot. Elastic bandages are used round the edges, especially where, as in the groin, there is likely to be any move- ment ; gauze bandages for the rest. If the surface is uneven, or if a large amount of discharge is expected, loose gauze rolled up lightly is ]:)laced, as much as may be nece.ssary, between the .superficial and the deep dressings. The dressing is changed the day following the operation, using the same pre- cautions, and taking great care not to lift it up toward the spray, but away from it, so that no unpurified air may enter beneath. Afterward it is left until the^ discharge is apparent somewhere at the edge ; but never for more than a week. [Another method of treating these large abscesses, is by evacuating the con- tents through a cannula, then thoroughly washing the cavity with warm water, then with iodine water, then injecting iodoform emulsion, then closing the skin puncture with iodoform collodion. In washing the cavity the walls of the abscess must be fully distended to allow the fluid to touch every jiart. The operation should be repeated from time to time as occasion may require.] HECTIC— ALBUMINOID DEGENERATION. 55 Hkciic. Profuse aiul long-continued siii)j)uration is accompanied by a i)eculiar form of fever known as "hectic." 'Ihe tenii)erature is perfectly regular, but remittent. In the morning it is normal, or only slightly raised ; in the evening it is 102°, 103°, or even 104° F. As the rise begins, always at the same time, there is a sensation of heat and thirst, sometimes jjreceded by a chill ; the face becomes flushed, especially the cheeks, on which there is often a bright red and strictly limited patch ; headache comes on, with a feeling of extreme weakness and de- pression, and the patient is restless and uncomfortable, tossing about in bed, unable to sleep. Then toward morning the temperature drops ; there is profuse perspiration, often soaking the bed-clothes ; and the patient falls into a deep sleep, which may last till late in the day. The pulse is always rapid, becoming softer, smaller, and more frequent as the case goes on. Emaciation is extreme; the eyes are sunken and bright, the pupils dilated, the skin anaemic, and the tongue very red, especially at the tip and edges. The urine deposits urates copiously, and diarrhoea is of common occur- rence toward the end ; the strength fails rapidly ; the mind begins to wander ; the power of taking food diminishes, and at leilgth death ensues from sheer exhaustion. The most typical examples of hectic are met with in cases of empyema or of large abscesses connected with the spine or hip that have been imperfectly drained ; but it may follow suppuration in any part of the body. It does not occur before an abscess is opened, and there is no doubt that it is due to the ab- sorption from the granulating surface of a substance produced by the fermentation (not necessarily putrefactive) of the discharge. The greater the amount of dis- charge and the larger the absorbing surface, the worse the fever. The treatment depends upon the cause ; if this can be removed the fever ceases ; if it cannot, the course may be delayed, but the end cannot be prevented. The strength must be supported by nourishing diet, tonics, iron, quinine, and cod-liver oil. Stimulants, especially port wine, are of undoubted use. The diarrhoea must be kept in check by astringents and mineral acids. Opium should only be given as a last resource, to relieve pain. The night-sweats, which are very weakening, can be checked by belladonna ; and the formation of aphthous ulcers in the mouth and on the tongue (w'hich are very injurious from the pain they cause in mastication and deglutition) must be prevented by means of borax and potassium chlorate. Typical hectic, with emaciation, flush, and profuse night-sweats, is met with in connection with many varieties of rapidly-growing malignant tumors. The cause is not known. Albuminoid Degeneration. This is one of the consequences of prolonged suppuration often associated with hectic. It has, however, been known to occur independently of the forma- tion of pus in syphilis and malaria. In surgery, at least, it is usually met with in connection w-ith tuberculous disease of bones or joints, and as a consequence of empyema. Morbid Anatomy. — The liver, spleen, kidneys, and the mucous membrane of the intestines are the parts usually involved. It begins in the media and intima of the small arteries and capillaries, and spreads from them to the connective-tissue elements and the unstriped muscular fibres. The epithelial lining atrophies. The substance of the cells is changed into a firm, homogeneous, waxy material, which appears translucent in thin sections, stains mahogany-brown wdth iodine, and red w^ith methyl-violet. It is nitrogenous, resembles albumen in many respects, but resists digestion and putrefaction. Symptoms. — The liver retains its shape more or less, but slowly and steadily increases in size until it may reach into the iliac fossa. It is firm, hard, and resistant ; the edge can be felt with unusual distinctness ; there isno pain or any 56 GENERAL PATHOLOGY OF SURGICAL DISEASES. apparent derangement of function. The spleen enlarges in the same way. The kidneys show the effect by the alteration in the urine ; this increa.ses in quantity, diminishes in density, and in the later stages contains a small amount of albumen and some hyaline casts. The mucous membrane of the intestine does not become involved until comparatively late, when, naturally, emaciation and diarrhoea soon become prominent features. The aspect of the patient is characteristic. There is a peculiar waxy pallor of the face which is unmistakable, and is of itself sufficient to establish a diagnosis. In addition, the anaemic condition of the lips, the emaciation, and the protuberant abdomen, can usually be recognized at once, Early removal of the cause has been followed by complete disappearance of all the symptoms, so that, some years after, no evidence of such a change could be detected. If this is attempted, however, it must be done before the disease is too far advanced. Hemorrhage into an Abscess. Capillary oozing is very common ; the granulations are exceedingly vascular, and the sudden relief of tension causes some of the thin-walled vessels to give way ; but it is very rarely serious. Usually it stops at once on exposure ; if it does not, ice may be applied locally and the part well raised. In very bad cases it may be necessary to plug the cavity with iodoform gauze — but this is very likely to be followed by a considerable degree of fever. Venous hemorrhage rarely occurs except from scarlatinal or diphtheritic sloughing in the neck. In this case the cavity should be thoroughly dried, the hemorrhage being checked meantime by pressure ; dusted well with iodoform, in the hope of staying the sloughing, and packed with iodoform wool or gauze ; but, especially in the case of the internal jugular, the prognosis is almost hopeless. If iodoform fails or is not at hand, turpentine is probably the most efficient agent. Arterial hemorrhage may occur under the same conditions, from ulceration into the carotid, or in the groin from the extension of phagedaenic bubo. The latter appears to have been more common in days gone by. Occasionally it is met with on the extremities, from the pressure of drainage-tubes or of sharp edges of bone. Fortunately, the hemorrhage is rarely instantaneous ; in nearly every case there is a warning. The treatment varies according to the circumstances. In the neck, if it is in the carotid or one of the branches near the main trunk, this must be ligatured at once. In the thigh, if only a few drops escape, cold and pressure may be applied ; but a tourniquet unscrewed must be placed upon the limb higher up, and a nurse or dresser instructed to watch ; and if there is the least recurrence, no further delay is admissible. In the leg, amputation is usually required. The complication is a rare one. I have on several occasions seen arteries lying, exposed and beating, on the floor of ulcers without hemorrhage ever occur- ring. As the inflammation extends into the coats, the endothelium becomes affected and a thrombus forms. Suppurating aneurisms are by no means always followed by hemorrhage. If, however, there is a foreign body cutting into the wall of the vessel, or if the ulceration is phagedenic, or even septic and diffuse, as in those whose health is broken down from any cause, the destruction may advance too quickly for repair, and then hemorrhage follows. Sinus and Fistula. A sinus or fistula is the suppurating track left by the imperfect healing of an abscess. The distinction between the two is not accurately kept. Strictly, the former has only one opening, and that upon the skin ; but so long as there is no communication with an internal cavity or with any of the hollow viscera (such as the bladder), the number is not material. A tubercular abscess, for example, may have two or more, connected by channels running in the subcutaneous tissue. In S/NUS AND FISTULA. 57 the same way a fistula should have two, of which one communicates either with the viscera or with a ca\ity of some kind ; the other may or may not be on the exterior ; in recto-vesical fistula, for example, both openings are internal ; in the biliary variety, only one ; but blind fistuh\3 (which are identical with simple sinuses) are occasionally spoken of in connection with the anus, on account of the close resemblance they bear to complete ones. Causes. — Non-closure of an abscess is due to the persistence of some irri- tant : tension, as when the contents cannot escape freely ; want of rest, owing to the continued action of muscles — the sphincter ani, for example ; the presence of dead bone, tubercular deposit, or foreign bodies introduced from without, and the existence of an obstruction to one of the natural ducts, as in stricture, are the most common. Occasionally fistulas are caused by actual loss of tissue (especially vaginal ones), or by the presence of malignant growths. As a rule, a sinus or fistula forms a narrow, more or less tortuous canal, lined with a kind of granulation-tissue which secretes a thin, watery pus. Exceptionally, when it is very short, as between the rectum and the bladder, it is covered with epithelium. The external orifice varies according to the cause ; when it is due to dead bone, there is usually a protuberant button of granulations, in the centre of which is a very small opening. Tuberculous sinuses, on the other hand, are sur- rounded by ragged, blue, and undermined edges. In the case of old fistulas the opening is not unfrequently depressed and sunken, because of the contraction of the granulation-tissue underneath." The internal orifice is generally well defined, although that, too, may be concealed beneath a flap of mucous membrane. When of recent formation, the structures that form the wall are soft and yielding ; but in old cases, particularly those in which the fistula gives exit to one of the secretions, they become hard, dense, and cartilaginous, so that, even when the cause is removed, healing is almost impossible without something further being done. Treatment. — In recent cases it is sufficient to remove the cause. Dead bone must be withdrawn or scraped away ; a stricture must be dilated ; if there is not free exit for the secretion, the orifice must be enlarged with a drainage-tube or tent, or by an incision ; and if, as in the case of sinuses in the groin, the con- tinual movement of the part prevents healing, pressure may be applied. Even those left by suppurating buboes can be induced to close by the proper application of a truss. In many cases, of course, the removal of the cause entails a serious operation. Fistula in ano, for example, is originally due to an absce.ss, but its persistence is the result of the sphincter, and this must be divided before the wound can close. In others in which, without any definite reason being found, the wound refuses to heal, an attempt may be made to stimulate the part, or even, in old cases, to excite acute suppuration. In those cases in which the walls are very thick and dense this is the only way. Injection of tincture of iodine may be tried first, or the introduction of a probe coated with nitrate of silver. If this fails, the granulations may be thoroughly scraped out with a sharp spoon or destroyed with the cautery. Finally, sometimes the only measure of any use is to lay the whole open from one end to the other, partly to place it at rest, partly to destroy the hardened, thickened tissues by causing acute suppuration. Where bleeding is feared, this is sometimes done with an elastic ligature tied as tightly as possible. Large fistulous openings between hollow viscera, or between one of these and the exterior, very often require extensive and repeated plastic operations. 58 GENERAL PATHOLOGY OF SURGICAL DISEASES. ULCERATION. Ulceration is the molecular disintegration and removal of the superficial structures of the body by the action of certain irritants, just as suppuration is of the deeper ones. An ulcer is the sore formed in the process, and in the same wav corresponds to an abscess. A burn — the actual cautery, for example, applied to the- skin — does not leave an ulcer, provided no other irritant is allowed to appear. A portion of the skin is killed ; the surrounding tissues at once begin to act with vigor ; lymph pours out ; new vessels are formed ; vascular granulation-tissue is produced in sufficient amount, and the dead part is replaced, more or less perfectly, without a trace of suppuration. If, however, any further injury is inflicted on the part — if the burn is exposed to the air, so that the dead tissue decomposes, or if the surrounding living parts are constantly rubbed by the clothes, or if they are injured in any other way — inflammation sets in ; the pyogenic organisms multiply, molecular disintegration begins on the surface of the body, and an ulcer is produced. As soon as the irritant ceases and the tissues regain their normal resistance, vascular granulation-tissue is formed as round an abscess, destruction comes to an end, organization begins, and the wound begins to heal. Sometimes this is called a healing ulcer, but the term is an inappropriate one, as the ulceration has ceased. Causes. — The causes of ulceration are the same as those of suppuration, predisposing and exciting. The former include everything, hereditary or acquired, local or constitutional, that can in any way impair the vitality of the tissues ; and these are of especial importance when the process is chronic : the latter are the same forms of micrococci that occur in acute abscesses. They generally gain access to the tissues from the surface (sometimes, as in pyaemia, through the blood), and the cells and fibres melt away before them because they are too weak to resist. There is the same contest between the irritant and the power of repair ; sometimes one gains the upper hand, and sometimes the other, and, as the case mav be, the ulcer spreads or heals. Not unfrequently, especially on the leg, there is scarcely any progress one way or the other for years. The irritant has very little power, but the tissues are so badly nourished that they cannot throw it ofif : and each winter sees the ulcer slowly getting larger, especially as age advances. There is the same question as in suppuration — whether long-continued mechanical or chemical irritation can cause ulceration of itself without the lique- fying action of the micrococci ; but the discussion is even more barren, as they are invariably present. Varieties. — Simple ulcers may be compared to acute abscesses, with this distinction — that septic germs, causing decomposition of the discharge, are (unless steps are taken to prevent it) always present with the pyogenic ones, weakening the tissues and preparing the way for their action. Specific 74 leers resemble, but less closely, caseous abscesses. These are due to the softening and disintegration of tubercular, syphilitic, and, occasionally, epitheliomatous masses in the interior of the body ; but, except in certain rare instances, they do not contain true pus until they are opened. The corresponding forms of ulcers are never the result of unmixed disintegration in this way. In addition to the caseation and liquefaction, septic decomposition is always present, and pus as well, from the presence of pyogenic micrococci. It is probable that the phagedaenic and gangrenous forms, which are usually separated from the rest, are merely the result of the ordinary germs, acting with greater intensity than usual, sometimes for anatomical reasons, more frequently because the vitality of the tissue is greatly impaired, or because there is some other poison (that of syphilis, for example) at work as well. They may be com- pared to diff"use suppuration ; the process of destruction is too rapid for the tissues GANGRENE. 59 to throw out a barrier of i^ranulations, or the poison is so intense that the barrier already thrown out clisai)i)ears. As soon as the tissues are able to resist the irritant, the leucocytes cease to melt away as pus, the peptonizing action of the micrococci becomes feebler, coagulable l)mph is formed, and new blood-vessels are thrown out. In other words, a layer of vascular granulation-tissue is developed upon the floor of the ulcer, exactly like the limiting fibrin round an abscess ; and repair begins at once, as in any other healing wound, by organization and contraction beneath, and organization and the formation of an epithelial layer above. GANGRENE. By gangrene or mortification is understood the death of a part of the body. A certain size is implied, in distinction from ulceration, in which the destruction is molecular and the tissues melt away imperceptibly ; but small patches of gan- grene are often present on the floor, or round the edges, of spreading ulcers, and the line between them is ill-defined. The term sloi/ghing is used for the soft tissues ; tiecrosis for the hard ones — bone and cartilage ; and, in the latter case, the dead portion when encased in living bone is known as a sequestrum. When not so encased, the dead portion is termed an exfoliiini. Gangrene is dry or moist according to the changes the part undergoes. In the dry form the color at first is pale, or dead white with a bluish mottling here and there ; the skin is shriveled, and as it were shrunken on the structures beneath ; at first, it has a peculiar semi-translucent look ; but very soon it loses this, becomes opaque and dark, and then grows more and more black until at length the part becomes hard, dried, and mummified. Putrefaction cannot occur because there is no fluid. In the moist form, on the other hand, decomposition is always present. The part is engorged with blood ; the haemoglobin soaks through and stains the skin, so that it becomes dark and livid ; bullae form on the surface, filled with reddish fluid of a very offensive description ; the epidermis is detached ; ashy-gray or green patches make their appearance ; the part becomes swollen, and crackles under the finger from the formation of putrid gases ; and the smell is most offensive. Which of the two forms occurs depends upon the amoimt of fluid present.* Dry gangrene, therefore, is chiefly met with in old people, with thin, spare limbs, in whom the arteries supplying the part slowly become blocked with thrombi. Even in them, however, a certain amount of decomposition usually takes place as the line of separation is formed, or when the gangrene involves the calf. In the former case the necessary amount of fluid is supplied by the liquefaction of the plasma under the influence of the pyogenic organisms ; in the latter it comes from the tissue itself. Causes. — The causes of gangrene are the same as those of inflammation, physical and mechanical irritants, and infective organisms. The chief difference is that they kill the tissues outright, either directly or by cutting off the blood- supply, instead of merely impairing their vitality. I. General. — These are, for the most part, predisposing only, but sometimes they are so powerful that, as in Raynaud's disease (symmetrical gangrene), it is scarcely possible to find a local one. They include anything that can in any way impair the general health or interfere with the quantity or the quality of the circulating blood. Cardiac disease of all kinds, valvular and degenerative ; loss of blood; exhausting illnes.ses ; prolonged fevers; Bright' s disease; diabetes; exposure ; starvation and intemperance, are some of the most common. The prolonged use of ergot is said to lead to gangrene, but probably only when it is assisted by other causes. [* It is easy to see that the conditioa of the veins and lymphatics must determine the relative moisture or dryness. When the lymph channels or veins, or both, are occluded, or contracted through swelling, then there must be cedema in the part.] 6o GENERAL PATHOLOGY OF SURGLCAL DLSEASES. Most of these act upon the tissues directly as well as through the circulation. Whether loss of nerve-power has much influence, except in so far as it impairs nutrition from disuse, is uncertain. There is more evidence in favor of nerve- irritation. That inflammation can be induced in this way is generally admitted ; and there are cases on record in which the process has been so severe as to lead to gangrene of the most acute type — sloughing bed-sores for example — within twenty- four hours after an injury. Whether this is due to trophic nerves, or to spasmodic vaso-motor contraction, brought about by reflex irritation, is not known. The existence of the former is not proved ; while in favor of the latter is a remarkable case recorded by Hilton, in which the pressure of an exostosis upon the ulnar nerve caused gangrene of the little and adjacent side of the ring-finger, the stimulus conveyed by the sensory fibres to the nerve-centre being reflected down the vaso-motor ones to the vessels, and cutting ofl" the blood-supply. 2. Local. — Any kind of irritant can cause gangrene, the degree of severity required being in inverse ratio to the activity of nutrition : a scratch or bruise is sufficient when the vitality of the part is low. (A) Physical or Mechanical Lrr Hants. Some of these act upon the tissues themselves ; others kill them by cutting off the blood-supply. Heat and chemical agents are examples of the former, arterial obstruction of the latter. Obstruction of an artery may be due to rupture, ligature pressure, thrombosis, embolism, or inflammation. As a rule, the collateral trunks enlarge sufficiently to make up for it ; but if the vessel that has given way is a large one, so that there is an enormous extravasation under high pressure ; or if the walls of the other vessels are rigid and atheromatous, so that they cannot dilate, the blood- supply is cut off" and that part dies. Venous obstruction, owing to the freedom of anastomosis, rarely leads to this ; but in strangulation by ligature, or when a piece of intestine is caught in a narrow canal, the veins are compressed first, and the congestion so caused gradually blocks the arteries. (^B) Organized Irritants. These are the same micro-organisms as in inflammation, only they are acting now with greater intensit}". In the one case they lower the Wtality of the tissues, in the other they destroy it. They differ from physical and mechanical irritants in the fact that their action is continuous : they spread wider and ^\-ider, invading the tissues farther and farther, until either their energy is spent or they meet with some part sufficiently well-nourished to resist. Of these some are certainly specific (anthrax, malignant pustule, glanders, and possibly a few more). Others' which, like these, invade living structures, do not give rise to specific diseases, but merely to inflammation of great severity. They impair the vitality of the tissues to such an extent that they slough. This is the case with spreading traumatic gangrene and hospital gangrene ; no specific germ has been proved to exist in them : they are merely the result of the ordinary organisms of suppuration acting under peculiarly favorable conditions. Whether noma, cancnim oris, and phagedaena should be included is still a matter for ques- tion. Carbuncles and boils are undoubtedly due to ordinary micrococci. This form of gangrene is always moist : putrefaction is present, as well, wherever the slough is exposed to the air : and the products bathing the surface of the sore, lowering the strength of the patient as well as the vitality of the tissues, materially assist the progress of the original cause. Subsequent Course. As soon as a part of the body has been killed, whether by mechanical, phys- ical, or organized irritants, an attempt is made to get rid of it. The success GANGRENE. 6i which attends this (Iciifiids upon three conditions: the nutrition of the tissues, the i)ersistence of the orii;inal irritant, and the presence or not of any other in addition. 1. Win- re the tissues are Jiea/tJiy, where the injury is not repeated, and where no other irritant is allowed to intervene, the dead portion is either absorbed or tlirow n off, according to its position. If it is in the interior of the body it sinij)ly undergoes degeneration and is tranquilly removed. A portion of tissue that is dead acts as a very slight irritant on the structures around. The pedicle of an ovarian tumor that has been ligatured and returned into the abdominal cavity is an instance ; the neighboring tissues become more vascular, leucocytes and plasma pour out in greater amount, the strangulated part gradually becomes invaded by them, new vessels are formed and extend farther and fiirther into its substance, and at length it comj^letely disappears. In the same way a bony secpiestrum of small size, and even dead substances of an entirely foreign nature, such as ivory pegs, can be removed. If it is in the skin, under the same conditions, the same changes occur round the buried part, but the exterior dries up and becomes hard and dense. Absorjj- tion, accordingly, is impossible, except to a very slight extent ; the lymph that is thrown out by the living tissues becomes organized ; the deep part is converted into fibrous tissue; the superficial, where it is in contact with dead material, is covered over with epidermis, which grows in from the margin, and at length the dried-uj) mass drops off by itself^ leaving a perfectly healed surface beneath. A burn, for example, covered up at once, may remain dry, and form a scab under which repair is completed without the least further loss of tissue or suppuration. The line along which the separation takes place is known as the line of demarca- tion ; on the one side is the dried-up dead material, on the other the living tissues, reddened, slightly swollen, and more tender than usual, because, owing to the presence of an injury, there is more than the ordinary degree of repair required, and the circulation is quicker and more active. It must be acknowledged that suppuration is rarely absent when the gangrene is of considerable size ; but it is an accident and not essential. The slough, if the adjacent tissues are healthy and uninjured, can be detached without the loss of a single leucocyte. 2. Where the vitality of the structures near is impaired, hut not very seriously. At once this gives a foothold to pyogenic micrococci, which are always at hand and ready ; suppuration takes place, and, although the gangrene does not spread, the loss of tissue is greater than is accounted for by the slough alone. {a) The general nutrition may be enfeebled from any of the causes already mentioned. A burn, which, in a healthy child, would heal without suppuration, may give rise to extensive ulceration in a person suffering from Bright's disease or diabetes. if) The local nutrition may be impaired, owing to the surrounding parts having been affected by the original injury. In frostbite, for example, part of the tissue is killed outright, but the vitality of the structures for long distances round is so enfeebled that they are unable to resist the onset of the micro-organ- isms. The same thing occurs in bad crushes and bruises ; large subcutaneous extravasations of blood are very prone to suppurate, partly because of the tension, but partly also because the tissues round are injured and unable to hold their own. {c) Other irritants may make their appearance and help to weaken the resistance of the still living tissues. These may be of the same nature as the original one, or different. Tension, for example, prevents a slough being detached without suppuration. Friction and want of rest do the same. Septic decompo- sition is still more powerful, the ptomaines it produces causing the death of the structures they touch to a depth that depends upon the activity of their nutrition. If healthy granulation-tissue has already been formed, the surface cells merely melt away ; but if the part is badly nourished and its vitality depressed, either from constitutional causes or from the original injury, or if the poison can soak into 62 GENERAL PATHOLOGY OF SURGICAL DISEASES. the tissues along the lymphatics, the destruction may extend for an unlimited distance. These causes lead to one result : the tissues around the slough are injured ; their vitality is lowered, and they have lost the ])o\ver of resisting the pyogenic organisms which gain access to them. The lymph that pours through the walls of the vessels melts away ; the leucocytes perish and become pus corpuscles ; the plasma can no longer coagulate ; the injured tissues undergo coagulation-necrosis, disappear, and add to the fluid already present \ and by degrees a layer of pus is formed, separating the dead material from the living lymph, which, as the surface melts away, is constantly renewed from the vessels round. If it is in the interior of the body, the slough is enclosed in an abscess, the micrococci having made their way through the blood-vessels or lymphatics, and having found a congenial soil in the damaged tissues that lie around it ; if, on the surface, it lies on the surface of an ulcer, and the pyogenic germs have, in all probability, reached it through the skin. 3. liliere the vitality of the tissues is very seriously depressed. It is no longer now a question of molecular disintegration or ulceration ; the surrounding part perishes en masse ; the gangrene itself spreads. The conditions under which this occurs may be cla.ssified in the same way. (<7) The general nutrition may be in fault. I have known gangrene extend from the foot to the thigh in both legs, and prove fatal within thirty -six hours, with all the symptoms of the most profound collapse, after two primary amputa- tions, one on each foot, performed with the strictest antiseptic precautions. The vitality of the tissues, from the combined eff"ects of Bright's disease, exposure, intemperance, and the carbolic spray, was so low that, uninjured, they were only just able to hold their own ; the least hurt killed them at once, and the contact of the tissues already killed was a sufficient irritant to destroy the vitality of those around. {U) The tissues may have been injured too seriously by the original cause. If amputation is performed for frostbite before the part has thoroughly recovered, the flaps are sure to slough. Their vitality is so low that they cannot withstand the additional hurt. {c) Another irritant may be added and comi)lete the destruction. Septic decomposition is the usual one. The ptomaines produced by this, if they are absorbed, act as the most powerful depressing agents, causing septic fever or saprsmia. If the tissues have already recovered from the original hurt, and are protected by a wall of newly developed vascular granulation-tissue, no ill-result follows ; a slough on the surface of a healing ulcer causes very little disturbance, unless it is assisted by tension, friction, or other modes of irritation ; but if there has not jet been time for this, or if the vitality of the part is too depressed, sloughing of the most extensive description is almost sure to follow. As the greater includes the less, so, if the gangrene spreads, suppuration always occurs. Only as the pyogenic micrococci require time before they can produce much effect, in the worst form of spreading gangrene, the tissues perish too soon. The consequences of gangrene, in short, depend upon the state of the part that is living. If the tissues are healthy, uninjured, and well-protected, they are easily capable of resisting such an irritant as contact with dead material, and set about repair at once. If, however, they are weakened by constitutional or local causes, or if they are exposed to further injurious influences, mechanical or chemical, their power of resistance is enfeebled, and according to the proportion their strength bears to that of the combined irritants, either molecular or molar death follows — suppuration or gangrene — and spreads until it reaches a part that is capable of successful resistance. GANGRENE. 63 Special Forms of Gangrene. Some of these are due to the action of infective organisms, others are not ; but as the one nearly always complicates the other, it is not advisable to consider them apart. I. Dry Gancrkn'e. — The most typical example is that caused by thrombosis in atheromatous arteries, commonly known as senile. .It always begins in the lower extremities and can generally be traced to some trivial injury. For some time past the feet and legs have been peculiarly cold and numb; there has been a constant sense of itching and formication; cramp has been very painful in the calf; then suddenly a dark-red or purple spot, sur- rounded by a dusky ring, is noticed, usually on the inner side of the great toe; and on examination it is found that the action of the heart is very feeble, that the tibial pulse can scarcely be felt, and that the arteries are rigid and hard. As a rule it is the seat of a constant burning pain, but sometimes this is not noticed. Gradually the central patch becomes darker, and encroaches on'the areola around ; this, without growing wider or narrower, slowly spreads farther and farther ; the toe becomes shrunken, dried, and hard; and at length the foot is involved. Progress is rarely uniform ; one toe after another may be attacked at intervals. Just below the ankle there is always a rest, sometimes a permanent one ; but the tendency is for the disease to progress, sometimes slowly, sometimes quickly, until exhaustion, with extreme depression and low wandering delirium, sets in. Post mortem the arteries are usually calcareous, rough, and irregular on the inner surface, and blocked or narrowed by coagula, often as high as the popliteal. Arterial embolism usually gives rise to the same form when it causes gangrene, but, as a rule, the collateral circulation enlarges sufficiently to prevent it. Excep- tionally, either because several trunks are plugged at the same time, or the condi- tion of the vessels round is such that they cannot dilate, the blood-supply is altogether cut off. It frequently occurs after endocarditis. The onset is sudden : there is a severe attack of pain in the course of an artery, generally where it bifurcates or gives off one or more large branches ; the part feels dead or numb, the temperature falls, the pulse below disappears, and then by degrees the skin passes through the same changes. Suppuration usually occurs while the dead part is being detached, because the living tissues next to it are too much injured to resist the action of the pyogenic micrococci. A certain amount of decomposition may be present, too, after this has taken place and supplied the necessary fluid, but so long as the general nutrition is good, there is little or no fever, and the death of the tissues is, except for the suppuration, limited to the original area. Symmetrical gangretie (Raynaud's disease) is very similar to this in its local changes ; but no lesion of any kind — embolism, thrombosis, or degeneration — has been found to account for it. Possibly it is due to arterial spasm arising from cold, and rendered persistent by a hyper-sensitive condition of the vaso-motor centres. It is usually met with in young an?emic subjects suffering from feeble circulation, and always attacks the extremities. In its slighter forms, cold, grayish-blue, ill-defined patches of local syncope or local asphyxia suddenly make their appearance after some trivial exposure, upon the hands or feet, or upon the pinna, very often symmetrically. After a time these may disappear, but occa- sionally the color remains pale or livid, then turns blue and purple, and finally becomes black. In some instances it is associated with haematinuria. Gangrene due to the direct effect of intense cold presents the same features (^frostbite). The part is frozen through ; the skin remains firm and white, and then passes through the same changes. This, of course, like all other forms, is more likely to occur when other causes, such as old age, starvation, fatigue, or exhaustion, exist ; and moist cold is certainly worse than dry. It rarely happens, however, in England that the temperature falls sufficiently for this. Usually, frostbite is caused by the too early application of warmth to a half-frozen surface, and the gangrene is moist. Slighter degrees of cold merely lead to vesication, 64 GENERAL PATHOLOGY OF SURGLCAL DISEASES. like heat, or superficial gangrene ; and the slightest, to an erythematous state in which the skin is deep red or livid, and subsequently, when warm, becomes painful and slightly swollen. Dry gangrene may also be caused by intense heat — the actual cautery, for example ; but, as a rule, in cases of burning, the tissues for long distances round are injured to such an extent that inflammation and suppuration follow. Potassa fusa, applied as it used to be when it was desired to form an issue, produces the same result — a limited, shriveled patch of blackened tissue, unable to undergo decomposition owing to the absence of fluid, and surrounded by a zone of sup- puration. A very rare form of arterial obstruction, due to endarteritis obliterans, some- times leads to the same result. I have known it occur in the vessels of the upper extremity, so that when amputation of the arm was performed, the brachial did not require ligature. The symptoms resemble tho.se of steadily advancing throm- bosis, attended with severe pain. Most of the cases have occurred after middle life, without any very obvious reason. All these forms of gangrene resemble each other in being practically unat- tended by decomposition. A portion of tissue is killed, either by being entirely deprived of blood, or by the action of some external agent. It acts as a foreign body, almost inert, so long as no other irritant is allowed to appear. The sur- rounding tissues are uninjured, and at once, if their nutrition is sufficiently good, commence the process of repair. Unhappily, in the senile form due to thrombosis (the most typical and the most common of them all), it usually happens that the clot extends farther and farther up the artery, so that successive portions of the limb become involved and perish ; and in any case the vitality of the part is very feeble. In other instances the blood-vessels round the injured area dilate ; lymph pours out through their walls, new vessels are developed, and. by degrees, a layer of vascular granulation-tissue (forming the so-called line of demarcation) is developed round the whole of the buried surface of the necrosed tissue. If this is small and completely surrounded, it may be absorbed and disappear entirely ; if it lies on the surface it gradually dries up, and is thrown off by the granulations beneath. Suppuration is not necessary for this process, although, unless the necrosed fragment is of very small size, it is nearlv always present. The pyogenic organ- isms gain access either through the air or through the blood-vessels or lymphatics. The plasma no longer coagulates, the leucocytes near the infected spot perish and form pus-corpuscles, and the walls of the vessels and the tissue, already organized, undergo coagulation-necrosis and melt away in the fluid. 2. Moist Gangrene. — This may commence as such, or it may be dry at first. Senile gangrene, for example, is very often dry until the calf is reached ; then, owing to the greater amount of fluid, decomposition sets in. Dry gangrene does not extend unless the original cause is repeated — unless, for example, the thrombus spreads higher up the artery. Moist gangrene, on the other hand, whatever the cause, spreads until it meets some structure suffi- ciently well-nourished to hold its own. The products of putrefaction, soaking into the living tissues near, lower their power of resistance, and if their nutrition is impaired in the least degree, or if the irritant is assisted by tension, want of rest, or any other cause, they must give way. If the conditions are exceedingly unfavorable, the surrounding tissues perish en masse (sloughing phagedena and hospital gangrene) ; if not quite so bad, if their vitality is merely impaired instead of being destroyed, they become inflamed, and as pyogenic organisms are always present in such circumstances, melt away as pus. Whether specific micro-organisms are present in many of these cases, as well as septic and pyogenic ones, is uncertain, and the difficulty is especially great in connection with such disea.ses as cancrum oris and phagedena. None, however, has yet been proved, and in the absence of this, it is more reasonable to assume that these diseases, attended with very characteristic and extensive destruction, GANGRENE. 65 are tlie result of the ordinary germs, acting under conditions peculiarly favorable to them : overcrowding, for instance, and poisoning by foul air, in the case of hospital gangrene ; and syphilis in the case of phageda^na. The simplest examjjle of moist gangrene is seen in a lacerated wound. A portion of the tissue is killed, it remains for two or three days adherent to the surface, slowly changing color, and then cpiietly drops off, detached from the part that is living by the vascular lymi)h thrown out. If it is very tough and hard — tendon, for example, or bone — so that the blood-vessels are scanty and unable to dilate, the process may take weeks instead of days. Bed-sores, due partly to pressure, partly to the irritation of urine and retained ])erspiration, are examples on a larger scale. The skin at first is reddened, then fluid collects beneath the epidermis ; this gives way, exposing the corium ; and the continued irritation and pressure combined soon cause it to slough. Decom- position sets in, and the poison so formed, added to the already existing causes, kills the tissues round until a part is reached where the vitality and power of resistance are sufficiently good. Nearly all forms of gangrene that are dry at first end in this way. Even if the centre remains hard and resists putrefaction, suppuration occurs around the margin, and the pus provides a sufficient amount of fluid for putrefaction. For- tunately, as a rule, by the time this has happened the tissues around the slough have recovered themselves, and have erected a barrier of young and vascular granulation-tissue, which may lose its surface as pus, but nothing deeper. When a limb is run over and crushed, or when a large artery gives way sub- cutaneously and cuts off the circulation by the pressure it causes {local traumatic goTigrejic), the changes are the same at first. Immediately after the accident the limb is cold and loses its sensibility, the skin is even whiter than natural, and is stretched and tense from the extravasation beneath, and the pulse cannot be felt. Then the color gradually becomes dusky and livid, especially toward the lower part, to which the blood gravitates ; purple and green patches make their appear- ance ; bullae form, filled with a reddish fluid ; the epidermis is detached from the corium beneath ; emphysematous crackling can be felt here and there, and the odor is most offensive. The subsequent course, whether the gangrene remains local or begins to spread, depends upon the power of resistance of the tissues that are .still living, to the combined irritants. If the size of the slough is small, the tension low, and the condition of nutrition good, the tissues soon protect themselves, and a line of demarcation gradually forms. If, on the other hand, the part involved is large, such as a limb, and the tension in it is high, the products of decomposition, unable to escape, spread into all the cellular spaces in the living structures near, and stream into the lymphatics, poisoning everything they touch, and causing intense inflammation. The local traumatic gangrene, assisted by decomposition, has begun to spread. The worst example of spreadiiig traumatic gangrene met with at the present day is that which sometimes occurs after compound (open) fractures, especially those due to direct violence. There is everything to favor its occurrence and its exten- sion ; an enormous extravasation at a high temperature ; a wound, so that decom- position can begin at once ; the opening usually valvular, so that the tension from the hypergemia that follows must be high ; fractured, and often dead, bone, which in some particular way is exceedingly favorable to decomposition ; and all the cellular spaces in the tissues round widely open still, with no protecting barrier of lymph. Under conditions such as these it is no wonder that, if septic decompo- sition occurs, and the products are not allowed to escape, spreading traumatic gangrene of the worst description follows. The part swells more and more ; the skin is tense, red, and burning hot ; the loose cellular tissue on the inner side of the limb and along the great vessels is boggy and oedematous, filled with a sero- purulent fluid which rapidly decomi^oses and causes emphysematous crackling ; the redness keeps spreading farther and farther, round the seat of injury it gradually 66 GENERAL PATHOLOGY OF SURGICAL DISEASES. becomes dull and livid, then the cuticle separates, the tissue becomes soft, and, if the patient live sufficiently long, the whole part decomposes. As described above, if the vitality is already depressed from other causes, constitutional or local (Bright's disease, for example, or cold), spreading trauma- tic gangrene will follow even when the irritant is comparatively slight. Local traumatic gangrene, unless the part is exceedingly small and the escape absolutely free, is always attended with fever. Even when there is only a lacerated wound with a few shreds hanging from it, there is some absorption, which dimin- ishes as the tissues become by degrees able to protect themselves. In the spread- ing form, setting in at once, before the cellular spaces, are closed, with an immense amount of poison and very high tension, the absorption is naturally excessive, and the constitutional disturbance may prove fatal in the first few days. In some cases the temperature rapidly runs up to 104° or 105° F.; the pulse is full and quick, and the respiration hurried and rapid. In others, and they are usually the worst, it scarcely rises at all, the pulse is small and feeble, the patient is delirious, the face is dusky, the tongue dry and brown, and the symptoms are typhoid from the beginning. If the patient survives the period of spreading gangrene, and the tissues gain the upper hand, resisting the further advance of the irritant, and throwing out a wall of vascular lymph, the fever begins to fall, especially of a morning, and assumes the remittent type, characteristic of suppuration without free exit for the pus. Given local traumatic gangrene — a part of the body, that is to say, killed by injury of any kind — the consequences, whether a line of demarcation forms, or inflammation and suppuration set in, or spreading gangrene follows, depend upon the vigor of resistance offered by the tissues, and the degree to which they are protected from other irritants. If they are healthy constitutionally, and were not injured when the neighboring part was killed, and are not injured by any other agent (tension, want of rest, or decomposition), lymph is thrown out, and repair is commenced at once. If they fail to a slight extent in one or more of these conditions — if, that is to say, their vitality is lowered — inflammation sets in and spreads until a healthier part, capable of better resistance, is reached. If they fail seriously — if their vitality is destroyed — the gangrene spreads. Treatment. — The general principles are the same in all forms, but special measures have to be adopted in the case of some of them. 1. Constitutional. — The reis always well-marked general depression; very often it is one of the predisposing causes, weakening the tissues and rendering them more susceptible to the action of injurious agents, and if not already present it always makes its appearance in the course of the disease. Everything, therefore, must be done to husband and maintain the general strength ; food must be nutri- tious but easily assimilated, and given, therefore, in small quantities at frequent intervals. Stimulants are required to assist digestion, or, if the heart is weak and the pulse feeble, to maintain the circulation. Opium may be given to relieve pain and procure sleep. Fresh air is absolutely necessary, particularly if decomposition is going on, and special attention must be paid to any constitutional disorder that may be present, such as Bright's disease or diabetes, ^^ery great care, however, is required in the matter of food, especially in the case of old people. It often happens that for years past they have taken it in exceedingly small quantities, their strength being economized to the utmost by rest and warmth, and any attempt to increase it only defeats its own end. Under the.se conditions it is not uncommon to find that comparatively large quantities of stimulants, especially brandy, are very well borne; and, provided the surrounding temperature is carefully main- tained, enable the patient to tide over the crisis. 2. Local, (i) Preventive. — Sometimes when the onset is gradual the cause of the gangrene can be removed in time. The constriction may be divided, for example, in the case of a strangulated hernia or paraphimosis : the tension relieved by timely incision in phlegmonous erysipelas or cellulitis, and the pres- sure in bed-sores distributed over a wider area, or transposed to another part of GANGRENE. 67 the body altoj^^ether. In many cases, however — especially those in which the blood-sui)i)ly is cut olT — any measure of this kind must be too late. (ii) Where this cannot be done, an attempt must be made to stay the pro- gress of the disease by preventing the repetition of the original cause and the access of any other. The circulation must be assisted in every po.ssiblc way. The part should be raised, .so that veins and lymphatics can empty themselves with ease ; the tempera- ture kept perfectly even, and absolute rest enforced. Nothing answers so well as investing the whole limb in cotton-wool, which may be impregnated with .some antiseptic to assist in checking decomposition ; poultices should always be avoided, and wet fomentations, which, by the moisture they contain, encourage the soften- ing of the epidermis. In some cases of senile gangrene, in which there is no surrounding inflammation, and the skin of the limb is not tender, gentle upward friction is of service, as it tends to emjjty the veins and increase the flow through the neighboring tissues. The least tension in any part must be relieved at once. Free incisions are often required, not only to reduce the pressure upon the skin, and prevent it sloughing, but, by giving exit to pent-up fluids, to check absorption and allow the blood to circulate more freely. The wide gaping of the cuts, the continued drain- ing from their edges not only of blood, but of inflammatory exudation, and the wrinkling of the skin on the following day, afford a very good explanation of the fall in the temperature and the diminution in the fever that always follow. [Application of external heat, by means of hot-water bags, will be found useful, not only in treatment, but as one of the aids to prevention.] Decomposition must be prevented. This may be accomplished in various ways. In many forms of local traumatic gangrene — where, for example, the fingers have been crushed, and it is not known how much is hopeless — prolonged warm and antiseptic baths are most beneficial. If the part is only small, corro- sive sublimate (one part in ten thousand) may be used for several hours a day at first, and then, when the putrefactive odor is overcome, for an hour night and morning. If the part is too large, so that absorption is feared, or if the patient complains of pain, boracic acid may be substituted, but it is not so efficacious. The injured part is dependent, it is true, especially when the lower extremity is concerned, but this disadvantage is fully compensated for by the relaxation of all the tense and inflamed tissues, by the regularity of the temperature, the free escape for the inflammatory exudation, and the impossibility of decomposition. When, on the other hand, the gangrene has a tendency to become dry, absorbent dressings and iodoform should be used. Salicylic wool, wood-wool impregnated with corrosive sublimate, moss treated in the same way — anything, in short, that checks putrefaction — succeeds in proportion to its power of absorption. The dressing, however, unless the gangrene is of the driest type, needs changing frequently, for fear that a solid mass of dried discharge may form like a scab over the ulcerating surface and keep the fluid beneath pent up. At the same time ten- sion should be relieved by suitable measures, gentle compression, elevation, and even incision, and sloughs or portions of dead tissues removed as soon as they are loose. The greatest care must be taken, of course, not to injure or irritate in any way the protecting barrier of granulations : this has been formed by tissues that are only just able to hold their own, and no more ; and the least damage done to them at once causes the sloughing to spread ; but this is no reason why parts which are clearly dead, and which can be removed without injury to those around, should not be taken away as soon as they can. As. the line of demarcation forms and gradually grows deeper and more defined, the sloughs of the soft parts usually separate of themselves, until at length the bone is left with — hanging around it — tendons and dense sheets of fascia, which, owing to the anatomical condition of the circulation, are only detached after prolonged suppuration. Sometimes when this is the case the soft parts may be very gently retracted, lateral incisions being made to give more room, and the 68 GENERAL PATHOLOGY OF SURGLCAL DLSEASES. projecting structures carefully divided ; otherwise the natural jjrocess of separation may take an immense length of time ; but this should not be attempted until the spreading of the gangrene is no longer feared. (iii) AiHputation. — In local traumatic gangrene — such, for example, as results from the rupture of a large artery, with or without fracture — amputation should be performed at once, sufficiently far above the seat of injury to secure healthy flaps. It means that the attempt made to save the limb has failed ; and if gangrene begins, it is certain to spread as high as the seat of injury, and very likely not stop there. Nothing, therefore, is gained by waiting. In spreading traumatic gangrene the conditions are different. If it is due mainly, or even in part, to constitutional causes, amputation higher up would be followed by the same consequences. In some very rare cases, however, it is purely local, due to the presence of a poison retained under high tension, usually decomposing, extravasated blood ; and then it is just possible that amputation higher up, performed sufficiently early, would succeed ; but in such cases as good a result may be obtained by free incision, relieving the tension and checking absorption. In no other case should amputation be performed until the line of demarca- tion is well established ; and even then, in the majority, it is wiser to wait until all the soft parts have separated and the wound so left is beginning to cicatrize. Excision of the projecting end of the bone, even with a certain amount of soft tissues round it, is a very much less serious operation than a formally planned amputation ; and, unless the patient is being exhausted by suppuration, is always to be preferred. Owing to the conical shape of the stump left by gangrene some- thing of this kind is always required. [It is the danger of the production of septicaemia that causes us to override this injunction frequently. The carrying into the circulation of highly infectious material is so dangerous to the patient, that early amputation must be done in many cases.] Special Forms of Gangrene. — Senile Gangrene. — Nutritious, digestible food, with a reasonable supply of stimulants ; rest, elevation, and equable warmth, are here the most important measures. The part should be well sprinkled with iodoform, and then covered up thickly with many layers of cotton-wool. Care must be taken never to keep it exposed for any length of time, and not to allow hot w^ater bottles too near. Poultices should not be applied under any circumstances. In this form of gangrene, in particular, opium is of the greatest value, and it has been said that recovery or not may be foretold from the way in which the patient stands its administration. Hutchinson has recently advocated high amputation (through the lower third of the thigh) in both the dry and the inflammatory form of senile gangrene : the limb is usually small and wasted at that point ; the artery is sound in Hunter's canal ; the flaps are well supplied with blood ; and old peoi)le, as a rule, resent operation very slightly ; their tissues are not prone to inflammation. The alter- native is to let the part alone, confining the patient practically to one position in bed, until a line of demarcation has formed, leaving a very conical stump, which does not heal of itself, and Avhich does not admit of being interfered with. Prob- ably, in many cases, in spite of the apparent severity of the operation, such a measure is really advisable, not, of course, if the gangrene is limited to the toes, or even to the front part of the foot, but if it extends to, or in the least degree above, the ankle. If it spreads to the calf, even the driest form is exceedingly liable to become moist, and then the inflammation nearly always proves fatal. In frostbite the greatest care must be taken not to warm the part too soon ; if it is exposed even to a moderate temperature before the circulation has recovered, moist gangrene is almost sure to follow. Amputation should never be performed until the line of demarcation is deeply cut. In that form which is due to embolism the same rule practically holds good, although an operation may be performed somewhat sooner ; the surrounding tissues PHAGEDENA— HOSPITAL GANGRENE. 69 are not so badly injured. J'he constitutional disturbance, however, in these cases is very rarely severe, and the risk of septic absorption very slight. PHAGEDENA. Phagedena is an exceedingly rapid form of molecular disintegration or ulcera- tion, chiefly met with at the present day in connection with syphilis. There is, in the ordinary variety, no sloughing, swelling, oedema, or extensive redness; simply the ba.se and the edges of the ulcer affected l)y it become liquid and melt away. In another variety, however, which is much more rare, sloughing is present as well, the surrounding tissues becoming swollen, tense, and hard, and then gradually turning black. No specific organism has ever been proved to exist, and it seems more reasonable to assume that the ulceration becomes phagedaenic because of certain predisposing causes, of which syphilis is a very important one. Exposure to cold and wet, privation, and extreme youth are probably not without influence. In the vast majority of ca.ses primary syphilitic sores that become jjhagedaenic (sixteen out of seventeen, according to my notes on the sub- ject) are followed by secondary syphilitic symptoms. Constitutional treatment is of very great importance. Phagedena may arise in connection with syphilis in people who are apparently strong and otherwise healthy ; but it is much more frequent in those who are broken down from long- continued exposure and intemperance. When it is practicable, nothing succeeds so well as prolonged warm baths and iodoform ; the former during the daytime, for from eight to ten hours, the latter dusted on at night. The ulceration nearly always ceases to spread at once, and the sore begins to throw out granulations. If this cannot be done iodoform may be. used alone, or if the sore is in such a position — on the ala of the nose, for example — that it is absolutely necessary to stop the extension at once, the patient should be placed under an anaesthetic and the acid nitrate of mercury applied freely. The pain, which lasts for twenty-four hours, may be controlled to some extent by using a lotion of cocaine, renewing it frequently. Unless the existence of syphilis can be definitely excluded, a mild mercurial course (Hyd. c, cret. gr. ij, gm. 12, with Dover's powder night and morning) should be com- menced without delay. HOSPITAL GANGRENE. Hospital gangrene bears the same relation to ordinary traumatic gangrene that phagedcena does to ulceration ; sometimes it is known as sloughing phage- dsena. It is a form of gangrene which breaks out under certain conditions that used to be of frequent occurrence in connection with hospitals, and attacks every kind of wound, small as well as large. It spreads with the greatest rapidity and is intensely contagious. The surface of the wound is covered with micrococci, which extend deeply into the substance of the tissues, destroying them wherever they come in contact with them. Whether they are the ordinary forms of staphy- lococcus and streptococcus working under peculiarly favorable conditions, or whether they are specific, is not known ; the former view is the more probable, as hospital gangrene never occurs except under certain conditions, and apparently never fails to be produced by them. Overcrowding and absence of ventilation will cause it anywhere ; probably the intensely poi.sonous substances produced in these circumstances, soaking gradually into the tissues for days and weeks together, impair their vitality to such an extent that the ordinary germs are able to act with the most unusual energy and produce the most disastrous results. The general nutrition is in the same condition as that of the case already mentioned, in which gangrene of both legs followed after primary amputation of the feet, only the cause is a different one. [The treatment of hospital gangrene requires the careful removal of the 70 GENERAL PATHOLOGY OF SURGLCAL DISEASES. sloughing parts with the forcei)s and scissors, and the appUcation of bromine sohition as strong as may be necessary.] In connection with this, it is noteworthy that sloiigliing celluHtis of the most intense description occurs in some cases of snake-bite, and in some forms of post- mortem poisoning, and, what is very significant, not always in the neighborhood of the wound. In the former of these at least it is practically certain that the gangrene is due to the virulence of an alkaloid, which, though it is not sufficient to kill the tissues at once, lowers their vitality to such an extent that they fall an easy prey to the micro-organisms that enter from time to time into the blood. In the latter — when, for example, all the cellular tissue on the side of the thorax becomes gangrenous forty-eight hours after a punctured wound of the finger — the same explanation is highly probable ; and it does not seem unlikely that hospital gangrene is really due to saturation of the blood with the scarcely less virulent poison thrown off by the lungs in cases of overcrowding. PHLEGMONOUS INFLAMMATION. Diffuse inflammation of the cellular tissue and skin, the so-called phlegmon- ous erysipelas, is another product of the ordinary micrococci of suppuration acting under peculiarly favorable circumstances. In many respects it resembles true erysipelas, especially in the conditions under which it occurs, but in its nature it is essentially different. Like erysipelas, it usually spreads from a wound ; those who are broken down in health from intemperance, exposure, and particularly Bright' s disease, are much more prone to it than others ; and in a very large pro- portion of cases a streptococcus is found in connection with it. But, on the other hand, it is not infectious, although it is in the highest degree contagious ; it always ends in suppuration and sloughing ; it may follow injuries of the most varied description — post-mortem wounds, bites of reptiles, or the sting of a wasp ; it attacks deep-seated parts of the body, such as the pelvic cellular tissue, after parturition or lithotomy ; and it is never accompanied by the characteristic, well- defined rash always present in true erysipelas. The affection of the skin is an altogether secondary complication, which may or may not be present, according to the original seat of inflammation. Further, the streptococcus, which is undoubtedly the ordinary S. pyogenes, is not confined to the lymphatics, as in the case of the S. erysipelatis, but migrates freely beyond into the cellular spaces, and penetrates through the adventitia of the vessels into their interior. Causes. — In some rare cases diffuse inflammation originates without a wound. Nearly always, however, an injury of this kind is present, opening up the submu- cous or the subcutaneous cellular tissue, or the deeper planes among the muscles or round the bones. When there is none, the germs — as in acute infective osteomy- elitis — gain access to the part through the blood. Occasionally the inflammation commences some little distance from the seat of infection ; and exceptionally it does not attain any great degree of severity until this is healed. The predisposing conditions are general and local. The former are those already mentioned in connection with gangrene — diabetes. Bright' s disease, the consequences of exposure, intemperance, starvation, and, briefly, everything that tends to interfere with the elimination of waste product or impair the general nutrition. Overcrowding and bad ventilation are very important in this respect ; probably their influence is due to the poisonous substances exhaled from the lungs, which, even when breathed for a short time, produce the most extreme depression. The local conditions are very simple : imperfect drainage, especially if there is a cavity filled with extravasated blood, is sure to cause it. It is for this reason that diffuse inflammation of the most disastrous character is so common after com- pound fractures or penetrating wounds of joints. Decomposition occurs under high tension before the tissues are able to protect themselves in the least, and the products are driven into the loose cellular interspaces, poisoning and destroying PHLEGMONOUS INFLAMMATION. 71 everything they touch. For the same reason the coiiditioii of the uterus after parturition, with an enormous development of celhilar and lymphatic tissue in the region of the cervix, renders it particularly susce])til)le. Bruising and tearing the structures round in performing an operation — in other words, lowering their vitality and hlling them with extravasated blood — greatly increases the liability to it. It is partly owing to this, partly to the effect of renal disease, that diffuse inflammation of the pelvic cellular tissue is so common and so fatal after lithotomy when the calculus is a large one. In other cases it is due to the local effects of virulent chemical poisons. Diffuse celhditis of the neck, for example, may result from the sting of a wasp, and sloughing over a very large surface has been known to follow the bite of a poisonous snake. Probably the alkaloid injected into the tissues lowers their vitality to such an extent that they are unable to offer any resistance to the micrococci, which are constantly finding their way into the blood. Whether the extremely fatal form of diffuse cellulitis which accompanies post-mortem wounds in cases of puerperal peritonitis is due to a similar alkaloid, or whether, on the other hand, it is the result of septic infection (infection, that is to say, with a living organism) is uncertain. The fact that the virulence of the poison diminishes rapidly as putrefaction sets in is consistent with either view ; the exceedingly early occurrence of the symptoms favors the former. Symptoms, i. Constitutional. — These vary greatly in severity, in the worst forms, such as those arising from post-mortem wounds, they are practi- cally the same as in spreading traumatic gangrene. They a.ssume a typhoid character almost from the first ; there may be a rigor or a succession of chills : the temperature rises rapidly to 105° or 106° F.; the tongue is dry and brown, the skin burning hot, the face dusky, and the pulse so small and quick that it is scarcely possible to count it. Delirium may set in, sometimes with profuse sweating, within twenty-four hours, and the result may be fatal, from the most acute form of septic poisoning, within the first few days. In pelvic cellulitis after parturition or lithotomy, the effect is almost as rapid, the patient sinking into a semi-unconscious, wandering state, with an irregular, feeble pulse, extremely high temperature, and the most profound nervous prostra- tion. When the cellular tissue of the limb is concerned, where the poison is not so intense or the absorption so rapid, the symptoms are less .severe, and usually assume the sthenic form, but the fever continues high and very irregular for days and weeks ; the emaciation and exhaustion are extreme ; there is always the danger of pneumonia and pleurisy, or, if the head or face is involved (par- ticularly the orbit), of suppurative meningitis; and if the patient survives the period of sloughing and acute absorption, pyaemia not uncommonly supervenes or hectic and diarrhoea follow, or the prostration is so great that some comparatively slight disorder sets in and proves fatal. 2. Local. — These naturally vary with the structure of the part, but the swell- ing is always very great, soft and oedematous at first, then becoming hard and brawny, and later, as the cellular tissue sloughs, softening again and becoming boggy. On the scalp it is usually due to wounds that open up the sub-aponeurotic layers ; the cedema spreads rapidly over the vertex, extending down to the eyelids in front, to the superior curved line or the occipital bone behind, and the zygoma on either side. The skin is exceedingly tender, but there is very little redness ; the glands in the neck are enlarged and swollen, and there is always intense head- ache and not unfrequently delirium. When it involves the orbit, the eyelids are immensely swollen, the conjunctiva is reddened and chemosed, the globe is pushed forward and fixed, and the pain is most intense. If the symptoms do not soon subside, the cornea becomes opaque and sloughs, the eyeball is completely disorganized, and there is very great danger of the inflammation extending along the veins or lymphatics to the sinuses of the cranium or the meninges, leading to thrombotic pyasmia or acute meningitis. Diffuse inflammation of the cellular tissue of the neck is no less serious. 72 GENERAL PATHOLOGY OF SURGLCAL DLSEASES. Usually it commences in the submaxillary region, caused, in all probability, by the absorption of some poison from the mouth. The swelling extends rapidly downward, beneath the deep cervical fascia, giving rise to the most intense pain, with violent constitutional disturbance, and pressing upon the veins and the trachea. Sometimes, even, it reaches to the mediastinum and involves the pleura or pericardium. The skin is white and tense, the swelling exceedingly hard and very painful, and any movement is impossible. In acute pelvic cellulitis the local symptoms resemble those of peritonitis, in which it often ends, except that the boundaries of the swelling are generally more defined. In the more chronic cases the uterus is fixed, and a hard mass is left projecting above the brim of the pelvis when deep pressure is made in the iliac fossa. If suppuration follows, the abscess may point in the iliac region above Poupart's ligament, or it may present in Douglas's pouch, or extend into the thigh, or the psoas muscle, or reach even as high as the kidney. In the case of the limbs, diffuse inflammation nearly always originates from a poisoned wound, a punctured wound of a joint, or a compound fracture. Occa- sionally it occurs in connection with acute suppurative periostitis. When the deeper planes are involved, the skin is tense, white, and cedematous, but burning hot to the touch and exceedingly tender. Very often it is mottled with dusky red patches, which correspond to the places of communication with the deep veins. The pain is extreme, of a tense, throbbing character, and movement is out of the question. Usually the inflammation extends higher up the inner side of the limb than the outer, very often following the course of the large vessels ; and the neigh- boring lymphatic glands are always enlarged and tender. When the part affected is the subcutaneous layer, the symptoms are for the most part the same, but the color is a deep, dusky red, shading off imperceptibly, not, as in erysipelas, with a sharply-defined margin. At first the skin is soft and pits on pressure ; then it becomes hard and brawny ; vesicles and blebs form upon the surface ; the color grows deeper and deeper, in one or two places it becomes almost purple, and then, here and there, it softens and becomes boggy to the touch. In other words, the subcutaneous cellular tissue has passed through the stages of extreme hyperaemia and exudation, and has sloughed ; in some places, if it is cut into, it is soft and gelatinous, distended with a sero-purulent fluid, which can be squeezed out of it like water from a sponge ; in others it has practically disappeared, and nothing is left but a sheet of pus, without any definite limits, mixed with the shreds and sloughs of the fasciae and the tougher parts of the connective tissue. Later still, if no incisions are made, the skin itself perishes, cut oft" from all source of nutri- tion except where some of the larger vessels enter it from the inter-muscular septa beneath ; here, in general, a few islets still persist in the middle of the destruc- tion. In the worst ca.ses, in which nothing has been done to relieve the tension, the fasciae and muscles are bared and dissected away from each other, the joints are opened, the bones exposed, and the limb is reduced to a perfectly hopeless condition. Prognosis. — The prognosis in the case of diffuse inflammation of the cellular tissue is always exceedingly grave. If the head is involved, portions of the scalp may slough, the pericranium may perish, and osteophlebitis, pyaemia, or menin- gitis follow. In the case of the orbit the danger is even greater, and at best the eye is almost sure to be destroyed. The inflammation may spread from the cellu- lar tissue of the neck to the pleura or pericardium, or it may prove fatal from extending to the larynx. After lithotomy it is practically hopeless. Even when one of the limbs only is concerned the danger is very great. Osteophlebitis, lymphangitis, or pyaemia may follow at any time. The inflammation may spread to the neighboring joints and lead to acute suppurative arthritis. The bones may necrose, the great vessels may be injured, and even when all these more serious consequences are escaped, the limb may be rendered useless and become a constant source of pain from the sloughing of the subcutaneous and inter-muscular cellular tissue. The wounds heal slowlv ; the cicatrices are adherent to the muscles or the PJILEGMOXOUS INFLAM.\rATION. 73 bones, so that they are constantly breaking down ; the lymphatics are destroyed ; solid ftdema sets in ; and, even after the most successful treatment, the part is left stiffened, cold, congested, and jjractically useless for active movement for months and even for life. Treatment. — In the most acute form of diffuse inflammation the prostration is so extreme and the heart fails so rajjidly that very little can be done. Stimu- lants — ammonia, ether, and l)randy — must be given freely as long as the jjatient can absorb them. Sometimes, when the constitution is otherwise healthy, and the effect is due to the local absorption of a chemical poison, it is possible to tide over the crisis, and under these circumstances enormous c[uantities may be given with very great benefit; but this is of no avail if the production of the poison con- tinues. In cases that are less severe, in which the immediate danger is not so great, careful watch must be kept upon the pulse, and everything must be done to sujjport the patient's strength. It must always be remembered that, unless it is the result of some very grave injury, diffuse inflammation rarely occurs except in those whose constitutions are thoroughly broken down, whose strength is exhausted, and who have been accustomed to the free use of stimulants for years past ; but, if possible, remedies of this kind should never be given alone, always in small quan- tities at a time, with beef-essence, milk, eggs beaten up, and other foods that possess a more lasting value. The local treatment is no less important. Everything must be done to check absorption from the surface of the wound and diminish the tension. Cold is of less value in these cases than in other forms of inflammation. The vitality of the part is already very feeble, and there is some danger of causing gangrene. If suppuration has not yet occurred, elevation and gentle elastic compression with many layers of cotton-wool may be tried ; if, however, this stage is already passed, more good may be done by means of warm fomentations and long-continued warm baths, assisted by thorough drainage. If the skin is hard and brawny, with severe pain and throbbing, incisions should be made without hesitation. It is no use waiting until fluctuation, or even local softening, can be detected ; they should be made before this, for the purpose of relieving the tension and allowing the inflammatory exudation to drain away. It is better to make them where the need is not absolutely certain than to leave them unmade. The depth to which they should be carried varies naturally with that of the inflammation : in most cases it is not necessary to do more than incise the deep fascise, and, as a rule, they should not be more than an inch and a half or two inches long. In planning them regard should, of course, be paid to the position of important structures and the natural folds of the part. The hemor- rhage is not unfrequently profuse for a short time, but it can always be checked by the pressure of some absorbent gauze or other similar material. Afterward warm fomentations may be continued, so as to encourage the discharge as much as possible. Other incisions may be necessary after the inflammation has ceased to spread, for the purpose of releasing sloughs or to give better exit to the discharges ; and then, as granulations spring up, every attempt must be made to procure cicatriza- tion as soon as possible. Some contraction is nearly always left, and often the tissues are extensively matted together, so that they remain cold and cedematous, but if the part is not hopelessly disorganized, very great improvement may gener- ally be effected by constantly-repeated massage, warm douches, and shampooing. In the worst cases, in which the joints are involved or the skin is extensively destroyed, amputation may be required, but it should not be performed until the acute symptoms shall have subsided. 74 GENERAL PATHOLOGY OF SURGICAL DISEASES. PY.^MIA. Pyaemia is an infective disorder, caused by the ordinary pyogenic micro- organisms, and distinguished from the other affections to which they give rise by the unusual prominence of some of the clinical and pathological features — rigors, metastatic abscesses, and diffuse inflammation of the serous and synovial mem- branes in particular. It is not a specific disease ; there is no evidence that other organisms than the ordinary pyogenic ones, the staphylococci and streptococci, are ever present. It is not even a disease of itself; it is merely the product of the ordinary germs that cause suppuration acting under peculiar conditions. If these organisms are rubbed into the skin so that the hair follicles are affected, they cause boils; under other circumstances, where the subcutaneous tissue is espe- cially dense, they give rise to carbuncles ; when the tissues are poisoned, either by the products of septic decomposition or by the ptomaine of a snake-bite, diffuse cellulitis follows ; if syphilis is present, phagedaena may occur ; if the body is poisoned by the inhalation of the exceedingly virulent substance thrown off by the lungs, hospital gangrene and sloughing of the most extensive character are produced ; and under certain conditions they give rise to pyaemia. The anatomical structure of the injured part is one. Pyaemia is especially liable to occur in injuries of parts in which there are large veins unable to collapse — such, for example, as the diploe of the skull, the medulla of other bones, and tissues infiltrated Avith inflammatory deposit. The method of dissemination is another, dependent to some extent upon this. In diffuse inflammation of the cellular tissue, the organisms spread either by means of the lymphatics, or in the connective-tissue spaces ; in pyaemia, the vehicle is the blood itself. For this reason, too, the infection is not a slow and gradual process, in which the neigh- boring tissues are overcome layer by layer in a widening circle, but immense quantities suddenly enter into the circulation, and are carried at once to a distant part. Another condition of very great importance is the presence of some foreign material in the blood-stream to cause embolism. The usual one is a fragment from some disintegrating blood-clot ; but experimentally it has been shown that perfectly inert matter, which can only act mechanically, is quite capable of pro- ducing the same effect. The mere presence of pus-microbes in the circulation (unless the amount is so large that they of themselves act as an embolus) is not sufficient to cause pyaemia ; but if particles of cinnabar are injected at the same time, so that they become impacted in the arterioles and injure the endothelial lining of the vessels, characteristic metatastic abscesses are produced. That form of pyaemia in which diffuse inflammation only occurs, without evidence of embol- ism, is distinguished sometimes as pyaemia simplex. In addition to these there are other conditions, less well known, which probably are not without influence ; the sudden entry into the circulation, for example, of considerable quantities of broken-down blood-clot, causing fever ; the development, in connection with the inflammation of bone, of substances which render the pus produced under these circumstances peculiarly offensive ; possibly, the inefficient excretion of the ptomaines generated in the alimentary canal when the kidneys are diseased ; peculiarities of the patient's constitution, etc. They do not cause the pyaemia themselves ; they merely determine its outbreak instead of, or in addition to, other forms of suppurative inflammation occasioned by the same germs. Defective ventilation, want of cleanliness, the use of ward sponges, over- crowding, especially the collection together of supi)urating wounds, and, briefly, all the circumstances that favor the development of the other forms of infective disease, favor equally that of pyaemia. Pathology. — The blood generally coagulates well ; as a rule, there is a great increase in the number of white corpuscles, while the red ones show signs of disintegration, breaking up into molecules and forming irregular masses without running into rouleaux. Cocci may often be found in abundance, both free and in the white corpuscles. PYEMIA. 75 Sonictinics the wound is ai)i)art.'iuly healing well, although a certain amount of suppuration is nearly invariable. More frequently it is foul and sloughing, with an offensive or ichorous discharge. 'I'he veins running from it are usually filled with softened clot ; the infective organisms spread from the surface of the wound to the cellular tissue around the vessels and invade their walls ; as the intima is approached a thrombus forms, and spreads farther and farther along the interior in advance of the inflammation. If the tissues are healthy, this j)revents general infection ; organization sets in, and the jjoison is shut off. If, on the other hand, the nutrition of the ti.ssues is feeble, or the j)ower of the germs unusally great, or a fresh injury of any kind is inflicted upon the part, degeneration follows instead of organization ; the clot softens and breaks down ; fragments of it are carried off into the blood-stream ; and with them the cocci which have gradually worked their way through the wall. When pyaemia starts from a wound that is healing without suppuration, or, as in acute suppurative osteomyelitis, when there is no wound at all, the thrombosis must be explained in another way. The micro-organisms of suppuration are of common occurrence in the circulation — at least, they can enter easily enough ; ordinarily they are innocuous ; the tissues are able to resist their action ; if, however, nutrition fails, whether from constitutional or local causes, or the endothelial lining of the vessels is injured, at once they make good their hold, coagulation-necrosis begins in the vessels, thrombi are formed, and, if the other conditions are favorable, pyaemia follows. Intravascular infection of this- kind may occur even in children who are to all appearance in perfect health. Probably in them it is rendered possible by some temporary depressing cause : want, injury, over-exertion, or exhaustion and fatigue. When pyaemia has already developed, it is of frequent occurrence, and thrombosis in distant parts of the body, especially in places that have been bruised or injured, with the attendant consequences of embolism and metastatic abscesses, is one of the usual symptoms. Infection with pyogenic micrococci (whether they come through the walls of the vessels at the seat of injury, or enter in other ways), with its attendant throm- bosis, leads to two kinds of abscess, one arising in connection with the veins and capillaries, the other embolic. a. Of these, the former may begin either in the neighljorhood of the wound, or in some distant part to which the micro-organisms circulating in the blood have been carried, and in which they have been arrested. In either case, the process and the consequences are the same. Thrombosis sets in ; a ring of coagulation- necrosis forms round the germs ; liquefaction follows ; the clot, and then the walls of the vessels and the surrounding tissues, break down and melt away ; and in a very short space of time an irregular cavity is formed, filled with a thin oily pus, colored in general from the mixture of a small quantity of haemoglobin, and surrounded by tissues that are undergoing disintegration as rapidly as they .can. The suppuration is always diffuse ; there is no evidence of organization, and no sign of limitation anywhere. The connective tissue between the muscles melts away, leaving them literally dissected out by the pus ; the synovial cavity of a joint, or a tendon sheath, is filled within a i^^x hours ; or one of the serous sacs is involved in the same way. In other words, there is diffuse inflammation of the cellular tissue, followed by suppuration and sloughing, as in the worst form of the so-called phlegmonous erysipelas. b. Embolic absces.ses occur in a different way. The thrombi in the veins, softened by the action of the micrococci, break clown ; loose particles are carried off in the blood-stream, and pa.ssing through the heart are driven into the vessels of the lungs. The smaller ones may pass through these, and then later be stopped elsewhere — in the liver, for example ; the larger ones are arrested at the bifurcation of a vessel, and give rise to embolic abscesses. The effect of a non-infective embolus depends upon the arrangement of the blood-vessels. If the collateral circulation through the part is good, no ill-result follows other than the obliteration of a short segment of the vessel. If the blood- 76 GENERAL PATHOLOGY OF SURGLCAL DLSEASES. supply is entirely cut off, local an?emia and gradual disintegration ensue; but if, as in the case of the lungs, there is a condition intermediate between these two, the blood pours in from all sides, without strength sufficient to force its way out ; the part becomes more and more congested ; the walls of the vessels give way ; the blood is extravasated into the tissues, and at length, when coagulation supervenes, the whole area is converted into a solid conical block. This is known as hemor- rhagic infarction. It is common in the lungs and spleen, the base of the cone lying toward the serous surface; but it never occurs in the liver or the subcuta- neous tissue. When the embolus is infective from the presence of jjyogenic micro-organisms, the same result ensues, but almost at once coagulation-necrosis follows, the central portion becomes liquid, and in a very short time the whole area of the infection, and the tissues for some distance round, are converted into pus. The change is so rapid as to resemble gangrene rather than ordinary suppuration. The pathological appearances in a fatal case of pyaemia consist, therefore, with the exception of the changes in the veins, almost entirely of abscesses and suppuration, sometimes diffuse, sometimes embolic. Only one organ may be affected, or several ; the abscesses may be all visceral, or all superficial. In some cases only one tissue is affected ; in acute suppurative periostitis, for example, the lesions may be limited to the bones ; in some forms of chronic pyaemia to the subcutaneous tissues ; in others — those especially that occur after the acute exanthemata — to the joints. Pericarditis, due to infective embolism of the coro- nary artery, is exceptionally frequent in suppurative osteomyelitis, pleurisy in otitis ; and abscesses in the liver when the urinary organs are involved ; but, except in this last-mentioned case, no satisfactory explanation for such coinci- dences is forthcoming. Symptoms. — No wound is exempt ; it may occur without one, but it rarely breaks out without distinct evidence of suppuration, or, at least, of the presence of pyogenic germs. Sloughing wounds, and those which are foul from the presence of septic discharges soaking into and poisoning all the tissues round, are naturally more liable than those covered with healthy granulations ; and septic fever and sapraemia are nearly always present as well. It may begin insidiously, the temperature becoming more and more irregular and the patient failing distinctly, without its being possible to say that pyaemia has set in ; or all of a sudden an intense rigor may commence without warning, and the temperature rise at once five or six degrees. After this it may fall again, but the characteristic feature is its extreme irregularity ; rigors may occur every day, sometimes with such even intervals as to suggest ague ; two or three may be present in the twenty-four hours ; or there may not be one for a week ; but, as a rule, the temperature is always suggestive of them, sudden and rapid rises occurring here and there without external causes. The pulse and respiration vary with the temperature, gradually becoming more rapid and powerless as the patient fails in strength ; any sudden change in either by itself is suggestive of fresh local trouble. The expression of the face is always peculiarly anxious, especially as each rigor comes on. The conjunctiva is often distinctly jaundiced, and the color is earthy, if not yellow. The tongue is red and smooth at first, later covered over with brown crusts ; herpes is often present, leaving painful cracks and fissures in the lips ; the teeth are covered with sordes, and aphthous ulcers are often scattered over the mucous membranes. Emaciation is generally exceedingly rapid, and in itself is highly suggestive ; the breath, and sometimes the whole body, exhales a peculiar offensive mawkish odor; the skin is marked by fugitive erythemata of a dusky red; sometimes vesicles, and even pustules, form upon it ; and in many cases it is exceedingly sensitive, the least touch causing the most intense pain. Delirium is not com- mon, unless the temperature is continuously high, until the strength gives way. Vomiting often occurs with the rigors ; albuminuria is present in a very large proportion ; but diarrhoea is unusual. PYEMIA. 77 111 addition to these symiJtoms, whicli are dependent ujjon tlie c;hanges in the blood, others arise from the local troubles. Any serous or synovial membrane may be affected ; abscesses may form in any part of the body, deep or superficial ; the viscera may be riddled with them ; or they may be scattered through the sub- ( utaneous tissue ; and wherever they occur, they are always diffuse. Many of these cannot be diagnosed ; metastatic ab.sce.sses in the lungs, for example, are always small, and cause but slight physical signs, w-hile the nervous system is so depressed that the pain, even when it is severe, is scarcely felt. Local tender- ness is always of very great significance ; and in most cases it is essential to insti- tute a thorough examination of the patient every day to make sure that no sup- ])urating focus anywhere is overlooked. Pyaemia varies very greatly in its intensity. In some cases — when, for example, it is due to acute osteomyelitis — it may prove fatal within the week, even before metastatic abscesses of any kind have been able to make their appear- ance. In others pericarditis, or some other lesion .so grave as to imperil life, sets in ahnost at once. Sometimes, on the other hand, it is very chronic, lasting even for months, with occasional rigors and abscesses, which in these cases are limited, or almost limited, to the subcutaneous tissues. So far as the progno.sis is con- cerned, a very great deal depends ui)on the locality of the secondary deposits. When the abscesses are superficial or confined to the joints, and when the fever does not run an extreme course, there is always the hope that recovery may follow, but at the expense of a long and tedious illness, with very likely one or more joints crippled and almost useless. Treatment. — When once pyaemia has developed, it does not appear possible to cut it short in any way ; all that can be done is to treat the symptoms as they arise, and prevent them from becoming themselves centres of fresh infection. Prevention, therefore, is all the more e.ssential — first, to prevent the poison devel- oping ; secondly, to prevent its being absorbed. Where it is practicable, every patient before operation should undergo a thorough course of preparation. It is a well-known fact that people in a robust state of health, taking active exercise, and consuming a large amount of food, are not nearly such good subjects for operation as those who have long been bed-ridden. Laid up suddenly, their bowels become confined, their liver is con- gested, the urine is thick and high-colored, and a certain amount of feverishness sets in. The surroundings should receive the greatest attention. Ventilation should be perfect ; nothing tends to such depression as the constant breathing of air that has been fouled ; and absolute chemical cleanliness must be insisted on. Bed, bedding, instruments — everything, in short, that comes in contact with the patient — must be scrupulously clean. Outbreaks of pyemia have been traced to the sudden disturbance of accumulations of dust, but in the majority of instances it is probable the actual vehicle of the poison is some material object. A wound requires even greater care. Everything that tends to irritate the tissues in the neighborhood — want of rest, tension, friction, or decomposition — lowers their power of resistance and makes them more susceptible. Where the drainage is perfect, so that the discharges escape at once, and the surface of the wound is kept dry, so that decomposition cannot occur, suppuration may follow, but it will be limited to the surface, and there is little or no fear of the pyogenic micro-organisms either finding their way into the cellular tissue and cau.sing diffuse suppuration, or entering into the blood-stream and leading to thrombosis, soften- ing, and metastatic abscesses. Ab.scesses should be opened at once and thoroughly drained. Joints that are filled with pus must be treated in the same way, or irrigated with a continuous stream of water. At first, the cartilages and the synovial lining are unaffected, and if only the contents are evacuated in time, and no accumulation is allowed, the mischief may be prevented from extending farther, and a very useful articula- tion left. In many instances, however, either fibrous or bony ankylosis results. 78 GENERAL PATHOLOGY OF SURGICAL DISEASES. The same jjlaii has l)een tried with the serous membranes, l)ut it is scarcely pos- sible to hope for success with them. Quinine is of some use in controlling the temperature, and appears to check the onset of the rigors and diminish their severity, but not to the same extent as in the case of urethral fever. Germicides taken internally are of no avail ; secondary deposits make their appearance even when the urine is almost black from the absorption of carbolic acid. Salicylate of soda and antipyrin may be tried ; and opium is always of use, both to relieve the pain and anxiety and pro- cure sleep. The food should, of course, be as nutritious as possible, and the supply of stimulants should be guided by the condition of the pulse. [Pain should be controlled by an anodyne, and beef-tea, with brandy or milk punch, freely administered.] ERYSIPELAS. 79 CHAPTER IV. DISEASES DUE TO IXFECTIVE ORG AN ISMS.— Continued. 2. SPECIFIC. KRYSIPELAS. Two kinds of erysipelas are clinically distinguished — simple cutaneous and phlegmonous. In the latter, however, the skin is involved secondarily : the true erysipelatous rash is not present, and there is no question that the inflammation is due entirely to the ordinary forms of micrococci. lCrysii)elas is an acute infective inflammation of the capillary lymphatics, caused by the presence of a micrococcus. The skin is, generally speaking, involved, hwX. sometimes it commences on the mucous and even on the serous surfaces. Cause.— A streptococcus can always 1)e found in the lymphatic spaces at the edge of the extending inflammation, chiefly in the superficial part of the corium and the subcutaneous fatty tissue ; it is not present in the blood-vessels. Whether it is the same as the streptococcus of suppuration (S. pyogenes) or not is still doubtful. According to Fehleisen, it is not ; by itself it never leads to the production of pus ; if this occurs, it is always the result of a mixed infection. According to others, however, all the differences may be explained by the method or site of inoculation, the degree of attenuation, or the individual power of resist- ance. Morphologically they cannot be distinguished, although it is said the micrococcus erysipelatis is slightly the larger of the two. It is very doubtful if the micro-organism can gain access otherwise than through a wound, but the smallest scratch or abrasion is enough. Exposure to draughts, sudden chills, the east wind, and the like, which are occasionally followed by an attack, and which certainly pre- ,_ "•"•. dispose to it, must be regarded as depressing agents, render- '■'■••. /(''"' \ ing the tissues more liable to infection. Erysipelas is occa- ,--^...-..") " f") '**••. sionally epidemic, and probably may be conveyed by air or \ ;•■ (.._ water; but it is certainly contagious and is especially liable to I ( ""^ l)e disseminated by dirty hands or sponges. /' / :|["'"' The predisposing causes include everything which can -...^ -r* either impair the general health or weaken the power of resist- ^ ,3 '""\ ;*'** ance of the tissues in the neighborhood of the wound. Among f,^. e. — streptococcus the former are included Bright's disease, intemperance in Erysipelatous. Pure ., .." ..'-.. Culture in Bouillon at food as much as in drink, gout, exposure, and privation. 37° c. stained with Overcrowding, the continued breathing of air loaded with ^^";^j^t'.';X95o(^««'«- the exhalations from other people's lungs, want of cleanliness, and general neglect of ordinary hygienic principles probably act in the same w-ay ; they all appear to interfere with the elimination of waste material of one kind or another, and so prevent the perfect nutrition of the tissues. Mechanical irritation, want of rest, congestion, or cedema, and the presence of foul or decomposing discharges soaking into the neighborhood of a wound, affect the surrounding stnictures, lowering their vitality and rendering them less capable of resisting. Under conditions of this kind the tissues, which, so long as they are healthy, are able to prevent the entry of foreign organisms and destroy, sooner or later, those that from some accident may have entered in, seem to lose their power of resist- ance altogether. Experiments in illustration of this have been performed by many observers. Chemical ferments, apparently containing no organic structure 8o GENERAL PATHOLOGY OF SURGLCAL DISEASES. of any kind, have been injected into the blood, and in a very short time it has been found that micro-organisms were present in myriads. One attack distinctly predisposes to another. Pathology. — Micrococci, forming chains, are found abundantly in the super- ficial lymj)hatics of the skin where the rash is sj^reading — not where it is fading, nor where it has })assed away ; they are much more scarce in the interstices of the tissues (though these anatomically l^elong to the lymphatic system), and are scarcely found at all in the vessels of the part. The other local changes are merely tho.se that are present in ordinary inflammation — dilatation of vessels, accumulation of inflammatory e.xudation, and of leucocytes. In fatal cases the blood is usually said to be fluid and uncoagulated, staining the interior of the heart and vessels. The spleen is soft and diffluent, the kidneys are engorged, sometimes showing signs of a catarrhal or interstitial inflammation, and the lungs are much congested, the smaller vessel being plugged with granular mas.ses, which are supposed to be produced by the disintegration of white corpus- cles. A similar change has been described in the ve.s.sels of the brain. Symptoms, i. Constitutional. — These usually precede the local ones by some hours, occasionally longer. There is a rapid rise of temperature to 102° or 104° F., Avith chills, or even a rigor ; vomiting, epistaxis, and, in children, con- vulsions are of common occurrence. The skin is hot and dry, the tongue is coated with a thick, creamy fur, the bowels are confined, and there is headache with general depression. The temperature usually continues high for three or four days and then gradually sinks, assuming the remittent type, but as it rises again with every local extension its course is rarely uniform. In the worst cases the symptoms are of a tyi)hoid character almost from the first ; the eyes are jaundiced, the skin is a peculiar dusky yellow, the pulse is very small, frequent, and feeble, diarrhcea is often profuse and sometimes very offensive, albumin is present in the urine (perhaps owing to the catarrhal inflammation), and there is a constant, muttering delirium, which may be due to the plugging of the cerebral capillaries. 2. Local. — The redness nearly always begins at the margin of the wound, sometimes where the skin is continuous with mucous membrane, as at the angle of the eye, or on the mucous membrane, very rarely some distance off. At first it is a bright rose-red ; exceptionally, and only in severe cases, it has a dusky tinge. The edge is irregular, but always sharply defined ; even when the rash is advancing it always marches by steps, suddenly showing a well-marked border some distance off. The skin is .swollen, cedematous, and pits on pressure. The raised margin can be felt, it is so clear. Where there is an abundance of loose cellular ti.ssue, as in the eyelid or the scrotum, the swelling becomes enormous in a very short space of time, but the pain is very slight. When, on the other hand, the skin is tightly bound down, as over the nose or the pinna, the color is livid, the swelling slight, and the pain intense. Very often in these circumstances the epidermis is detached from the corium beneath, forming bullae, which af first contain clear serum, but .soon become full of pus. As the inflanmiation subsides these burst, dry up, and form scabs, but there is no ulceration or destruction of the cutis. In severe ca.ses the fluid they contain is stained with blood. The neighboring lymphatic glands are always swollen and tender ; very often this is the earliest sign, and it is usually ])resent before the blush shows itself. As the disease advances the redness involves one area after another, fading in the centre as it spreads by the circumference. Sometimes this continues for two or three days only, sometimes for much longer periods, until perhaps the greater part of the body has been traversed. Then the temi:)erature falls suddenly, the last- formed reel patch ceases to spread, the swelling disajjpears. the skin becomes wrinkled again, and the i)ain and tenderne.ss disapi)ear. Desquamation always follows a severe attack, and when the head is involved, the hair falls off. but it speedily grows again. In rare cases erysipelas is erratic, disappearing in one i)art and breaking out ERYSIPELAS. 8i in another ; and. in very exceptional instances, metastatic, suddenly subsiding aiid attacking some internal organ instead. Abscesses are uncommon, although occasionally the lymphatic glands break down and suppurate. \'ery often a relajjse occurs, sometimes two or three, but they are rarely so severe as the original attack. Acute suppurative arthritis, men- ingitis, pleurisy, and peritonitis have been recorded as complications ; and occa- sionally in erysipelas of the face the mouth and fauces become involved, leading to erysipelatous laryngitis and cedema of the glottis. Pyaemia occasionally follows it ; and sometimes, especially after repeated attacks, a condition of solid cedema is left, which is very disfiguring when the face is concerned. Diagnosis. — The sudden rise of temperature, with headache, vomiting, and constipation ; the enlargement and tenderness of the neighboring lymphatic glands ; and the peculiarly sharply-defined margin of the redness, are character- istic. The last serves to distinguish it from simjjle lymphangitis. Erysipelas commencing in the mucous membrane of the fauces resembles ordinary catarrhal pharyngitis, but is infinitely more severe. The constitutional symptoms are even more marked than in the ordinary cutaneous form ; the throat is swollen and burning hot ; the mucous membrane of the palate is thickened and of a brilliant red ; the voice is lost ; swallowing is exceedingly painful ; and the glands at the angles of the jaw are enlarged and very tender. The prostration in these cases is usually extreme, and, in addition to the ordinary risks, there is always the fear of the inflammation extending to the larynx. Prognosis. — The severity of the initial fever is no guide. [In youth and middle age recovery is the rule.] At the extremes of life ; when the head, face, or chest is involved ; when the disease continues for any length of time, and particu- larly when there is old-standing nephritis, the prognosis becomes very grave. A dusky red, instead of bright eruption, jaundice, delirium, blood-stained bull^, and a sudden rise in the pulse-rate, without strength, are very serious omens. In many cases broncho-pneumonia sets in and proves fatal ; in others signs of congestion of the brain ; in others, again, the symptoms resemble those of typhoid with diar- rhoea : or the i)atient sinks from exhaustion, worn out by the long-continued fever. Treatment, i . Constitutiojial. — It must always be remembered that, although the fever at the commencement of an attack may be sthenic, it tends very rapidly to assume a typhoid character. A purgative is nearly always required at first : even when there is diarrhoea it may usually be given with advantage, and particularly when, from the patient's appearance or habits, it is probable that the liver is congested. Afterward the bowels may be kept gently open by means of effervescent salines. In the slighter ca.ses nothing else is required, though quinine with mineral acids may be given to stimulate the appetite. In the more severe ones. Avhere the tongue is dry and brown, and the pulse is losing its strength and fullness, bark and ammonia with ether answer better than anything. If the temperature is high quinine or anti- pyrin may be given, but they appear to have little effect upon the disease. Per- chloride of iron, which, according to some, acts as a specific when given in large and frequent doses, has in my hands failed completely. I have often noticed a distinct improvement when it has been left off and quinine and carbonate of ammonia substituted. Stimulants are usually required, especially in the aged and in those who are accustomed to them. The guide to their administration is the condition of the tongue and the pulse. They .should always be given in small quantities at a time, and, if possible, with beef-tea, meat -jelly, milk, arrowroot, or other food that can be easily absorbed. The object is to sustain the action of the heart and supply it with strength until the activity of the poison begins to subside. Very often after the first day or two the patient will take liquid food readily, and then there is not the same necessity. 2. Local. — Many attempts have been made to check the spread of the micro- organisms in the tissues, but not with any great success. Injections of carbolic 82 GENERAL PATHOLOGY OF SURGICAL DISEASES. acid and of sulphocarbolate of soda are recommended. American surgeons are said to have used bromine vapor and creasote with advantage. Salicylic acid is reported to have succeeded when injected hypodermically ; and many other germi- cides have enjoyed a local reputation. In most cases, however, it answers better to treat the symptoms. Strong antiseptics in particular should be avoided, as the additional injury they inflict upon the tissues may cause sloughing. The burning pain can be relieved by excluding the air and using gentle pressure. Cold may be grateful to the patient, but care is required in employing it, for fear of lowering the vitality of the part too far. Oxide of zinc and starch are sometimes dusted thickly over the skin, but in many ca.ses they cause intoler- able itching. Extract of belladonna mixed with glycerin, and covered with a thick, soft layer of cotton-wool, is greatly to be preferred. Three or four coats of lead paint, mixed with glycerin to prevent its cracking, have a very satisfactory effect, partly, no douVjt, owing to the absorption of the lead and its action upon the capillaries ; but the ordinary lead lotion is equally good if evaporation is checked by using five or six thicknesses of lint. In very mild cases the surface may be painted over Avith a strong solution of nitrate of silver in ether, or with collodion, or tincture of iodine, though the benefit is probably due to the mechanical effect upon the epidermis. Rest, gentle uniform pressure, and elevation, if the part will admit of it, are of material help in relieving the pain and inflammation. When the tension is extreme it is sometimes necessary to make a few punctures ; for want of this I have known the eyelids slough, but such circumstances are rarely met with in uncom- plicated erysipelas. [Occasionally the application of a blister to the sound skin, by temporarily occluding the lymphatics, may prevent the spread. The tincture of iodine is absorbed and is potentially germicidal. Vapor of bromine is useful in prevent- ing the spread to other patients.] SEPTIC INFECTION, OR TRUE SEPTICEMIA. In the strict sense of the term this name should be reserved for an acute specific disease caused by a micro-organism which multiplies in the l)lood, so that the most minute trace can communicate it by inoculation, as in the case of anthrax. It is not of necessity attended by septic fever or sapraemia, on the one hand, or by the local manifestations of pyaemia, thrombosis, embolism, or suppuration, on the other. The smallest wound is sufficient ; there is a short period of incubation — eight or ten hours in acute cases — and the symptoms steadily increase in sever- ity. Sometimes it is known as progressive septicaemia to avoid confusion Avith sapraemia. That such a disease can be artificially produced l)y pure cultivations in animals is beyond doubt. Whether it ever occurs in man by itself, so that it can be distinguished from all other troubles that are caused by infective germs, is open to question. It must be remembered that after the injection of a minute quantity of a chemical poison into the blood, myriads of micro-organisms make their appearance, and care must be taken not to mistake effect for cause. It is possible that some of the exceedingly fatal ca.ses of post-mortem wounds that occur in connection with puerperal peritonitis are examples of septic infec- tion ; but, on the other hand, it is by no means improbable that they are really due to .sapraemia, the inoculation of a virulent poison (as happens sometimes from the bites of venomous reptiles) causing such extreme depression that the tissues either succumb at once, or are too much weakened to withstand the action of other germs. Other exam])]es are fortunately very rare. Pathological Appearances. — The changes found post-mortem are practi- cally the same as those in other acute specific fevers. Cloudy swelling is universal ; the brain and pia mater are congested .; the spleen is enlarged ; and the number of white corpuscles in the blood apparently increased ; but in the most acute cases SEPTIC INFF.CTIOX, OR TRUE SEPTICEMIA. 83 there is nothing more definite. In those which have lasted a little longer, or in which the temperature has been very high, petechias may be found upon the skin and the surface of the serous meml)ranes, and sometimes these and the lining membrane of the heart show evidence of acute inflammation. Unless, however, the endocarditis has distinctly a.ssumed the ulcerative form, embolism does not occur. When the disease has lasted longer it is usually complicated by the jjres- ence of local inflammation. Symptoms. — The wound itself may have been absolutely unnoticed, but usually it is inflamed and painful, and sometimes there is tenderness running tVom it in the direction of the lymphatics. Otherwise it shows no change. The general symptoms commence, as a rule, al)out eight or twelve hours after the injury, with the most overpowering depression ; headache is extremely severe ; there may be a rigor of great intensity, but very seldom more than one ; the temjjerature begins to rise at once, the pulse is small and feeble from the first, the respiration is hurried and shallow, and in a very short time delirium sets in, and ^.-^'^ Fig. 7. — Blood of a mouse killed by inoculation of the bacillus of mouse septicaemia. A thin layer of the blood has been dried on a cover-glass, carefully heated, stained with a watery solution of methyl blue and mounted in glycerin. (X 70o). White blood corpuscle with horseshoe-shaped nucleus, and numerous minute bacilli in and around it. Red blood corpuscles. Small bacilli between corpuscles. {After IVoodhead.) stupor and coma rapidly follow. The central nervous system from the first is entirely overcome. Sometimes there is a rash upon the skin not unlike that of scarlatina. Lung complications are of frequent occurrence. Diarrhoea may be present, and albuminuria, after the first two days, is almost invariable. Later, if the case becomes chronic, inflammation of the serous membranes and of the endo- cardium may set in, and various local troubles, with saprsemia and suppurative fever, may make their appearance. The diagnosis from saprsemia is practically impossible [except from the history of the case], although septic infection is more probable when there is a distinct incubation period. No other diseases occurring under such conditions ever cause symptoms of such severity. Treatment is of little use. An attempt should be made to limit further absorption by the thorough application of caustics ; there is evidence to show that, in the case of some other acute specific and infective disorders, destruction of the seat of inoculation is of considerable benefit. Quinine and antipyrin may be 84 GENERAL PATHOLOGY OF SURGICAL DISEASES. given when the temjjerature is high, and stimulants — alcohol, ammonia, and ether — if the pulse shows signs of failing. Otherwise, nothing is of much avail ; the case usually terminates fatally in a few days [but it may be prolonged for many weeks. Mercurials, in minute doses, are said to be beneficial]. ANTHRAX. Anthrax, or malignant pustule, is an acute infectious disease, caused by a spe- cific bacillus. Woolsorters' disease is the same thing under a different form, and so is the splenic fever of cattle. The bacillus anthracis is the largest and most easily recognized of pathogenic organisms. It consists of rods, from five to ten micromillimeters in length, abruptly cut at the ends, and capable, under suitable conditions, of producing spores which possess the most extraordinary powers of resistance ; their tenacity of life is so great that catgut prepared for ligature in the ordinary way and kept in a dilute solution of carbolic acid has shown itself capa- ble of transmitting the disease. It can grow in the tissues, or in the blood, or outside the body, provided there is a sufficient supply of oxygen and the tempera- ture is kept up. Naturally, those are most exposed to it who have to deal with hides, wool, etc. : tanners, dock laborers, woolsorters, and others, but it may occur in butchers, and there is evidence to show that it has been transmitted by flies. The mode of entry is either through the skin — as in malignant pustule and some cases of malignant oedema — or through the mucous membrane of the respira- tory or alimentary tract (woolsorters' disease). In the former case, characteristic local changes precede the clinical symptoms ; in the latter, the bacillus enters at once into the blood-stream, penetrating, so far at lea.st as the lungs are concerned, between the uninjured epithelial cells. Each of these forms, as the infection spreads through the body, may be attended at a later period by the primary lesion that is characteristic of the other; thus, if the patient lives sufficiently long, malignant pustule may develop upon the skin in a case of woolsorters' disease, and secondary intestinal anthrax may show itself in the course of malignant pustule. The bacilli themselves may be found in enormous numbers at the seat of infection, in the inflammatory effusion that is poured out round it, and in the fluid of the vesicles that lie upon it. They are also present in the blood, especially where, as in the spleen, the circulation is slow ; and they exist abundantly in the ecchymoses that are found in the mucous membranes and under the serous coverings of the viscera. The period of incubation is very variable — from a few hours to ten days, and even more — probably depending upon the dose and upon the facilities for general distribution afforded by the anatomical structure of the part. The mode of action is, to a certain extent, mechanical, but the chief effect is due to the production of some substance Tan albumose, in all probability) at the expense of the tissues. In patients who have survived, the bacilli have been found in all the excreta, and in one remarkable case, recorded by Davies Colley, they were still present in the urine a month after the man had recovered from the attack. Recently, it has been shown by Hankin that an albumose possessing similar toxic properties can be extracted from a cultivation of anthrax, and, further, that minute doses of the same, given previously to inoculation, confer a certain degree of immunity, while large ones only hasten the result. Morbid Anatomy. — The pathological appearances in the case of anthrax are very similar to those that occur in other forms of acute blood-poisoning. Decomposition is rapid, the blood does not coagulate, all the viscera are congested, the spleen in particular, and sometimes the mesenteric glands are enormously en- larged. There is a blood-stained effusion in all the serous sacs, and hemorrhages are not unfrequently present in their walls. Ecchymoses are common, on the mucous surface of the intestine, sometimes forming raised blackened patches, which are surrounded by a zone of gelatinous infiltration, similar to that in the primary affection upon the skin, and occasionally sloughing has commenced already. ANTHRAX. 85 The seat of infection, if it is on the skin, shows no sign of suppuration ; all the angry redness and much of the swelling disappear /<7j-/-w(7/'/'<7;/ / the centre forms a hard, blackened slough ; round it the tissues are filled with a blood-stained fibrinous effusion ; and further away all the parts, sometimes for long distances, are infiltrated, cedematous, and dark with hemorrhages. Bacilli are present in abundance throughout the whole infected area and in the ecchymoses. Symptoms. — The constitutional symptoms, as in septic infection, are those of the most intense depression, whether the poison enters by the skin or the mucous membrane. In some cases, especially in malignant pustule of the face and neck, there is a delay of only a few hours ; in others more than a week may pass ; then the temperature begins to rise and becomes exceedingly irregular ; shivering sets in, with general pains all over the body ; the pulse becomes small and feeble ; sometimes there is cyanosis, and occasionally severe dyspnoea from oedema of the glottis. General cramp, diarrhoea, and vomiting are of frequent occurrence; some- Fig. 8. — Bacillus anthracis from the spleen of a cow tKat succumbed to an attack of splenic fever. The specimen was taken some time after the organ had been removed from the carcass, and in presence of air, spores had begun 10 form in the bacilli. Specimen was dried, heated, stained by Gram's method, with methyl violet and vesuvin, and mounted in Canada Balsam. (X 700) The anthrax rods and filaments, some of them with bright points or8pores,are stained with methyl violet. The cells of the splenic pulp are stained brown by the vesuvin. (After Woodhead.) times there are convulsions, especially toward the end ; or the patient becomes delirious and comatose. In other cases, the symptoms are typhoid almost from the first. Death usually occurs from heart failure, sometimes rather suddenly ; or it may be caused by asphyxia, especially when there is oedema of the glottis ; or by fever and general exhaustion. Broncho-pneumonia and enteritis are more prominent, as a rule, where the infection is internal ; but often in these cases the course is so rapid, and the constitutional symptoms so severe, that the physical signs are insignificant in comparison. The seat of infection, when it is upon the skin — the so-called malignant pus- tule — is characteristic. A small, red, itching papule forms first. As the effusion increases, this becomes a vesicle, filled with blood-stained serum, resting upon an indurated base. Soon the vesicle breaks or dries up, leaving a blackened, central scab, or slough. The effusion continues to increase ; an indurated area, rai.sed considerably above the surrounding level, is rapidly developed ,; the surface becomes a peculiar purple-red, and ring after ring of vesicles form upon it round 86 GENERAL PATHOLOGY OF SURGLCAL DISEASES. the central slough ; then the cedema spreads to the tissues near, until sometimes the hard, brawny swelling and the peculiar dusky redness extend up the whole limb, or, if it is on the face or neck, spread over the whole surface of the upper part of the body, and to the deeper structures, especially the larynx, as well. The black central slough continues to enlarge in most cases as the neighbor- ing vesicles fall into it, but no pus forms. There is always a little depression in the middle, probably from the drying up of the effusion, and this makes the areola round appear more prominent than it really is. The intense brawny hardness, the rapidity and extent of the cedema, and the peculiar rings of vesicles are the most striking local features, though these last occasionally are wanting. Pain is always peculiarly slight. In some cases, in which the infection has taken place, in all probability, from an internal surface, so that the organism gains access to the blood at once, and only involves the skin secondarily, the central papule and vesicle are wanting : there is merely an enormous, brawny cedema of the subcutaneous tis- sues, and then of the skin, appearing first in separate spots (which, as they increase in size, soon fu.se together), and becoming covered with irregularly scattered groups of vesicles. The working of the organism is exactly the same, except that it begins from beneath, and is widely spread from the first, instead of being super- ficial and local for a time. This variety is sometimes distingui.shed as a malignant oedema. Diagnosis. — There is no difficulty when the local signs are well-marked. The central purple depression A\-ith the indurated dusky base, covered with rings of vesicles and surrounded by wide-spreading oedema, is distinctive. In addition, the peculiar absence of pain in the earlier stages of the disease is most noteworthy, and separates it at once from ordinary forms of carbuncle or diffuse inflammation. Internal anthrax and malignant oedema are not so easy, although it may be clear, from the extreme constitutional depression, that there is some very grave form of blood-poisoning. Ordinary broncho-pneumonia or gastro-enteritis seldom causes such intense prostration and cyanosis : and the comparatively slight development of the physical signs by the side of the condition of the patient is very suggestive. But, in the absence of local e\-idence, it is only possible to determine the particular form of blood-poisoning that is present by a reference to the occupation and sur- roundings of the patient, or, better, by a microscopic examination of the blood. The bacillas is of such size, stains so readily, and is so distinctive and so widely distributed, that it can scarcely be overlooked. Prognosis. — In external anthrax, if the seat of inoculation is excised or destroyed sufficiently early, the prognosis is fairly good. Recovery has followed even when the patient was already so infected that bacilli were present in the sputum, urine, .sweat, and faeces (Davies Colley). Apparently the focus of inflam- mation acts as a laboratory, from which the poison is discharged into the system. In woolsorters' disease, where the stress of the complaint falls upon the intestinal or pulmonary mucous membrane, and when the face or neck is involved, or the oedema is widespread, and shows a tendency to involve internal organs, such as the larynx, there is much less hope. Treatment. — If the infection is local, the whole thickness of the skin and cellular tissue should be excised, with an eighth of an inch of the cellular tissue around. Then, if there is any ecchymosis or oedema visible on the cut surface, the actual cautery, or potas.sa fusa, should be applied freely. When the oedema is too extensive for this, all that can be done is to inject hypodermically all round it a solution of carbolic acid (i in 20), in the hojje that it may soak into the tissues. Free incisions at the same time should be made into the subcutaneous tissue, and the wounds irrigated with a similar solution, or one of corrosive sublimate. Sulphite of sodium, in ten-grain doses, is said to be very successful in animals, and should therefore be given a fair trial. Quinine has been recommended, and also corrosive sublimate. Of course, the diet should be good, and, if necessary, stimulants s^iven freelv. GLANDERS. 87 (".LANDERS. This is another variety of infettive disease, caused by a specific germ, the bacillus Mallei. Like ])yi\iinia, anthrax, tubercle, and, to a less extent, syphilis, it varies very greatly in different cases, the severity of the attack, and the nature of the symptoms being modified by the anatomical structure of the seat of inocu- lation, the method of dissemination, and jjrobably the dose of the poison. It may be acute or chronic ; it may affect especially the mucous membrane of the nose and the respiratory tract (glanders), or it may spread slowly in the cellular tissue and lymphatics (farcy) ; and, not uncommonly, after continuing in the chronic form for a greater or less length of time (I have known it upward of a year in a horse), it suddenly becomes acute; but, in all cases, although its manifestations and its course are almost as variable as those of tubercle or pyaemia, it is one and the same disease, caused by the same species of organism. The bacillus is a small rod, somewhat shorter and thicker than that of tubercle, and usually exists in pairs. It is not capable of spontaneous movement, [and spores have been proved to exist by Baumgarten and Rosenthal]. Usually, it enters through wounds, especially at the corners of the nails; but, in all proba- bility, it posses.ses the power of infecting the respiratory, if not the alimentary, mucous membrane. It may be transmitted from man to man, but, as a rule, it is caught directly from horses, or a.sses. Other animals show varying degrees of susceptibility to it. Local changes are usually produced at the seat of inoculation ; there is a period of incubation of some days, then the part becomes red and swollen ; the skin breaks down, and a foul ulcer is left, spreading at its edges and its base, but without anything in itself characteristic. From this the organism spreads, with more or less rapidity, in the cellular tissue round, in the lymphatics, or in the blood, the severity of the symptoms and the acuteness of the attack depending to a very large extent upon this. Whenever it spreads it causes inflammation ; granu- lation-tissue is produced : and this, as in the case of tubercle and syphilis, under- goes caseation (unless it is near a mucous or cutaneous surface, when it may break down at once), so that the yellowish-white, cheesy nodules and tubercles (farcy- l)uds. when they can be felt from the exterior), are formed in various parts. Suppuration follows, whether through the action of the specific bacilli, or because of the presence of pyogenic organisms in addition, is not known : and then ulcers, abscesses, and diffuse forms of inflammation break out in all the infected regions. The bacillus exists in the cheesy masses and in the pus ; not unfrequently it can be found in the blood as well in man, but this does not seem to be the case with horses. Symptoms. — It is met with, naturally, chiefly among those whose occupa- tions render them liable to infection, and it may be acute, so that it proves fatal within three or four days, or chronic, lasting for months, and possibly ending in recovery after a long and severe illness. The constitutional symptoms depend upon the acuteness of the attack. In the worst cases they resemble those that are always present in intense blood- poisoning — muscular tremors, low-muttering delirium, etc., with high fever, and a small, feeble pulse. When it is less severe they depend practically upon the number, size, and situation of the abscesses and ulcers, and upon the extent to which suppuration and septic absorption take place. In the majority of cases they do not terminate fatally at the commencement from the intensity of the fever ; either broncho-pneumonia sets in, from the constant inhalation of the odor from the foul and decomposing sloughs, or the patient sinks at length from exhaustion, utterly worn out by pain, inability to take food, profuse suppuration, and fever. The most chronic cases recover, but always seriously crippled. Glanders may commence with inflammation and ulceration 6i the mucous membrane of the nose, or this may occur later in the course of the disease. In the case of the former, it is i)robably due to direct infection. At first there is a 88 GENERAL PATHOLOGY OF SURGLCAL DLSEASES. thin, profuse, watery discharge ; this rapidly becomes ijurulent and exceedingly offensive; the inflammation spreads and becomes more and more severe; the whole of the mucous membrane of the nose ulcerates and sloughs ; the bones are exposed and bare, already eaten away in places ; the eyes, the frontal sinuses, the antrum, the pharynx, and palate are rapidly involved ; and the whole of the face and neck become swollen, livid red, hot, and inflamed, as in the worst form of phlegmonous erysipelas. Such cases usually prove fatal at a very early period ; one, that I have seen, terminated on the fourth day from the commencement of the outbreak. In the chronic variety (farcy) the distribution of bacillus takes place chiefly by the lymphatics; nodules form in the skin, the subcutaneous tissues, along the course of the lymphatic vessels, and then, later, in the internal organs. On the :^N^^ Fig. 9. — Fibrous nodule from a case of actinomycosis (from the tongue of a cow). Stained in Spiller's blue. (X 50.) f^mgus growing in the centre of a follicle. Large endothelioid cells near the fungus. Fibro-cellular tissue away from the centre of the follicle, in which round cells predominate. More fibrous tissue, still further from the fungus, forming a fibrous capsule. (A/ter IVoodhead.) skin they appear first as minute papules scattered in irregular groups ; these soon enlarge into pustules ; the base upon which they rest becomes reddened, hardened, and infiltrated, and then they break, leaving foul, irregular ulcers. In the sub- cutaneous tissue the same changes occur, only the so-called buds usually attain a larger size before supjniration sets in, and the same thing is met with in the viscera and the lymphatic glands, the symptoms naturally varying with the number, size, and situation of the abscesses. Probably, after a time, dissemination takes place, as in pyaemia, by the blood-stream as well. Diagnosis. — Acute glanders can hardly be taken for anything else. The chronic form, on the other hand, may remain uncertain for a considerable time, a certain amount of fever, with vague, flying pains, being associated with a cutaneous eruption and the formation of lymphatic nodular swellings in many other dis- A CriNO MYCOSIS. 89 orders — syphilis. tul)ercle, ijyoemia, etc. The steady persistence with which the swellings form, enlarge, and l)reak down in spite of everything, must soon, how- ever, attract attention. Treatment. — This is similar to that of anthrax; the seat of inoculation should be thoroughly cauterized, and if the mucous membrane of the nose is involved, the whole cavity should be irrigated with carbolic acid, corrosive subli- mate, dilute sulphurous acid, or perhaps sulphite of sodium. Absces.ses must be opened and treated in the same way, and the general strength must be maintained as well as po.ssible. If the nose is not infected, great care should be taken to ])revent it. Probably this takes place in many ca.ses secondarily, and is due to the patient himself conveying the poison to the mucous membrane. Recovery after this has happened is very rare. v:* Fig. 10. — Actinomycosis. Tongue of cow. Section stained in Spiller's blue. (X 300.) Centre of mass of conidia (conidiophore). Pear-shaped conidia. Endothelioid cells. Fibrillar tissue near the margin of the follicle. Spindle-shaped cells, seen especially near the margin. {After Woodhead.) ACTINOMYCOSIS. Actinomycosis is a disease caused by a peculiar form of fungus that attacks herbivorous animals (including man), gaining access to the tissues either through wounds or through the mucous membrane of the respiratory or alimentary canal. There is some evidence to connect it with rye, and, perhaps, with barley. An epi- demic occurred in Seeland, from eating rye grown on recently-reclaimed ground, and on two or three cases the disease has distinctly originated in a wound of the mucous membrane of the mouth, caused by a grain of rye, showing that at least it may be the carrier of the infection. In cattle it usually begins in the tongue or the jaws, generally the lower, and spreads thence to the cellular tissue of the submaxillary and cervical regions. The fungus is easily recognized by its characteristic star-like masses of mycelium. The granulation-tissue that forms the tumors, and the pus in the 7 90 GENERAL PATHOLOGY OF SURGICAL DISEASES. abscesses and ulcers, contain myriads of yellow, rounded bodies like millet-seeds. Each of these is made up of little threads, which radiate, star-like (whence the name), from one common centre, and, after a time, enlarge and terminate in club- like structures which probably contain spores. In ca.ses of suppuration, however, these are not always plain, and the color is not always so clear. Nothing is known with regard to its life-history, except that it has been found in the muscles of a pig, and that water and dilute saline solutions destroy it at once. Infection usually takes place through the mouth, either from a wound or through some carious tooth ; but the fungus has been found in the tonsil and as a primary growth in the tubular glands of the mucous membrane of the large intestine. Cutaneous wounds are occasionally affected, and, from the fact that it has been found abundantly in the cavities in the lungs and in the pus from medi- astinal abscesses, it is highly probable that, sometimes at least, the spores are inhaled and, sinking into the alveoli of the lung, set up broncho-pneumonia. Wherever it comes, it causes chronic inflammation, which closely resembles that caused by tubercle, at least in its histological features. Giant-cells develop around the fungus ; outside there is a meshwork filled with epithelioid cells, and outside these again others resembling leucocytes. Caseation soon begins in the middle, and the nodules formed in this way continue to enlarge at the margin and decay at the centre, until, like tubercle, definite ca.seous masses, which sooner or later break down into pus, are formed at all the infected spots. Suppuration is probably always due to the coincidence of pyogenic germs, for occasionally nodules of very considerable size are found intact. As soon as it breaks out the disease assumes a much more rapid course, the constitutional symptoms become more severe, and septic fever, hectic, and very probably pyasmia (the particles of the fungus serving as the embolus), make their appearance as well. Symptoms. — The disease at the beginning is usually chronic. Enlargement of the lower jaw, or an ill-defined swelling in the submaxillary region, or a reddish but painless nodule upon the skin, is often the first sign noticed, and for a time there is nothing to distinguish it from all other forms of slowly-growing granula- tion-tumors. Wherever it is, it grows steadily, not involving blood-vessels or lymphatics at first. Then, sooner or later, suppuration begins ; the pain and swelling rapidly become much worse, the size increases, the skin becomes red and glazed, and the constitutional symptoms become as severe as those of infective cellulitis or diffuse osteomyelitis. Secondary deposits soon follow, and, as might be expected, no organ in the body is exempt, caseous nodules and abscesses con- taining the characteristic millet-seed bodies having been found nearly everywhere, even in the brain. Diagnosis. — The only certain diagnostic feature is the presence of the char- acteristic mycelium. When the teeth are attacked, the disease can usually be recognized before it has gone too far ; one after another becomes loose and carious, and the cavities that result from their extraction are filled with ma.sses of granula- tion-tissue breaking down into pus. In other cases, however, especially when there is merely a slowly-growing subcutaneous tumor, there is nothing at first distinctive about it. It is impossible to diagnose it from other diseases that lead to the production of masses of granulation-tissue, and from sarcomata. The prognosis, especially if the whole seat of infection can be removed in time, before suppuration has occurred, is very good. In some cases the disease has been very chronic, lasting for years ; in others, however, it rapidly becomes disseminated all over the body, often being complicated with true pyaemia, and proves fatal, either from some vital organ becoming involved or from exhaustion and suppu- ration. [Treatment. — While this edition was passing through the press there was published a statement, emanating from the Agricultural Department at Washington, to the effect that potassium iodide had been tried and found very useful in arresting the progress of the disease.] TUBER CUL OS IS. 9 1 TUBERCULOSIS. Tuberculosis is an infective disorder caused by a specific micro-organism which gains access to the body either through the skin or the mucous memljranes, and gives rise to characteristic changes. The bacilhis occurs in the shape of very thin, non-motile rods, from two to eight micromillimeters in length, and is found abundantly in the interior of the giant and epithelioitl cells that constitute what is known as a tubercle. It is not present, with rare excei)tions, in caseous debris, or the liquid material that fills caseous abscesses, although this is intensely infective. The probable explanation is that spores, which are formed in the body, and which have the appearance of vacuoles when seen under the microscope, are present, but are not stained by the ordinary reagents, and conseciuently are not recognized. That this bacillus is the cause of tuberculosis, and the only cause, must be considered proved ; it is always found in connection with tubercular deposits; it does not occur without them, and inoculations with a pure cultivation practically invariably give rise to local or general manifestations of tuberculosis. As, how- ever, the changes that occur and the results that follow present an immense variety, it is clear that there are other causes modifying its action. Predisposing Causes. — In large towns and in large institutions, especially where there is overcrow-ding, the tubercle-bacillus must be practically of universal Fig. II.— Tubercle Bacilli in Sputa. Stained with gentian violet. Contrast stain Bismarck brown, Weigert's method. (X 45o.) {After Woodhead.) distribution ; yet only a few are attacked by it, and of those who are attacked a great many recover from it. It can only thrive in those who are in some way susceptible, whether this susceptibility is due to local or constitutional causes. Heredity is of some consequence. There is no doubt that when full "allowance is made for the effects of surroundings the members of some families are much more subject to tuberculosis than those of others. This tendency Avas, at one time, known as scrofula, and certain personal peculiarities were suppo.sed to be associated with it ; but as the name was allowed to include both the constitution which indicates a predisposition to the formation of tubercle, and the effects of the disea.se itself, it is better to drop it altogether. If its et>Tnology is taken into consideration, it should be confined to those cases in which, from the thickening of the tissues of the neck (caused by the glandular enlargement), the hypertrophy of the upper lip, and the diminished prominence of the chin, the profile bears some resemblance to that of a pig. The general conditions of life are probably of much greater importance. Everything that tends to lower the vitality of the tissues, overcrowding in particu- lar, uncleanliness, bad food, exposure to cold and wet, or want of exercise and fresh air, increases the liability. On the other hand, the children of tubercular parents, even when they themselves are already the subjects of the disease, may recover, and, in many instances, completely regain their health, so that there is 92 GENERAL PATHOLOGY OF SURGICAL DISEASES. no evidence of the disorder but the scars it leaves, if they are removed sufficiently soon to a proper climate and fed sufficiently well. Age, again, is not without influence. Tubercular inflammation may occur at any time of life, even in old age, but it is very much more common among the young ; and it is especially prone to attack those parts of the body which are at the time the seat of special functional activity — the lymphatic glands and the bones in youth, and the testes in adult life. Every organ of the body may be attacked, although it is very much more frequent in some than in others. True tubercular ulceration is not common upon the skin, independently of lupus and anatomical tubercle, which are due to the same caase acting under special conditions. (Lupus, that is to say, always gives rise to tuberculosis when inoculated in animals, although the converse has not been observed : and bacilli apparenth- identical have been found in anatomical tubercle of the fingers.) In the subcutaneous tissue it forms cheesy nodules, which break down and leave sinuses lined with tubercular granulations. The mucous mem- branes of the respiratory, alimentary, and genito-urinary tracts are often attacked by it, the lymphoid follicles enlarging and breaking down .so as to leave superficial ulcers, which slowly extend in depth and breadth until huge, ragged excavations are formed. The serous sacs are specially favorite seats for it. The synovial membranes of joints may be converted into gigantic masses of soft, gelatinous granulation by it. The bones, especially in children, are often involved, and not unfrequently the disease, which asually begins in the growing layer between the epiphysis and the shaft, spreads from it to the joint. The lymphatic glands naturally rarely escape, while all the viscera are more or less subject to it ; the mamma, ovaries, thyroid gland, and the voluntary mascles being curiously free. Local predisposition to tubercle maybe acquired as well. If the vitality of any part of the body is impaired by injury, inflammation, over-use, etc., the tubercle-bacilli, supposing they gain access to it, have all the better chance of living. It is owing to this, among other reasons, that it is so often localized in joints, and that tubercular disease of the h-mphatic glands of the neck is so fre- quent. It may, of course, be that the common form of eczema of the head in children which causes this enlargement is itself tubercular, and that the lym- phatic glands are infected as a natural consequence; it issaid^n proof of this, that tubercle-bacilli have been found among the epidermic cells ; but it is scarcely possible that this is true of the carious teeth and of the inflamed and enlarged tonsils, which are not seldom the starting-point. It is enough that some slight irritation is excited in a lymphatic gland by the quantity or quality of the lymph passing through it ,: if once the tubercle-bacilli gain access to it — and they easily may through any abrasion — they are able to grow and thrive and prove the focus for a fresh dissemination. Other circumstances, which cannot be called predisposing causes, modify the effect of the bacilli to a very considerable degree. The dose is of importance. A single bacillus is probably enough. It is taken up bv a leucocyte : this wanders some little distance in the tissues, and then, under the influence of the irritation, becomes transformed into a giant-cell, in which the bacillus multiplies. Clearly, however, the effect is likely to be much greater and more rapid when the infection is either a large one or frequently repeated; as when a patient continues to breathe air loaded with germs. Asa rule, infection with small quantities gives rise to local manifestations. The metJiod of infection is another point. There can be now no doubt as to the possibility of infecting recent wounds. Many cases have been recorded in which wounds have gradually developed into tuberculous ulcers from which the bacilli have spread along the lymphatics to the neighboring glands. The period of incu- bation is said to be about three weeks ; a red nodule forms at the point of inocula- tion : it slowly increases in size: the centre breaks down, discharging a minute caseous mass, and a typical tubercular ulcer is left, with raised, reddened, and irregular edges, sometimes covered with granulations, and an uneven base, TUBER CUL OSIS. 93 inciiiiL'd to bleed. In most cases, however, the l)a(illi enter the celliihir tissue directly, either through inflammatory abrasions of the surface, as in eczema capitis and otorrhea, or in the case of mucous membranes, even without this. In the lungs it seems probable that they may develop Hrst in the epithelium that is heaped up in the alveoli in pulmonary catarrh. The dissemination is chiefly regulated by the anatomical structure 0/ t/ir part. The bacilli may spread slowly in the surrounding tissue, and the seat of infection enlarge continuously without involving other structures. They may be carried into the lym])hatics, and arrested for a time, or even permanently, in the glands. They may get into the blood-stream and rajjidly spread all over the pulmonary or systemic circulation ; the wall of a vein may be ruptured by some accident, or torn in some operation, or the tuberculous focus may gradually ulcerate through it and burst into the interior. The same thing may occur with one of the arteries, though much more rarely ; and finally, if the lining membrane of one of the serous or synovial cavities is attacked, the infection may spread rapidly over the whole surface. The presence of a viecJianical eiu/)o/us, although it may not be of so much importance as in the ca.se of pyogenic micrococci, when in all probability it deter- mines the formation of metastatic abscesses, is certainly of consequence in connec- tion with tubercular arthritis. It is not uncommon to find that this has originated from a wedge-shaped sequestrum in one of the articular ends of the bones ; and it is a fair suggestion that cutting off the circulation and lowering the vitality of the segment is of very considerable a.ssistance to the development of specific germs. As the action of jjyogenic organisms is materially assisted by t\\e presence of septic decomposition, the ptomaines formed by this soaking into the tissues, lower- ing their vitality, and rendering them less capable of resistance, so it is with tubercle-bacilli. If suppuration occurs in connection with a tuberculous cavity, the process of destruction becomes exceedingly rapid. On the one hand the pyogenic organisms grow with greatly increased vigor in the tissues that have been weakened by the tuberculous process ; on the other, the risk of general dissemination is very greatly increased by the possibility of the walls of the ve.ssels giving way. Pathology. — Tubercle-bacilli, wherever they are implanted, at once set up chronic inflammation of a somewhat special character. The earlier changes are the same as with any non-pyogenic germ ; the capillaries dilate, more plasma pours through, and the leucocytes collect in larger numbers. Then, however, an enormous multinuclear cell develops at each point of infection, so peculiar in its appearance that for a long time it was believed to be a formation special to tuberculosis. The most typical tubercles are the youngest, those which are firm and gray, standing out from the tissues around as minute, but distinctly circumscribed, masses. Each of these is made up of smaller ones, containing in their centre a giant multinuclear cell, and sending out in all directions processes which branch and form a kind of network. In the meshes, round the central mass, lie other cells, known from their general appearance as epithelioid ; and these in their turn are surrounded by numbers of smaller ones, identical with ordinary leucocytes. In this, however, there is nothing peculiar but the regularity of the arrangement. Structures precisely similar may be produced by other causes than tubercle-bacilli ; similar giant-cells can be found in any chronic inflammation, especially those forms which are poorly supplied with vessels ; and they are surrounded by similar groups of epithelioid and lymphoid corpuscles. The specific character is due to the tubercle-bacilli, which can be found in the central mass, and in and between the epithelioid cells. The semi-translucent, gray, non-vascular nodules formed in this Avay are typical of tuberculosis. Sometimes, in the infiltrating form of growth, they can- not be recognized in the masses of round-celled granulation-tissue thrown out as a 94 GENERAL PATHOLOGY OF SURGICAL DISEASES. result of the continued irritation ; but, as a rule, they can be found forming a ring round the margins of growing tubercles, invading all the tissues near, and spread- ing into the lymphatics. As soon as the nodule is developed the central portion begins to degenerate, probably killed by the ptomaine excreted by the bacilli. Fatty degeneration and caseation follow, and as the infiltration continues to spread at the margins and decay in the centre, enormous masses of what is soAiietimes called crude or yellow tubercle are formed, the centre soft and cheesy, the margin consisting of typical gray nodules, which keep spreading as the jmrt already formed degenerates. The subsequent progress depends partly upon the relative vigor of the tissues, partly upon the anatomical structure of the area involved, and the opportunities for dissemination afforded the bacilli. What is known as obsolescence may occur. The bacilli, unable to make head- way, gradually cease to extend, and perish. The outer w-all of leucocytes thrown out by the healthy tissues around gains the upper hand, organization sets in, and a dense, fibrous capsule is formed, shrinking and becoming harder year by year. In the centre is a little caseous or calcareous mass, which may remain quiet for the rest of life, but which is always liable to become the source of future mischief. Liquefaction may take place. As the caseous centre increases in size, espe- cially if it is near a cutaneous or mucous surface, it gradually becomes more and more liquid, until at length a cavity is formed, filled with a fluid which in external appearance resembles pus, and which used to be taken for it. It is thinner, how- ever, and whiter ; caseous masses float about in it, and under the microscope it consists simply of molecular fat, without a definite pus-corpuscle anywhere. Absce.sses formed in this way tend slowly to increase in size until at length they approach the surface. Their walls are lined with granulation-tissue, pale, insuffi- ciently supplied with vessels, and containing myriads of tubercle-bacilli, and here and there small caseous masses, softening to add to the fluid. Outside this, and sometimes projecting so as to form septa in the interior, are the larger vessels, sheets of fascia, and dense fibrous structures that resist invasion. Growth takes place by the development of tubercles in the walls, following the easiest route, until at length somewhere the subcutaneous cellular tissue is reached. The skin at first separates, unaltered, from the deep fascia, and is lifted up so as to form a soft, fluctuating swelling, perfectly white and natural in texture. After a time, however, it shares the same fate ; the bacilli invade it from beneath, tubercles form in its deeper layers, the surface becomes reddened, and at length the abscess breaks, leaving a long, sinuous track, winding in all directions from the original starting-point, and lined with a layer of tubercular granulatio.ns mixed with caseous debris. Obsolescence may occur even when the skin has been reached, and the abscess extends from the dorsal spine to the thigh ; the fluid disappears, the tubercle-bacilli cease to grow, the caseous debris becomes more and more inspis- sated, and at length forms a dense, solid mass, which slowly undergoes cretification and remains encapsuled in fibrous tissue for the rest of life. In children this is not uncommon, as tubercular disease of joints is in them distinctly a disease of a certain period. In other cases extension takes place along the lymphatics. The neighboring glands enlarge, typical miliary tubercles make their appearance in the interior, forming foci, which, as elsewhere, spread by the margin while they decay in the centre. The capsule, formed of dense fibrous tissue, becomes thickened from the tension, and resists for a great length of time, but at last either it gives way, so that the caseous liquid spreads into the loose cellular tissue round and infects it, or suppuration occurs (periadenitis), and when the abscess bursts or is opened a caseous gland is found lying at the bottom, or adherent to one side, covered over with granulations. Before this, however, the mischief, as a rule, has spread to the neighboring glands and formed a chain, of which it is impossible to find the end. Finally, dissemination may take place through the blood-vessels, and, accord- SYPHILIS. 95 ing to the i)art of the circulation invol\e(l, acute miliary tuberculosis may develoi) in one or every organ in the body. In tuberculous disease of the kidney, for examjile, it may be limited to the lungs. When this occurs, the constitutional disturbance is generally so .severe that the result ])roves fatal before the tulfercles have attained any size or undergone more than incipient degeneration. Results. — So long as the tuberculosis is local, recovery may be complete, with the exception that the i)ortion of tissue infected is lost, whether it is removed by operation or undergoes caseation and degeneration with the products of the inflammation. This may take ])lace even when the lymjjhatic glands are involved. The tuberculous i)redisposition appears in many cases to ])e of limited duration. Scrofulous scars are left in the neck : Pott's disease causes permanent deformity, or hip-disease leaves a limb shortened, distorted, and wasted ; but as the period of growth ceases and the lymphatic glands and the ends of the bones lose the func- tional activity which characterizes them in youth the tubercular process sometimes ceases too, and cicatrices, which remain healthy through the rest of life, are left to show the mischief that has taken place. The tissues round recover sufficiently to throw out vascular granulation-tissue, and this becomes organized. Death may occur either as a direct result of the tubercular process, dissemina- tion taking place and proving fatal from the fever that accompanies it, or from a vital part, such as the brain, being involved ; or as an indirect consecjuence due to the hectic, exhaustion, amyloid disease, etc., that follow on suppuration in con- nection with caseous foci. Treatment. — i. Local. — Where it is practicable, there is no doubt that the seat of infection should be removed. If this cannot be done, an attempt may be made to check the further progress by the use of germicides, of which, perhaps, iodoform is the most to be trusted. On the other hand, when the situation or the extent of the growth ])recludes this, all that can be done is to place the tissues in the best possible ])osition for dealing with the germs themselves, and protect them from every other injurious influence. Fortunately, age is often of great assistance in this ; it seems as if, sometimes, about puberty the susceptibility suddenly ceased, the tissues gained the upper hand, and repair commenced at once. 2. Constitutional. — Fresh air ; if possible, sea air ; but an equable tempera- ture, not too moist, and especially free from cold winds. A moderate degree of warmth suits some ; a cold, dry climate agrees better with others, but no general rules can be laid down for this. A thoroughly nutritious diet, with cod-liver oil, iron, and other tonics, is equally important. Stimulants are not required by the disease, although often they materially assist the digestion. The clothing should be light, but warm. A fair amount of exercise should be taken, and, in short, the conditions of existence should be, as far as possible, ideal. SYPHILIS. Syphilis is an infective disease, due in all probability to the action of a specific organism. Its course, its power of indefinite multiplication in the body, and the fact, not only that it is contagious, but that it can only be propagated by contact, mediate or immediate, are sufficient proof; but it must be remembered that, in spite of the number of those who have tried, no one has yet succeeded in pro^ ing the existence of such a thing to the satisfaction of the rest. In many respects syphilis differs considerably from the specific infective dis- eases already described. In the first place, although it commences acutely, its course is chronic and persistent. Wherever the inoculation takes place the imme- diate effect is local ; then the lymphatics become in\-olved, and ver\' shortly the poison is distributed through the whole body by the blood-vessels ; but after this stage is past it remains in the tissues, either latent altogether or with very slight evidence of its existence, and perhaps suddenly, after many years, breaks out again. Then it is not only propagated by direct infection to other individuals, but it is 96 GENERAL PATHOLOGy OF SURGICAL DISEASES. hereditary ; the poison can be transmitted through the ova and spermatozoa, so that characteristic lesions make their appearance in the child before or shortly after birth ; and this transmissibility to the eml)ryo is retained long after the power of infection by direct contact is lost. Further, Avhile other specific germs cause, for the most part, some one definite form of inflammation, which, though it may be modified by locality, is yet characteristic of the cause, syphilis does not limit itself in this way. There is, it is true, a characteristic lesion, but it is also true that there is no form of inflammation which is not imitated, and imitated some- times so closely that the diagnosis can only be made by the result of treatment. It must be acknowledged, therefore, that if the microbic origin of the disease is considered proved, there is yet a great deal that requires further elucidation. The difficulty is not lessened by the fact that syphilis, or at least its initial lesion, is often complicated by the presence of another trouble, known as chan- croid, in distinction from the true form of chancre ; and it is still, to some extent, a matter of discussion what relation these two bear to each other. Chancroid or Soft Chancre. A soft chancre, or chancroid, is a sore developed upon the genitals as a result of contagion, and is distinguished from the hard or true chancre partly by the absence of induration, but chiefly (as this is only relative) by the fact that it is seldom followed by constitutional symptoms, and that the period of incubation is much shorter ; the one is always under a week and generally under three days, the other is always more than three Aveeks and is often as much as five. Soft chancre is never met with except upon the genitals, and is probably due to infection from retained and decomposing purulent discharge. The intensely irritating character this possesses may be judged of from the fact that soft chancre occurring on a mucous surface is almost sure to infect the opposite side, and if the secretion is pent up, as in the case of phimosis, is almost certain to become phagedaenic. No specific germ has been proved in connection with it. It can be inoculated times without number without conferring the least degree of immunity. It is never followed by any other result than those which are so common after all foul and sloughing sores on parts that are never kept at rest, and constitutional treatment is of little or no avail for it. There is a popular impression that certain people are peculiarly liable to it, which may reasonably be accounted for by local conditions ; it does not appear to be dependent upon syphilis, but it may be very closely imitated by a true syphilitic chancre on a person who has already suffered from that disease, and who has not yet passed through the period of immunity that one attack confers. Under these circumstances, if there is a second infection, the character of the primary sore is often very much modified, both as regards period of incubation and amount of induration ; and although it is a true infecting sore it may present the appearance of an ordinary chancroid. In women, in whom the hardness is often slight and sometimes wanting altogether, the difficulty is especially great. Symptoms and Cause. — The favorite situation is on the mucous surface of the prepuce, or just behind the corona. A small red papule is the first sign ; by the third or fourth day this has become a pustule with a bright areola, and in twenty-four hours more it breaks, leaving a sore with angry base and edges. In some few cases this heals without any further ulceration ; probably the infection has never really penetrated into the submucous tissue. More frequently it con- tinues to spread, the edges are sharply cut, perhaps undermined ; round them is a bright red rim of inflammation ; the base is grayish or yellow, covered with a slough ; and the whole thickness of the mucous membrane is destroyed. The sore is usually circular in shape and very tender. On the glans it may be perfectly soft, without sign of induration ; but when it is upon the skin the base is often infiltrated to such an extent that it is nearly as hard as a true infecting chancre. The margin, however, is different ; in a soft sore the edge of the induration is SYPHILIS. 97 ill-tlefmed ; it shades off imperceptibly into the healthy tissues around, and no limit can be made out, Init, at the same time, it must be recollected that this is e) The second group include dermoids of the ovary and testis, and perhaps may be attributed to exceptional formative powers and tendencies to variation in the structures from which these organs arise. But since the Wolffian duct has recently been shown to be of epiblastic origin, the possibility suggests itself that these cysts may also be derived from the epiblast. Distribution. — On the head and face they are more often situated over the lines of sutures. Their commonest site is beneath or near the eyebrow, especially toward the outer side ; but they are also found at almost any part of the orbital margin. On the skull they are more often observed on the temple near the fronto- maxillary suture, round the anterior fontanelle and over the mastoid process ; but they may exist at any part. On the face they occur over the middle line of the nose, the fronto-nasal suture, and rarely on the cheek. On the neck they are placed laterally, viz., over the parotid gland, near the angle of the jaw and along the anterior margin of the sterno-ma.stoid at points corresponding to the lines of the first three branchial fissures. Or they are median, being commonest here beneath TUMORS— C YS TS. 1 2 9 the hyoid bone (sub-hyoid cyst). Those of the skull and orbital margin are always deeply placed and attached to the i)eriosteiim. They often lie in a depres- sion in the bone, which may even be jjcrforated ; or the cyst is placed entirely within the skull. In the College of Surgeons' museum is a parietal bone jjer- forated at its centre ; from the aperture a dermoid cyst was removed and the patient died of meningitis. Some dermoids near the angle of the jaw and along the sterno-mastoid have deep connections attaching them to the styloid process and sheath of the carotid vessels. Cysts formed during the closure of the body walls are observed, especially near the junction of the first and second bones of the sternum and near the um])ilicus ; also in the thoracic and abdominal cavities and even in the lung itself. In con- nection with the development of the central nervous system, dermoids occur in the brain and over the spine. They are fairly common over the sacro-coccygeal region, constituting one of the varieties of congenital sacral tumor. Precisely similar cysts are also generally distributed. I have met with two over the scapula and one near the breast. They exist as rarities in the limbs. Those of the digits are often due to implantation of epithelium by wounds. The dermoids of the ovaries are situated within the o5phoron ; those of the testicle within the tunica vaginalis, and sometimes are enfolded by the parenchyma of the gland. Dermoids found in various parts of the abdominal cavity are often of ovarian origin, having become separated by twisting of their pedicles. Structure. — The dermoid cysts included in group {a) are usually simple in structure. They have a lining possessing the microscopic characters of skin, which shows the normal arrangement of the epidermis with papillae. Some are devoid of both hairs and glands ; others are furnished with hairs and sebaceous glands, while in a smaller number the wall also contains sudoriparous ones. The contents are fatty matter, of oily, honey-like, or buttery character. This is derived from degen- erated cast-off epithelium and from the secretion of sebaceous glands. Microscop- ically it shows epithelium and crystals of margarin and cholesterine. Similar cysts to these form a large proportion of group (<5), i.e., dermoids of internal organs, not apparently connected with epiblast. Cysts of the same nature as dermoid are found in the floor of the mouth, in the neck and omentum ; they are lined with pavement or with columnar-ciliated epithelium, and may conveniently be described as mucoid cysts. I have examined a sublingual cyst from John Hunter's collection, of this nature. Some of the cysts of the neck are covered on one side by skin and on the other by mucous membrane, indicating that the lining was derived from the epithelium on each side of a branchial cleft. They may even open externally, like a persistent branchial cleft. Complex dermoid tumors occur in the ovary, scrotum, sacro-perineal and maxillary regions, in the thorax and abdomen, and, in one instance, in the orbit. Many of them are included in the group of congenital tumors to which the name of teratomata has been given. They are for the most part cystic, or solid. The cysts are respectively lined in varying proportions with skin and with mucous membrane. Those having an integumental covering present the ordinary features of dermoids ; and in the ovary and elsewhere may contain hair, teeth, nails, and overgrown sebaceous glands, which even reach the complex- ity of a mammary gland. The cysts are embedded in a stroma of young or of mucoid connective tissue in which may be found in varying frequency plates of bones, cartilage, unstriped and, very rarely, striped muscle, with nervous elements of various kinds, i.e., uni- and multi-polar cells, medullated fibres and fibres of Remak. Further, traces of organs may exist as lungs, intestine, eye, and lymphoid tissue. In the sacro-coccygeal and maxillary regions a complete series of transi- tions between dermoid cysts and parasitic foetuses has been observed.* Bland *I have suggested that the complexity of these tumors depends on the period of embryonic life and the extent of the blastoderm involved in the disturbance, the tumor being more complex the earlier the disturbance. I30 GENERAL PATHOLOGY OF SURGICAL DISEASES. Sutton has sought to connect the origin of certain simple and complex dermoids with some fcetal canals, as the infundibulum, the hyo-lingual duct, and the neuro- enteric passage. Period of Origin. — The nucleus of all dermoids is congenital, with the excep- tion probably of some cysts of the ovary. Cutaneous dermoids do not usually appear till puberty, and this circumstance may be connected with the accelerated activity of the skin, shown by the development of the hair in certain parts. Dermoid cysts and tumors of the ovary are commonest between fifteen and thirty years of age. They occasionally become the seat of epithelioma and of sarcoma. A few instances have been recorded in which dermoid cysts of the ovary have been ruptured, and their contents, escaping, have become implanted on the omen- tum and peritoneum and have given rise to small secondary cysts of the same nature. 5. Congenital Hygroma. — These tumors of infancy are most commonly situ- ated on the neck and gluteal region, and less frequently in the axilla, on the arm, thigh, and cheek. Like other cystic tumors, the proportion of solid tissue and cyst varies greatly. The tumor may be chiefly composed of numerous intercom- municating loculi embedded in gelatinous connective tissue, or may be for the most part .solid, the cyst spaces being small and scattered ; exceptionally it is com- posed of one large cyst. The cavities are loculated, their walls are smooth and rendered irregular by imperfect septa. Their contents are serous fluid, in some instances sanious, rarely creamy, and rich in cholesterine. The tumors always lie beneath the deep fascia, and tend to spread widely in an irregular manner between the mu.scles, even infiltrating their substance. In the neck they occup>y the front or lateral aspects ; they are often attached to the sheath of the large vessels and may extend upward behind the pharynx to the base of the skull, downward beneath the deep fascia into the thorax, or into the axilla. The loculi and spaces are lined with an endothelium, the borders of which are irregular, but not den- tated in the manner peculiar to lymphatic vessels. In some instances their walls are surrounded by a layer of unstriped muscle fibre. The stroma in growing portions of the neoplasm has the characters of embryonic connective tis.sue. When the morbid growth infiltrates muscle or a gland, striped muscle and epithelium may respectively be found in it. The pathogeny of these tumors is still somewhat doubtful. The form, lining, and nature of the contents of the loculi point to their being a variety of lymph- angeioma. They originate at a very early period of intra-uterine life, probably the fourth or fifth month. Symptoms. — They may merely giv^e rise to inconvenience from their size, but in the neck often cause serious symptoms from pressure on the trachea, the gullet, and large vessels. Treatment. — Tapping may be resorted to with good effect when large cysts exist. Setons have been used for the purpose of setting up suppuration and inducing occlusion of the cysts in that manner. Tincture of iodine may also be injected for the same purpose. But these means are attended with the danger of setting up cellulitis. The safest method is excision. This operation should not be lightly undertaken, since it is attended with much difficulty and danger, owing to the deep expansions of the growth and the displacement and matting together of important structures. Electrolysis has also been employed, but not with satisfactory results. SOLID TUMORS. Fibromata. Fibromata are tumors composed of adult or well-developed fibrous tissue. They form distinctly circumscribed, encapsuled, movable ma.sses, which are either lobulated or uniform in outline. They also occur as pedunculated subcutaneous TUMORS— FIB R OMA TA. 131 tumors (molluscum fibrosum) and as polypoid growths from mucous membranes. In consistence they vary from a density approaching that of cartilage to a succu- lent, yielding, but still not friable tissue. Fibromata of the labia majora and pedunculated fd)romata of the skin are often extremely succulent, and large (juantities of serum exude from them on section ; this variety was formerly described as the fibro-cellular tumor. A section of the firmer fibromata displays a number of outstanding fibrous bands on a gray, yellowish, or oj^aciue white ground, or the section is firm, uniform, and dull white. The fibres either interlace, are arranged concentrically, or in parallel lamellae. A scraping yields no juice. Microscopically the firmer tumors are comi)osed of looser or more compact bundles of fibres, often wavy and inter- lacing, or disposed chiefly parallel to each other (Fig. 16). Situated on the bundles, in small numbers, are flattened nuclei of connective-tissue cells, the proto- plasm of which may be demonstrated to anastomose by processes around the bundles. The softer forms are made up of interlacing fibrillaj, more or less thickly studded with large round or oval connective-tissue cells, whose protoplasm is continuous with the fibrill^. As varieties, fasciculated and lamellar fibromata have been described. In some of the laminated fibromata layers of connective tissue are concen- trically disposed around blood-vessels and nerves. When a nerve and its branches are involved, as, for example, the pes anserinus, a very curious tumor composed of tortuous anastomosing cylinders (plexiform neuro-fibroma) of fibrous tissue is formed. The fibrous nodules of cartilaginous density found on the pleura and in the capsule of the spleen are examples of laminated fibromata in which the laminge are arranged parallel to the surface. The distribution of the fibromata is exceedingly general, for they occur wherever connective tissue exists, the following being the chief sites : the skin and subcutaneous tissue, fasciae, capsules of joints and synovial fringes, the nerves, the nose, gums, the periosteum of the lower jaw, ovary, round ligament, and breast. Painful Siibciitaneoiis Tubercle. — These tumors are situated in the corium or subcutaneous tissue, are rounded, rarely exceeding half an inch in diameter, and are usually single. They occur with much greater frequency on the lower extremities, and are more common in women than in men. Insignificant in themselves, they attract attention from the severe darting pain to which they give rise, sometimes associated with extreme tenderness. Probably in many cases the pain is much exaggerated by hysteria or allied conditions. The precise relation of these fibromata to nerves is still a matter of (juestion. Many observ^ers have failed to find any connection with a nerve, while in other cases nerve-filaments have been traced into the tumor or found spread out over its surface. xAnd, in certain instances, the whole tumor has been stated to be composed of non-medullated nerve-fibres (Virchow). A passing allusion may be made to the small fibromata which occasionally form around the punctures for ear-rings. They are notable from the fact that not rarely they recur after removal, but show no other sign of malignancy. Fibromata may undergo mucoid metamorphosis and also calcification, the latter change being often observed in those connected with the jaw. Friction or other forms of irritation may act as exciting causes ; in two instances I have observed symmetrically-placed fibromata over the ligamentum patellae. They do not recur after removal, but their relations with the sarcomata are exceedingly close. At times the differentiation between fibroma and fibro-sarcoma is impossible without the microscope. And, again, a fibroma may exist for many years and ultimately develop into a sarcoma. Diagnosis. — Fibromata are circumscribed, fairly movable, usually smooth, dense, but elastic and heavy. When pendulous and oedematous they are of soft and yielding consistence. Microscopically they exhibit adult fibrous tissue with 132 GENERAL PATHOLOGY OF SURGICAL DISEASES. scanty cells, and at growing points it may be observed that the young cells are forming adult and well-developed fibrous tissue ; while in the fibro-sarcomata the cell-elements are abundant and their transformation into fibrous tissue is incom- plete. Li POM AT A. Lipomata or fatty tumors resemble ordinary adipose tissue, except that the individual vesicles are often of larger size. They are circumscribed or diffused. The common circumscribed lipoma of the subcutaneous tissue is easily recognized by its lobulated or slightly irregular outline, its mobility, and its elasticity, which often approaches semi-fluctuation. The overlying skin, on being raised, is found to dimple slightly, owing to connective-tissue fasciculi which pass between it and the tumor. This shells out readily from a capsule of condensed connective tissue, and its surface is smooth, but deeply fissured and lobulated. The trunk and especially the shoulders are the seat of election of lipomata ; perhaps, it may be said broadly, the regions of the shoulder and pelvic girdle. But they are sometimes observed on the limbs, and I have seen two cases of multiple lipomata on the arms of women. Fig 13. — Fatty Tumor of 37 years' growth on arm of woman, aet 1 Fig. 14 — Diffused Lipoma of Neck,- They also form between muscular planes, in the tongue, uterus, walls of stomach and intestines, in the scrotum around the tunica vaginalis, in connection with the periosteum of the skull and other bones, and with the sheaths of blood- vessels. Appendices epiploicce may enlarge and constitute tumors. Masses of fat connected by a pedicle with the peritoneum are also found protruding through the linea alba, and along the inguinal canal into the scrotum, where they simulate omental hernia. Age exercises a marked influence on the formation of lipomata ; middle life, when adipose tissue is accumulating, being that in which the great majority occur. But cases of congenital lipoma are not very rare. The parts affected chiefly are the .sacro-coccygeal region, perineum, neck, and back; and the formation of fat may be associated with congenital hypertrophy. Mechanical irritants, as carrying weights on the shoulder and back, are exciting causes ; and it would appear in such cases that an irritative new formation of connective tissue undergoes fatty transformation. Degenerations. — Lipomata undergo softening or oily change ; and, in tumors of long standing, the connective-tissue septa may become calcified. Very large and, especially, pendulous tumors are subject to ulceration of the dependent skin, perhaps followed by sloughing and suppuration. TUMO RS— A/-VX OMA TA . 133 An extensive formation of fat is exceptionally associated with myxomatous or sarcomatous peri-renal tumors — lij)omatous myxoma. True lipomata are, of course, essentially innocent; but they tend to grow continuously. The diagnosis is usually obvious from the physical characters of the tumor, its seat, and the age of the patient. Diffuse lipoma constitutes, as its name implies, a non-circinnscribed, doughy mass, usually forming a collar around the neck, and composed of separate masses ; one of these projects from the nape, another from each parotid region, and another hangs beneath the chin like a devvla]). Or such a mass may be j^resent in any one of these regions without the others being affected. I'he subjects of this peculiar growth are usually obese, and often addicted to immoderate use of alcohol. Brodie recommended for it large doses of liquor potassae. Myxomata. Myxomata are new formations of loose, fibrillar connective tissue, permeated with fluid which is rich in mucin. The physiological prototype of these growths is found in Wharton's jelly of the umbilical cord. The commoner examples of Myxomatoii.'i Enchondm^ \o ^X M_y.ioma M:4 En c/iofn/rM/itB Jiound cell Myjcoma Lijjoma ST/aline Mi/xo/na imaloiis ili/xoma Fig. is. pure myxoma are pedunculated, as the polypi of the nose, rectum, and some polypi of the uterus. Their dependent position and narrow pedicles favor oedema. This may to some extent, but probably does not entirely, account for their succulence ; for in nasal polypi cysts are found evidently resulting from mucoid transformation of their substance. Pure myxomata also occur in the subcutaneons tissue, beneath the periosteum, and in the nerves, constituting one variety of neuroma. A section exhibits a glistening, pale, jelly-like tissue, the surface of which is raised in the centre. Microscopically, the neoplasm is composed of stellate and round cells, of which the protoplasm is prolonged in delicate filaments forming a felting of fibrils (see Fig. 15). The stellate cells are chiefly characteristic of mucous connective tissue ; in some growths they exist exclusively, while in others the round cells preponderate. The vessels are usually abundant and clearly seen, owing to the transparency of the tissue ; they often form a wide meshwork. Pure myxomata do not recur if completely removed, but in the large majority 134 GENERAL PATHOLOGY OE SURGLCAL DLSEASES. of so-called myxomata the mucous is mingled with sarcomatous tissue. These growths are described further on as myxo-sarcomata. The diagnosis, except when the tumor is deeply seated, is patent, from the appearance, consistence, and seat of the growth. Enchondromata. Enchondromata are tumors composed of cartilage, chiefly of the hyaline variety. They present well-marked physical characters. Their surface is nod- ulated and uneven, extremely firm to the touch, but not rarely there are soft points produced by mucoid degeneration. The section is glistening, smooth, and translucent, and almost invariably shows a number of separate masses or lobes divided by bands of connective tissue containing blood-vessels. These bands are often continuous with the membranous capsule constituting the perichondrium. In other cases, the section is often greatly modified by secondary changes. Microscopically, the commoner forms have practically the same structure as ordinary hyaline cartilage. In many the cartilage cells are more irregularly distributed, and more numerous in proportion to the matrix; the capsules are larger, and in growing parts of tumors a single capsule often contains two or more cells. The cells at the periphery beneath the perichondrium are flattened. Not rarely stellate ones are observed, especially in the parotid tumors, when the car- tilage is produced by chondrification of connective tissue. But .such cells are also observed in tumors of bone ; for example, of the fingers. Fibro-enchondromata, /. €., growths with a fibrous matrix, occasionally occur (Fig. i6). The degenerations of chondromata are important, owing to the way in which they modify the physical characters. Mucoid metamorphosis produces liquefaction of the matrix and the formation of cysts, so that the whole mass of a large tumor may be converted into a large cavity surrounded by a thin wall of cartilage ; or the whole tumor may be rendered uniformly soft and diffluent. The opposite condition may result from calcification and ossification, which begin in the centre of the tumor ; or, if it spring from a bone, from the parts adjoining the wall. The process of calcification consists simply in the deposition of lime-salts in the matrix and cells, while in ossification the cartilage is converted into true bone. In the latter the cells proliferate, their capsules enlarge and open into each other, blood-vessels penetrate into the mass of young cells thus formed, and tuberculae of bone are then developed around the vessels. In some instances the matrix of enchondromata is extensively converted into connective tissue. Cartilage cells are also prone to undergo fatty degeneration, a change obvious to the naked eye by the appearance of ochre-yellow patches. The distribution of enchondromata is very wide; they occur most commonly in the bones, in glands, as the parotid, the testicle, and breast, and in the subcu- taneous tissue. Any bone may be affected, but the digits of the hand most fre- quently ; next in frequence, the lower end of the femur, the head of the tibia, the humerus, and the great toe. Among other bones less liable to these growths may be named the base of the skull, vertebra, ribs, pelvic bones, lower jaw, and scapula. Enchondromata of the digits merit a special notice. They are nearly always multiple, originate in infancy or early life, and grow into large, nodulated masses around the digits and metacarjoal bones, with great deformity of the hand. Their increase ceases with that of the skeleton generally, and in such cases hered- ity may often be traced. They spring from the medullary cavity and expand the bone or burst through its walls at one point and then envelop it. Their source is probably from small masses of primordial cartilage which were not removed in the formation of the medullary cavity, but remained quiescent for a time and ultimately took on active growth. Enchondromata at the ends of the long bones — as the femur — are usually sub-periosteal, and in all probability originate from portions of the growing epiphysial disc, which in like manner remained unossified. Tumors of the shafts of the long bones usually surround them more or less com- TUMORS— OS TK OMA TA . 35 pletely, but are often connected with a mass in the medullary cavity, which may indicate that they have sometimes the same mode of origin as those of the digits. The cartilage occurring in jjarotid tumors is formed by the chondrification of the connective-tissue stroma. These neoplasms are usually largely composed of myxomatous tissue, which, in morbid growths, is often associated with cartilage. Pure enchondromata occur in the testicle, but in the majority of cases the carti- lage is combined with sarcoma-tissue (chondro-sarcoma). In fact, the sarcomatous granulation-tissue is, in part, directly transformed into cartilage. Secondary tumors, under these conditions, are formed in the lym))hatic glands, lungs, etc., likewise largely comjiosed of cartilage. Hence it was that some enchondromata were formerly believed to be malignant. It is scarcely necessary to add that pure enchondromata are innocent. The diagnosis is usually clear ; the chief factors are the situation of the tumor, its slow growth, its extreme hardness, weight, and its nodulated surface. Filromn x /•'//r/iont/romct Osfeoie/- \ C'/io/itiromtf Oa/coma Fig. i6. OsTEOMATA. Of these there are three varieties : The ebiirnatcd, compact, and cancellous. The eburnated have no prototype in the normal skeleton, except, perhaps, in osteo-dentine. They occur as small, flat elevations or bosses on the surface of the skull, and are histologically peculiar in having no Haversian canals, the small, flattened lacunas being arranged in lines parallel to the surface. Eburnated osseous growths, usually described as diffuse osteomata, also spring from the bones of the face ; they form irregular, ivory-like masses, filling the frontal sinuses, growing from the orbit, especially near its margin, or involving the whole superior maxilla. I know of two instances of tumors of this description, springing from the orbit, in which the skin ulcerated, the osseous mass protruded, and ultimately wa.s shed like an antler. Compact osteomata are observed on the shafts of the long bones, with which their structure is identical (Fig. i6). They sometimes form slightly-raised over- hanging masses with a wide base of attachment to the bone. 136 GENERAL PATHOLOGY OE SURGICAL DISEASES. The name cancellous sufficiently describes the structure of the third variety, the most common and widely distributed of all. With rare exceptions they are situated on the diaphyses of the long bones, near to, but not necessarily over, the epiphysial disc, and are covered with a layer of cartilage, the deeper surface of which grows continuously and is converted into bone. This fact, and their situ- ation, leave no room for doubting that they originate from aberrant portions of the epiphysial disc which have not been converted into bone. Genetically they are therefore closely allied to the enchondromata of bones. I have observed that such exostoses are more common in rickety subjects. At times they are multiple, affecting all the long bones of the skeleton ; and in such cases, like the multiple enchondromata, they cease to increase in size after the completion of growth. A marked hereditary tendency often exists. The distal phalanx of the great toe beneath the nail is a common site for exostosis. These osteomata should not be confounded with exostoses formed by ossifica- tion of the attachments of tendons and muscles, such as occur in connection with the adductor magnus, the psoas and iliacus, or the deltoid. Lastly, osteomata are in rare instances found altogether unconnected \vith bone — in the subcutaneous tissues, for example, of the buttock or thigh. Masses of bone are also formed in the gracilis and deltoid muscles, but these can hardly be considered as true tumors, being, perhaps, the result of inflammation or over-use. Those which occur in the adductor longus are known as " rider's- bone," because they are met with in cavalry soldiers and rough-riders. Fig. 17. — Non-striped Myoma (Uterine Fibroid). Stained with Picro-carmine. (X 450.) a. Mass of non-striped muscular tissue, in which the rod-shaped nuclei and the parallel arrangement of the fibrils are .seen ; b Similar bundles of fibres cut transversely. 1 he sections of the fibrils have the appearance of rounded cells, the section of the roimd nucleus is seen as a dot in some of the sections ; c. Spindle-shaped cells, of which the fibrils {/) are composed ; d. Pink fibrous tissue ; e. Connective-tissue corpuscles. {After IVoodhead.) Myoma. [Myoma is a tumor composed of muscular tissue. There are two principal varieties : One, composed of striped muscular tissue, very rare, termed Rhabdo- myoma, and the other of unstriped muscular tissue, and is termed Leio-myoma. The latter is the more common form, and may be found in any organ in which unstriped muscle-tissue is a normal constituent. The uterus, the wall of the bladder, the prostate, and the kidney are the most common seats of the leio- myomata. When in the uterus, the myomata are designated according to the tissue from which they spring, as intra-miiral, siibnmcous, and subserous. '\ TUMORS— MYO-FJBR OMA TA—ANGEJOMA . 137 MvO-FinROMATA. Myo-fibromata, as the name implies, are composed of muscle and fibrous tissue, in varying proportions. The muscle presents the ordinary characters of the unstrii)ed or involuntary variety, and is distributed in interlacing fasciculi. The outline of individual fibres often is not easily distinguishaljle in sections, but the fibres may be readily isolated by teasing after hardening in chromic acid. In some growths of long duration the fibrous tissue j^reponderates. The naked-eye characters resemble tho.se of a coarse fibroma, the section being marked by distinct interlacing fibrous bundles. The growth is well-defined, and can usually be enucleated without difficulty. Degeneration — either mucoid, fatty, or calcareous — is not uncommon, and patches of softening or collections of serum, forming cysts, may develop within them. They occur in almost all structures containing unstri])ed muscle ; with great frequency in the uterus ; in the ojsophagus, intestine, bladder, testicle, ovary, round ligament, and in the prostate, in which they constitute the chief ])ortion of the common enlargement of that organ. Their growth is slow, and clinically they are benign. Spindle-celled sarcoma, which also occurs occasionally in the uterus, can often only be distinguished with great difficulty from myo-fibroma. Angeioma. Under this name are included naevi, cavernous tumors, and aneurism by anastomosis. Ngevi, or " mother's marks," are tumors composed of convolutions of dilated capillaries lying in the corium and subcutaneous tissues. They are always congen- ital, and at birth may exist as a tiny red or purplish speck, which spreads more or less rapidly. As a rule, the growth is exceedingly slow, and it may be questioned if, in a large number of cases, the increase much exceeds that of the surface of the skin. Their fate, if left alone, has not been carefully studied : some shrink and wither, others appear to become warty, papillated, and deeply pigmented. In one case which I observed a Uccvus of the ear developed into an aneurism by anas- tomosis. Superficial naevi — those, that is to say, that involve the corium — appear as bright red, or purple, and slightly raised patches. Deeper ones, lying subcu- taneously, form rounded, rather ill-defined, doughy, or spongy tumors, which diminish in size on pressure, and communicate a bluish tint to the superjacent skin. Many naevi involve both skin and subcutaneous tissue. The superficial form is usually described as a capillary, the deeper as a venous or cavernous n^evus, but no distinction as regards their minute structure can be drawn between them ; both are made up of tortuous anastomosing capillaries, usually only moderately dilated. A section through a subcutaneous, or so-called venous or cavernous, neevus exhib- its a number of whitish, firm, fat-like lobules, united by connective tissue, show- ing to the naked eye few indications of its real structure. In rare instances the capillaries become so much dilated as to form cavernous sinuses, but this is cer- tainly the exception.* The capillaries of naevi are lined with a layer of plump endothelium, and bounded with a thin lamina of connective tissue ; they are usually closely approximated and are supported by connective-tissue trabeculae rich in nuclei. Hair follicles, sebaceous and sudoriparous glands are interspersed. The treatment of these growths is detailed elsewhere. Cavernous angeiomata are met with in the liver, kidneys, and in the walls 01 the intestines ; in a leg which I di.ssected numerous cavernous tumors were situated along the course of the large veins. They are composed of large venous sinuses separated by narrow connective-tissue trabeculae. Aneurisms by anastomosis are rare and are usually situated on the scalp. They have an expansile pulsation, and their surface is irregular from the projection of tortuous dilated arteries. One, * A good example of this is in llie Royal College of Surgeons' Museum, No. 407. 10 138 GENERAL PATHOLOGY OF SURGICAL DISEASES. which I injected and examined, involved the whole jnnna of a young woman, and was entirely comi)osed of a very delicate net-like anastomosis of minute arterioles. [The editor has seen a very large congenital aneurism by anastomosis, in a child of two years, which involved the penis and entire scrotum.] Lymphangeiomata. These are to the lymphatic vessels what naevi are to the blood-vessels, and, like the latter, are congenital. Tumors composed solely of dilated tortuous lym- phatic channels have been described, but usually fibrous hypertrophy of the affected part is associated with many dilated and tortuous lymphatics, as, for example, in macroglossia. I have observed considerable dilation of the lymphatics in congen- ital hypertrophy of the hand and foot. Congenital hygroma of the neck, as pointed out already, is probably a form of lymphangeioma. Neuroma. The great majority of tumors classed under this heading are simple fibromata springing from the peri- or endo-neurium. They are either merely embedded in the nerve-trunk or form nodular thickenings of it, and even individual fasciculi of the trunk may present minute bead-like enlargements. It is not rare to meet with cases in which nearly all the nerve trunks of the body are studded with fibro-neu- romata. Occasionally these neoplasms are associated with molluscum fibrosum of the skin. Rare instances of true neuroma, composed of convoluted bundles of medullated nerve fibres have been recorded, and Virchow has described tumors composed of delicate threads, which he regarded as amyelitic fibrils. Myxo- and spindle-celled sarcomata also occur in nerve trunks, and it may be noted that it would be difficult to distinguish histologically the latter from developing nerve fibres. Sarcomata. Sarcomata are tumors derived from the connective-tissue constituents of the body, but their elements never develop into fully-formed or adult structures ; they are always arrested at some intermediate stage in the formation of the various con- nective tissues, as fibrous tissue, bone, or cartilage. Their elements are, therefore, often described as embryonic, and they are spoken of as embryo-tissue tumors. This name implies a theory which is both misleading and untrue. It is mislead- ing because an inference is apt to be drawn that these tumors originate from em- bryonic rudiments of connective tissues, whereas by far the majority originate in adult life, and, as far as we know, from adult tissues. It is also untrue, because certain sarcomata, as the spindle-celled, have no counterpart in the connective tissues of the healthy embryo. The true prototype of the various forms of sar- coma may be found in the transitions of granulation cells to form fibrous or scar- tissue and callus, and clinical evidence abounds indicating that many of the sarcomata of later life have an inflammatory or irritative origin. On the other hand, many of those observed during the first five years of life may, with much probability, be referred to an irregularity in or arrest of development. The sarcomata are divided into three chief varieties, the round-celled, spindle-celled, and myeloid. Between these many intermediate forms are observed ; thus, round and spindle-cells may be mingled in nearly equal propor- tions — tnixed sarcotfia ; and myeloid cells are associated either with round or with spindle-cells. Again, the spindle-celled sarcomata shade off indefinitely into the fibromata (see Fihro-sarcomata) . Round-celled Sarcoma. — These again are divided into two sub-varieties, the small and the large. The former is much the commoner, and its component cells are about the size of leucocytes or granulation cells. In the latter they are as large as those of squamous epithelium. A section of a round-celled sarcoma under the TUMORS— SA R COMA TA . 139 microscope shows a uniform surface formed of closely-crowded cells, ]>erhaps intersected here ami there by a band of connective tissue. In this respect and the character of the cell it differs essentially from cancer. The nuclei are large and the protoplasm around them scanty ; in fact, many of the small round-celled tumors appear to be composed almost entirely of nuclei, in many of which evi- dence of nucleus division (karyokinesis) may be demonstrated with appropriate reagents. The intercellular substance varies ; it is usually scanty and homo- geneous, sometimes formed of delicate interlacing fibrillae prolonged from the protoplasm of the cells, and sometimes of homogeneous bands. The blood-vessels are usuallv abinidant, and in many instances have no proper wall. They are lined with rounded endothelium, which rests directly ujjon the cells of the tumor. Hence, they often become dilated or rupture and form blood-cysts, which give rise in tumors of bone to pulsatile expansion. Spindle-celled sarcomata are composed of either small or large spindle-cells analogous to the fibro-blasts of young granulation tissue ; they possess an oval nucleus, and their extremities are prolonged into a more or less delicate fibre. TrahecnloT Spindle -cell Spindle cell partly cross cut //f^( J Giant -cell orMyelnid Large Bound-Cell Fig. 18. — Sarcoma. Small Round Cell or Lymplw Sarcoma The cells are closely approximated, and are arranged in parallel or intersecting fasciculi or bundles. Many spindle-celled sarcomata show a partial transformation into fibrous tissue. The protoplasm of the cells unites to form a coarse stroma, only the elongated nuclei remaining visible, as may be observed, in many sub- periosteal tumors of bones ; or the protoplasm is prolonged into filaments which unite in fasciculi (fibro-sarcomata). Such tumors can only be distinguished from fibromata by the large number of nuclei present, the imperfect development of the fibrous tissue, their succulence, and relatively rapid growth. Myeloid sarcomata occur almost exclusively as central tumors of bones — rarely sub-periosteal — and in the gum as epulis. They are characterized by the presence of irregular multi-nucleated masses of granular protoplasm (giant-cells), the physiological prototype of which is the osteoclast. They are associated either wdth round or spindle cells, or both, and transitions from the round to giant-cells may be observed (Fig. 18). A section has, in parts or over the whole surface, a peculiar maroon-red tint, by which the nature of the tumor may be recognized. Many sarcomata of bone undergo partial transformation into cartilaginous or I40 GENERAL PATHOLOGY OE SURGLCAL DLSEASES. osseous material. In the former (chondro-sarcoma) the intercelhilar substance is abundant and hyaline, and becomes chondrified. The latter (calcifying or osteo- sarcomata) are composed either of round or spindle cells. The round cells are enclosed each in a mesh of a delicate fibro.us reticulum in which lime-salts are deposited. The process is analogous to the calcification of the imperfectly formed fibrillar matrix of bone sometimes observed in rickets, and in callus. In osteo- sarcoma the secondary growths in lymphatic glands and internal organs are also calcified. Myxo-Sai-coi7ia. — Some tumors of the breast, parotid gland, testicle, and rarely of the periosteum, have a white, translucent, gelatinous aspect, due to mucoid metamorphosis. Under the microscope they show, in varying proportions, branched and round cells, which stand out distinctly in an abundant homogeneous stroma (Fig. i8). Only a portion of the growth may have undergone this change, the remainder being composed of ordinary round or spindle-celled tissue. Alveolar sarcoma is another sub-variety, clinically unimportant, and is found in bone, muscle, and subcutaneous tissue. The cells are large, round, and not unlike epithelium; they form either small masses in alveoli, bounded by delicate bands of fibrous tissue ; or, more often, each cell is enclosed in a mesh of a fibrous network. Melanotic Sarcoma. — These present characteristics pathologically and clin- ically midway between the sarcomata and carcinomata. They, for the most part, originate in moles of the skin and in the choroid of the eye, and have also been observed on the vulva, hard palate, and growing from the matrix of the nails. They are extremely common in white horses. In color they are black or sepia- brown ; and a section may be pigmented uniformly or only in small parts, the remainder resembling medulla. Histologically they usually have a more or less marked alveolar structure, the stroma being scanty. The cells in cutaneous tumors are round or irregular from pressure, often of large size, and may have an epithe- lial aspect ; they are sometimes mingled with spindle cells. The tumors of the choroid are commonly composed of spindle cells. The pigment is deposited in granules within the cells ; and, to a smaller extent, lies free in the stroma. Individual cases of melanotic sarcoma vary greatly in malignancy. In the majority, the prognosis is exceedingly bad. Shortly after the appearance of the tumor, small, pigmented, secondary nodules are seen in neighboring parts of the skin, and the nearest lymphatic glands become affected, the growth sometimes extending directly in lines along the lymphatic channels. Within a brief space dissemination takes place in internal organs, the liver being a favorite site for them ; and, in some instances, the skin over the whole body is dotted with the growths. On the other hand, melanotic tumors, having the same general appear- ances, may grow slowly, and not recur even after a tardy removal. From the foregoing account it may be noted that the melanotic sarcomata of the skin closely approach the cancers, in that they possess an alveolar structure, often an epithelioid type of cell, and in the fact that they originate in connection with a structure — the skin (itself pigmented) — derived from epiblast. And further, as in cancers, the lymphatic glands are early affected. It may subse- quently be shown that those attributed to the choroid really spring from the pigmentary layer of the retina, which is also of epiblastic origin. I have myself observed in two instances melanotic tumors continuous with tap-like ingrowths of the epidermis, as in epithelioma ; and for these reasons am impelled to believe that these tumors are really, in many instances, cancers origi- nating in patches of imperfectly developed skin, such as moles. Simple, Circumscribed Melanotic Masses. — A very remarkable and rare disease has been described under this name, in which innumerable, well-defined masses of black pigment are formed simultaneously in many organs and structures. The primary focus of infection often cannot be ascertained. The nodules vary in dimension from a microscopic grain to the size of an egg or fist, and are observed TUMORS— SARCOMA TA. 141 in the subcutaneous tissue, peritoneum, breast, and in the muscular substance of the heart. The pigment-granules constituting the masses accumulate in the cells of the normal tissues, namely, in the connective-tissue cells, muscular fibres, and epithe- lium ; these are destroyed, and the tissues are replaced by a nodule, or a tumor softened at the centre, there being no trace of a cellular new-formation, such as exists in melanotic sarcoma and cancer. The disease in man i)roves fatal in a few months ; whilst in horses, in which it is common, its progress is slow. Lymphosarcoma. — This must not be confounded with lymphadenoma. It is a variety of round-celled sarcoma, originating in a lymphatic gland, extending by contact to a whole group and to neighboring chains, but never, like lymphadenoma, involving simultaneously the whole lymphatic system. The disease not unfre- quently attacks the mediastinal glands, spreads along the bronchi into the lungs, and involves the pericardium. The morbid growth is medullary in character, but rather firm, and yields a milky juice. The microscopic structure presents a rough resemblance to the cortical portion of the lymphatic gland, the chief part consist- ing of 1} mphoid cells, arranged in rounded masses or in irregular cylinders lying in the meshes of a coarse, fibrous stroma. A reticulum, such as is found in lymph- adenoma, does not exist. Glioma, or glio-sarcoma, is a variety of connective-tissue tumor arising from the neuroglia of the brain, retina, and, in rare instances, the spinal cord. It is commonest i^n the retina of children, and spririgs probably from the granular layers. Retinal gliomata are composed of small round cells, united by a scanty homogeneous or fibrillar intercellular substance. In those of the central nervous system the protoplasm of the cells gives off prolongations, which are continuous with a felting of delicate fibrils. In the central nervous system these growths appear as white, or pinkish, ill-defined masses, firmer than the surrounding brain-tissue, into which they merge insensibly. Usually they are situated in the convolutions, and are solitary, but occasionally multiple. Although they possess the features of local malignancy, they do not give rise to metastasis in distant organs ; in this respect, however, glioma of the retina is distinctly worse, being very prone to recur locally. Myo- or Rhabdo-sarcoma. — Mixed tumors composed of round cells and striped muscles have been observed in infants or young children. They are adherent to and sometimes infiltrate the substance of the kidney, and in some instances have involved both organs. Similar growths occur in the testicle ; and both striped and unstriped muscle not rarely are present in cystic sarcomata of that organ. In the rhabdo-sarcomata the muscle takes the form of transversely striated fibrils, or of elongated spindle-cells, also striated. Adcno-sarcoma. — Certain sarcomata of glands, as the breast, parotid, and testicle, contain a variable amount of the normal gland-tissue distributed through- out their substance. The sarcoma-tissue originates in the stroma of the organ, expands and stretches out the gland-tissue, the epithelium of which must therefore grow to cover the increased surface, but otherwise there is probably no new formation. Certain of the ducts or gland-tubules are obliterated, and the inter- vening portions may be dilated, and form cysts, into which, in the breast and sometimes the tescicle, rounded masses of sarcomatous stroma protrude. Adeno- sarcomata may be made up of almost any form of sarcoma-tissue ; but the stroma is commonly composed of round or stellate cells with a large proportion of fibrillar connective tissue (Fig. 19.) Cylindroma. — This name is given to peculiar neoplasms of rare occurrence, and mostly sarcomata. Their chief distinguishing feature is the presence of intersecting hyaline bands and cylinders, which are produced either by mucoid degeneration of strands of cells, or by greatly thickened blood-vessels, the sheaths of which have undergone hyaline change. The latter condition is more often observed in cerebral tumors. A somewhat similar appearance is met with in growths of nerve-plexuses, as the pes anserinus, in which the cylinders result from thickening of the endoneurium. 142 GENERAL PATHOLOGY OF SURGICAL DISEASES. Endothelioinata are growths arising from the endothelial linings of various cavities of the body and of the blood-vessels. Endothelium being derived from mesoblast and belonging to the connective tissue, these growths must be included in the connective-tissue series. Psammoma, or angciolithic sarcoma, originates in connection with the membranes of the brain and spinal cord. It is characterized by the presence of spheres, usually calcified, resembling in structure and mode of formation the brain-sand of the choroid plexus. The spheres are united by fibrous tissue, and are sometimes arranged in a dendritic fashion. They are composed of very large and thin endothelial plates, disposed in concentric laminae, and, according to Cornil and Ranvier, are formed by buds springing from the walls of blood-vessels, which are numerous. Presumably the cells are derived from the endothelium of the blood-vessels. In their clinical character these tumors are innocent. General Characteristics of Sarcomata. — Great variations exist in their physical characters. The majority have a well-defined, rounded, and at times a largely nodulated outline, and many are distinctly encapsuled. Some of the softer, round-celled forms infiltrate like cancer. Their consistence includes every grade, from that of soft brain-tissue, or jelly, to that of a fibroma : in color they are creamy or pearly white, and often blotched with various shades of red, yellow, and brown, produced by changes in extra vasated blood. The section is uniform, homogeneous, faintly fibrillar, or distinctly fasciculated. Some indication of the structure may be obtained from the naked eye character. Thus the round-celled growths are usually soft, medullary, or semi-gelatinous ; the spindle-celled have a smooth, rather firm, homogeneous section, and a few faint, fibrous bands only can be traced on their surface, or they may be distinctly fascicular. The appearances of some of the special varieties have already been described. Modifications result from the various forms of degeneration affecting a part or the whole of the mass, /. e., mucoid, fatty, or caseous ; or from hemorrhage and cyst-formation. When the skin gives way over a sarcoma it usually protrudes as a red, soft mass of granulation-tissue. The duration, progress, and malignancy of these tumors offer as much diversity as their physical characters. Soft, medullary, rapidly-growing neoplasms, and the melanomata, are the most malignant, some- times killing, from generalization of the growth in internal organs, within a few months. At the other extreme the spindle-celled sarcomata of the skin and the fibro -sarcomata grow exceedingly slowly ; but they are prone to recur near the cicatrix, again and again after removal, and five or six operations may be per- formed before the patient succumbs from exhaustion, or dissemination of the growth. Such tumors were formerly described as " recurrent fibroids." As regards prognosis, the rapidity of growth, consistence, and locality are of more importance than the microscopic structure. Of this it may broadly be said, that the elementary round and spindle-celled growths, especially the former, are more malignant than those in which there is an attempt to organize and form fibrous tissues. Locality is a most important element, sarcomata of the testicle being, for example, much more malignant than those of the breast. Of tumors of bone, the myeloid are by far the least malignant — probably, in great part, because, being usually central, they are enclosed by an osseous capsule. The mode of generalization of sarcoma differs essentially from that of cancer ; in the former the blood-vessels are numerous, thin-walled, often mere channels in the growth, and thus the conditions are most favorable for the escape of its elements into the veins, whence they are carried into the heart, lungs, and other viscera ; while, in the latter, secondary growths first appear in the nearest chain of lymphatic glands, and from these the tumor elements pass into the blood stream. But it is erroneous to suppose that the glands are never affected in sarcoma, for in growths of the testicle and tonsil it is the rule (Butlin). Glands are also often involved by contiguity, when the growth originates near them, as in tumors of the ilium. An outgrowth from a sarcoma may project into, and grow for a great TUMORS— PAPILL OMA TA. M3 distance along, a vein. In a mixed-cell sarcoma of the forearm, I found a pro- longation extending for some distance along, and occluding one of the veins at the bend of the elbow. Epithelial-Tissue Tumors. This large and important group comprises tumors derived from the epithelium of the surfaces and glands of the body ; and which, speaking broadly, originate from the epi- or hypo-blast. It need scarcely be remarked that these tumors are composed of both epithelium and connective tissue ; in fact, in some, the latter preponderates, as in contracting scirrhus ; but it is the epithelium which takes the initiative in growth, and gives to the tumor its si)ecial character. These neoplasms are divided clinically into two groujjs — the innocent and the malignant. To the former belong papilloma and adenoma, to the latter carcinoma. A tfeno -sa rcom a Adeno -Mi/j::oma fjTrom i'reastj Adenoma yfrcim Breast, [AefoUules . \ growi/tp cystic) tS^ Adenoma I'y'ra/Ti skin o/Jhrv ari/i) deno-jfihro' sarcoma, fymm iip) Fig. 19. — Adenoma. Papillomata. The simplest are merely overgrowths of the normal papillae of the skin or mucous membrane, each consisting of a central stem of connective tissue, con- taining capillaries, and covered on the surface by a thickened layer of cuticle, which at the end may be prolonged into a point. Such papillomata occur fre- quently upon the skin and tongue. Others are composed of a series of minute outgrowths, subdivided at their tips (compound papilloma). Others again, in the bladder, form branched or dendritic ma.sses, covered with columnar epithelium (villous growths) ; while those that occur in the ducts of the breast, and in ovarian and parovarian cysts, are more complex still, the interstices between the papillae being prolonged down- ward as glandular tubules. The external form and consistence necessarily vary very greatly, even in those springing from the same structure. For example, warts ; fleshy, vascular verruca ; and even long, spiral horns — composed of closely-packed cornified 144 GENERAL PATHOLOGY OE SURGICAL DISEASES. papillae — may appear upon the skin. The cause is usually some irritant, and, therefore, papillomata are often multiple, as in the case of warts on butchers' hands and of the verrucas, which are associated with discharges from the generative organs. In some cases this is so striking that a local infection has been suggested as the cause, and various forms of bacilli and psoro.spermis have been described in connection with them. Adenomata. Adenomata are hyperplasias of gland-tissue of which the epithelium presents the regular and orderly arrangement, reproduces the general form, and does not overstep the general limits of the gland in which they originate. Clinically, they are always innocent, but so closely do the so-called adeno-carcinomata resemble them histologically that it is rather by their general characters and limits than by their microscopic structure that they may be distinguished in some instances ; for example, the true adenomata of the intestine never pass beyond the mucosa, while the cancers extend through it, penetrate the muscular coat, and even involve adja- cent organs. Adenomata are described as tubular, acinous, and follicular, accord- ing to the type of gland-tissue. They occur in the breast, intestine, cutaneous glands, ovary, thyroid, parotid, liver, and kidney. Physical Characters. — In the breast and skin they are nodulated, encapsuled, and freely movable ; in the uterus and intestine they form polypoid outgrowths ; in other organs, as in the ovary, they may involve the entire structure. Cysts are frequently present, being formed either from gland-tubules or from closed follicles, as in the ovary and thyroid. Microscopically, the simplest form is the common mucous polypus of the rec- tum, which is composed of tortuous branching tubules lined with a single layer of columnar epithelium, and whose archetype is the Lieberkuhn's crypt. The stroma is soft, oedematous, and made up of a fibrillar tissue with stellate and round cells. The common statement that adenomata do not secrete is erroneous, for the tubules of rectal polypi pour out quantities of mucus, and many ' ' goblet cells ' ' may always be observed ; and in a specimen of fibro-adenoma of the breast, removed soon after lactation, I found a quantity of milk which exuded from the section. In fibro-adenoma of the breast the gland-tissue takes the form of elongated, curved, narrow cul-de-sacs, probably elongated acini, or of ducts cut across or terminating in trefoil-shaped alveoli. The new formation of gland-tissue is often inconsiderable, and it would appear as if that of a mammary lobule were merely stretched out and deformed by a growth of connective tissue. Cutaneous adenomata are of two kinds — the sudoriparous and sebaceous. The former are composed of tortuous columns of small, spherical epithelium, the latter of gland-tissue of an acinous type, the acini being filled with fatty matter and epithelial cells. Both form freely movable, firm tumors, having a lobulated structure, and they are prone to undergo calcerous degeneration. The sebaceous adenomata are usually situated on the scalp. Carcinoma. Carcinomata are overgrowths of the epithelial linings and glands of the body, which spread indefinitely by infiltration through contiguous structures, and are prone to affect early the lymphatic glands by transference of their elements along the lymph channels. Those originating in glands offer an irregular, disordered, and rudimentary resemblance to the mother gland ; sometimes it is closer, but the likeness is never so exact as in the adenomata, the arrangement of the cells being less regular, with no attempt at the formation of a basement membrane. Some of the clinical differences have already been alluded to. Cancers are divided anatomically into groups, in accordance with the nature of their epithelium. Squamous epilhc/io/na, for. example, springs from the stratified epithelium of TUMORS— CA R CINOMA . M5 the skin ami mucous membrane ; cylindrical-cclIaU from the coUimnar epitheHum of the mucous tracts and glands, and sphcroidal-ccllcd, from that which lines secreting structures in the breast, kidnev, testicle, etc. Siiiiamous-ccUcd Epitheliomata.— '\\\(t^ form flattened, superficial, or more ffard Carcinemci ^iver sccondV ie breast the right side shows Tialftraiis/'ornicc? liver Hs'xiir . the (eff scirrhuus suhstancc. j/ircei almost {lu'imllccl Ca Lara noma \\ (Cerebellum, seconclaru \j\ ^ la breast.) '« Hard Carctnoina (Jdciirfi, seand?[ to trrenst, tJie early si age at t/n's end) dfinnl ,)>r Alveolar Carcinoma /'rrcliuji fri/^/it side shous ifte ends o^ tiro Lieier/CuhnfoUidrs tlie cancer aj?/iears to extend ^roni these into the subtitticom, coat A Cu/inder - JEhithelial Carcirioniu (colon, a similar struc- ture foiiTid in h'ver it/" same case) £/tithehoma , or H/dthelinl CarcL/iij/tiii- Soft Carrijioma (Kidney secondary te (h'sopAuffas: lower left /land corner shiM a renal lobule witli a cast J I Ac lu'O caneir aliyoli. Jieil l/its a!t evidenlli/ transforma- tions of'sU4:k lubes ]iipAt edye, new gra - nitle tissue in the ilroma Left edc/e, -■ develop - of Ihis inla a spt/idle cell tlroma Hard, Carcixma Qileura sedl to breast the oldest part at lAis end) Epitkeli'oma or KpitkeJial Carxi- noma ^skin of^ cTiieA' shouinn the yland like Structure ', several birds nesl Ijodie-S are seen. The stroma is ofcrmeclii'e lis- sue , ^iyhly char- f J/^d with younq f^ cells.) ^ SpUhehoma or Epithelial Camnoma Separata Cells Fig. 20. — Carcinoma, (a) Cell-nests. deeply infiltrating growths on surfaces lined by squamous or transitional epithelmm They'often spring'from a crack or papilloma, an old ulcer, a scar, or a patch of epithelium thickened by long-standing inflammation. The superficial outgrowth or hypertrophy of epithelium constituting a wart or papilloma is sometimcb^ followed by an ingrowth of the deeper layers, as, for 146 GENERAL PATHOLOGY OF SURGLCAL JDISEASES. example, in chimney-sweep's cancer. However arising, the earh'est change is an elongation of the inter-])apillary processes of epithelium, and an infiltration of the corium or mucosa with leucocytes. The processes continue to grow downward as tap or finger-like prolongations, and soon are studded with cell-nests ; finally, the normal boundary between the epithelium and sub-epithelial connective tissue is broken down, and the growing cells are merged in the subjacent connective tissue, which is infiltrated with leucocytes. The epithelioma may then be said to be definitely formed. The growth now extends in the direction of least resistance — namely, along the connective-tissue interspaces — and nuclei are carried with the lymph-stream into the lymphatics. A general infiltration or injection of the con- nective-tissue interspaces and lymphatics results, comjiosed of tortuous columns and rounded masses of epithelium. In epitheliomata of the tongue, skin, and some other parts, the central cells of the tap-like prolongations from the surface and of the deeper masses become cornified, so that a trans- verse section shows a number of concentric laminae bounded by a layer of epithelium, like the rete mu- cosum. These are the epidermic globes, cell-nests, or birds' -nests. But other smaller concentric whorls are interspersed irregularly throughout the growth, and perhaps may more strictly he termed cell-nests ; they are much smaller than the epidermic globes, and are composed of a few plump, central cells, un- dergoing proliferation, surrounded by two or three layers of small, flattened cells (Fig. 20). Ulceration usually occurs through breaking down of the superficial portions of the neoplasm. The surface of the ulcer, whether it fungates or is excavated, is surrounded by a raised, hardened, often sinuous edge, and its base is indurated in pro- portion to the depth of the infiltration. At times the surface is papillary, or is covered with thickened epithelium, as in growths on the heel ; and even an extensive epithelioma of the tongue may present no ulcera- tion. The lymphatic glands are involved very early in the disease, and if left alone its duration may be only a matter of months. Death supervenes from exhaustion, consequent on the local effects of the disease, and from cachexia, resulting from secondary growths in internal organs. The chief seats of epithelioma are the junctions of skin and mucous membrane — as the lower lip, anus, and vaginal orifice ; parts especially exposed to irritation, as the tongue ; various parts of the skin, the glans penis, the palate, posterior wall of larynx, vocal cords, oesophagus, cervix uteri, and urinary bladder. In the latter organ it often produces soft papillary or vegetative outgrowths. Rodent Ulcer, Rodent Epithelioma, Cancroid of the Skin. — These names are given to an exceedingly chronic, slowly-growing form of epithelioma affecting the upper part of the face of people advanced in years. Its favorite sites are the external canthus, the side of the nose, and temple. The disease first appears as a slight thickening of the skin, which spreads as a flattened, slightly-raised, super- ficial nodule, of which the centre becomes abraded. An ulcer results, having a smooth, dry, pinkish-red surface, which spreads, with a slightly-raised, rounded, firm border. Exceptionally, the centre of the nodule remains smooth, pale, and cicatricial, while the growth continues to extend at its periphery. Histologically, rodent epithelioma is made up of rounded or lobulated masses of very small, round, or slightly flattened cells, usually invading only the corium. Cell-nests with cornification are absent, except occasionally in the thickened superficial epithelium covering the edges. In sections of growths before ulceration has taken place, the epidermis sometimes forms an unbroken layer, and has no connection with the underlying characteristic neoplasm. The sebaceous glands in the neighborhood are enlarged, undergoing transformation into the small-celled Fig. 21. — Epithelioma of stump, of two years' standing, from a man, jet. 58. TUMORS— CARCINOMA. 147 growth, in which the sheaths of the hair follicles are also involved. There can, therefore, be no question that this peculiar neojjlasm sjjrings from the sebaceous glands and hair sheaths, and not from the epithelium of the surface. It is placed above the convolutions of the sudoriparous glands. The disease may exist for years, producing by its extent great disfigurement, and even destroying the bones of the skull and face, but it never implicates the glands. There is a great ten- dency to local recurrence after removal. Cylindrical-ceUed cancer, or epithelioma, is the common form of morbid growth met with in the alimentary canal, from the cardiac orifice of the stomach to an inch above the anus ; below this point squamous-celled epithelioma occurs. It is also observed in the mucous membrane of the body of the uterus and in the bronchial tubes. In minute structure these neoplasms form a more or less close reproduction of gland-tissue after the tyjje of the tubular mucous gland. They are made up of a number of cylinders and alveoli lined with cylindrical epithelium, and result from a growth downward of the mucous glands into the muco.sa. This becomes in consequence greatly thickened and upraised ; subsequently the growth extends through the muscular coat, which on section appears much increased in breadth. So close a likeness in many cases does the new formation bear to gland- tissue that cylindrical-celled cancer is classed by Continental pathologists of high repute among the adenomata, notwithstanding its malignancy. But in some tumors, not otherwise differing in type, the cells retain the young spheroidal form, and are distributed in solid- columns or rounded masses, instead of forming a lining to the alveoli. The naked-eye characters offer a great variety in form and consistence. A large number are firm and cicatricial, and the disease either con- stitutes a distinct tumor, or in the intestine has the appearance of a limited cica- tricial contraction. Some form soft medullary masses fungating into the intestine, whilst in others ulceration is the prominent feature, adjoining viscera — as the blad- der in cases of cancer of the rectum — being often penetrated. Excepting rodent epithelioma, this variety of cancer perhaps exhibits the slowest progress. Second- ary deposits are found in the mesenteric glands and in the liver, to which cancer- ous emboli are carried by the portal veins. The seats of predilection are the cardiac and pyloric orifices, the sigmoid flexure and rectum. Spheroidal-celled Cancer. — This occurs in the breast, testicle, ovary, nose, and palate. The common cancer of the breast may be taken as an example. This takes the form either of a general infiltration of the gland, or of a nodule, the physical characters of which are detailed elsewhere. The earlier stages which I have studied in chronic mammary indurations do not differ essentially from those of epithelioma. The first step is the proliferation of the epithelium lining the ducts and acini. These become choked and the surrounding tissue thickly infiltrated with leucocytes. Next the epithelium breaks through the basement mem- brane and grows into the connective-tissue interspaces, where the bulk of the neo- plasm is formed. As a rule, the true gland-tissue has already undergone atrophy. A reactive new-formation of connective tissue follows the inroads of the epithelium. If dense fibrous tissue is formed in abundance, the tumor is hard and scirrhous ; if the connective tissue is soft and small in quantity, it is medullary. Between these extremes every grade may be observed. The amount and distribution of the epithelium offer corresponding variations. In scirrhus it is scanty, the cells are small and arranged in elongated groups (alveoli), between the broad fibrous bun- dles. In softer tumors the cells are large, often coalescent, and arranged in long chains and columns, or in large rounded masses. Rare examples are met with in which a closer likeness to gland-tissue exists, owing to the arrangement of the cells in the form of a lining to the alveoli. The clinical terms, hard or scirrhous, soft or medullary, have lost their patho- logical significance ; the difference depends on the relative amount of the stroma and epithelium respectively. Cancers undergo fatty, mucoid, and colloid metamorphosis. The fatty change is common in cancers of the breast, and in squamous-celled epitheliomata, 148 GENERAL PATHOLOGY OF SURGLCAL DISEASES. from a section of which worm-like masses of fatty epithelium may be expressed. Colloid metamorphosis (colloid carcinoma) occurs in growths of the stomach, intestines, ovary, thyroid, and rarely in the breast. In this change drops of colloid material appear in the protoplasm of the epithelium, pressing the nucleus to one side and distending the cell in the form of a vesicle. The cell wall gives way and the cells merge together in a gelatinous mass. In the alimentary canal these often constitute exuberant outgrowths, which on section exhibit to the naked eye large alveoli bounded by thin bands of stroma and containing soft, white, jelly-like material. Cancers of the breast more commonly undergo mucoid metamorphosis, which attacks the stroma. The epithelium is unaltered, and the alveoli are bounded by broad, transparent, hyaline bands of connective tissue. A section presents a uniform, moderately firm, gelatinous aspect. Such growths are described as carcinoma myxomatodes. The chief characteristics, common to all cancers, are as follows : they form infiltrations which spread indefinitely without any sign of boundary or capsule. On section a reticulated or alveolar appearance may usually be distinguished with the naked eye. Their alveolar structure is marked under the microscope, a con- dition not met with in any other form of malignant tumor except the alveolar and melanotic sarcomata. A scraping of the surface yields a milky juice. This cannot be obtained from soft sarcomata until they have been kept about twenty-four hours. Cancerous ulcers resulting from growths in the skin are usually crateriform, with infiltrated edges. The elements of the disease are carried directly along lymphatic channels to the corresponding group of glands, from which general dissemination by the blood takes place. Among organs commonly the seat of secondary formations are the liver, lungs, heart, adrenals, kidneys, spleen, and the bones. The disease also spreads by contiguity in neighboring parts and by transference along the lymphatics; thus, in a case of contracting scirrhus adherent to the skin — in which there were one or two nodules — an injection of Berlin blue permeated the alveoli of the primary growth and passed into the minute lymphatics of the skin, demonstrating the direct communication of the former with the lymphatic system. The blood-vessels of cancer ramify in the stroma, and capillaries never penetrate between the cells, as in sarcoma. The largest number of cases occur between the ages of 41 and 50 ; after that they gradually diminish. A considerable proportion are met with earlier in life, but only 4 per cent, before the age of 20. Sarcoma is a disease of an earlier period, and originates for the most part between the ages of 15 and 35. PART II. GENERAL PATHOLOGY OF INJURIES. CHAPTER I. THE GENERAL EFFECTS OF INJURY. SHOCK. Shock is the effect produced upon the nervous system by violent stimulation of peripheral nerves or by mental emotions. Causes. — These are exciting and predisposing, but the latter are in many instances so important that the distinction between them can hardly be main- tained. The immediate cause is usually the excessive stimulation of a number of sensory nerves, as in extensive burns or when a limb is crushed ; but the seat of injury, the mode of infliction, the surrounding conditions, the age, sex, and temperament of the patient, and particularly the amount of blood lost, are of very great importance. Injuries of the abdomen, urethra, and testis are especially liable to be followed by shock. The effect of a blow upon the epigastrium, of the passage of a catheter, and of violent squeezing of the testis, is well known ; the most typical examples are produced in this way, and sometimes they are so severe as to prove fatal. Concussion of the brain may be regarded as a form of shock, modified by the predominance of certain special and local effects. Division of the cord in castration ; section of the bone in amputations ; blows upon the cardiac region ; and, still more, injuries to the heart itself, are not uncommonly followed by very severe shock. Loss of blood, if sudden, may of itself cause the most intense shock, and in all cases is a very grave addition. Exposure to cold during operations renders a patient especially liable to it, particularly when ether is used. Mental emotion is of the highest importance ; of itself it is sufficient to produce a fatal result, and in all cases it is a very powerful element. In railway accidents, for example, and in earthquakes, shock is especially severe ; it may cause death without any discoverable lesion, and not only immediately from intense emotion, but later, after some days or weeks, from gradual failure of power. The nervous system is so profoundly affected that it is unable to recover itself: one single stimulus has left upon it an overpowering impression. Those who are worried and anxious suffer more se\"erely than others, and nothing is more disastrous than the conviction that an operation will be fatal. On the other hand, in great excitement or intense mental preoccupation, not only shock, but even pain is not felt, at least for the time. Afterward, OAving to exhaustion, reaction is usually more acute. In children the element of mental emotion is much less prominent, and unless there has been great hemorrhage or prolonged exposure to cold (both of 149 ISO GENERAL PATHOLOGY OF INJURIES. which they stand very badly), they suffer much less than adults. Probably, too, this is one of the reasons why the shock in amputation for disease is so much less than it is in a primary operation. Old people are usually affected very slightly, but when it does occur in them it is very grave. No pathological lesion has ever been found ; even the condition of the heart is not constant, although it is usually flaccid and relaxed. The change is essen- tially a molecular one \ the energy of the active tissues, especially the nerves and muscles, suffers the most extreme depression ; they are incapable of putting out any force, or of producing the amount of heat requisite to maintain the tempera- ture of the body \ the power of doing work of any kind is lost. Those are most liable to suffer from it whose nervous system is already in what must be called, for want of a better term, a state of depression, whether this is due to natural temperament, or to cold, exposure, fatigue, violent emotion, loss of blood, or other accidental conditions. Symptoms. — Two varieties of shock are described, the one characterized by extreme depression, the other, which is much the more rare, by great excite- ment. Upon what the difference depends, why one form should occur and not the other, is not known. In the ordinary form the patient lies perfectly quiet with the eyelids half- closed and the limbs in the position that chance may have placed them ; conscious, but paying no attention to anything around ; able to speak feebly and slowly, but entirely incapable of any mental effort. The face has lost all expres- sion ; the skin is cold, pale, and clammy, that on the forehead often being covered with perspiration ; the pulse is frequent, generally more or less irregular ; the artery seems to collapse and empty itself between each beat ; the respiration is shallow, and the temperature far below normal — sometimes as much as three or four degrees. The sphincter ani is usually relaxed ; urine, if the bladder is full at the time of the accident, is retained ; but afterward, for many hours, the secretion stops almost altogether. In the worst cases, such as are almost certain to prove fatal, there is complete absence of the sense of pain. I have many times seen patients dreamily looking on, without a sign of intelligence, while broken fragments of bone were being removed and search made for bleeding arteries, in limbs that had been crushed in a railway accident. Vomiting is of frequent occurrence ; in head injuries it not uncommonly marks the onset of reaction, and in a few moments the face becomes flushed and the pulse regains its vigor and fullness. In other cases it may either occur at the commencement, when it is of comparatively little significance, or later, after a few hours, and then it not uncommonly marks the beginning of the end. Shock may be almost instantaneously fatal ; I have known death to occur within five minutes from puncturing a small hydatid cyst in the liver ; or it may begin more gradually and slowly become worse and worse until death ends the scene. The other variety, that which is characterized by furious excitement, is more uncommon. Its onset is nearly always gradual ; at the first there is some ground for hope, and the general condition appears not altogether unsatisfactory, although the pulse is very rapid and devoid of power ; very soon, however, the patient becomes restless aud begins to talk volubly and incoherently; delirium sets in ; the limbs are thrown wildly about, utterly regardless of pain ; and in a short time this is followed by a condition resembling furious mania. The result is invariably fatal, from collapse. Diagnosis. — Syncope due to failure of the blood-supply of the brain rarely causes any difficulty ; with hemorrhage, especially when it is internal, it is differ- ent. In many cases of injury to the abdominal viscera it is practically impossible to make a diagnosis, the two are so often associated. Given a case of severe con- tusion followed by collapse, it may be due to shock alone or to shock complicated by hemorrhage from rupture of the viscera or tearing of a mesenteric artery or SHOCK. 151 vein, and there is no certain method of separating one condition from the other. Faihire of sight due to ana;mia of the retina, constant yawning or deep sighing inspirations, and throwing the arms about over the head, are very suggestive of hemorrhage, but nothing more; and a great deal of blood may collect in the abdominal cavity without causing any marked degree of dullness. Prognosis. — The condition of the pulse and the temperature together give the best clue (always provided there is no hemorrhage), but a great deal depends upon the kind of injury. Shock may prove fatal almost instantaneously, or it may be very severe at first and gradually pass off; or, especially after extensive injuries, it may steadily grow worse and worse, until at length the pulse fails com- pletely. The maniacal form is nearly always fatal. Whether an operation should ever be performed during the continuance of shock is a question that depends u])on the injury. So far as primary amputations are concerned, I am sure that the best course to follow is to stop the hemorrhage, prevent decomposition by wrapping up the limb in a strong solution of corrosive sublimate (i part in 500), and leave it, not until reaction is beginning, but until it has thoroughly set in — and this may not be for more than forty-eight hours. It is impossible at first to say whether the patient will live or not ; when in this condition, an operation will almost certainly prove fatal. Even when reaction is commencing, the same result is highly probable. I have on more than one occa- sion seen a patient's face suddenly change and felt the skin grow cold again as the bone was being sawni through ;" while if the hemorrhage is stayed and decompo- sition prevented (as it can be in nearly every case), the patient at least can come to no harm. The exception to this is where it is necessary to perform an operation, such as opening the abdomen, for the arrest of hemorrhage. This must, of course, be done at once. Ether is the anaesthetic usually recommended for operations in these cases, but chloroform is as safe if given in very small quantities ; a patient suffering from shock is already almost insensible to pain, and requires very little to produce complete anaesthesia. Treatment. — Hemorrhage must, of course, be stopped at once ; crushed limbs rarely bleed from the large vessels, but often there is a considerable amount of general oozing, which is serious in such a condition as this. Very hot water (with corrosive sublimate), and afterward firm bandaging, is the most satisfactory method. The elastic tourniquet should not be used, as it is liable to cause slough- ing. Where a mass of muscle projects from the end of a crushed stump and persists in oozing, it may be ligatured and cut away. Warmth is the first essential — hot blankets round the patient, and hot bottles outside these. Stimulants are usually required, but they must be given in very small quantities, at intervals of half an hour, and careful watch must be kept upon the condition of the pulse ; as it improves the intervals can be lengthened. If there is much sickness, a larger amount may be injected into the rectum. Subcu- taneous injections are sometimes resorted to when the patient is insensible and an immediate effect is desired. Ether, perhaps, acts more rapidly than brandy, but its effect is more evanescent. In many cases ammonia may be given with advan- tage, either wath the brandy (liq. ammoniae aromat., 3j) or even, if the heart is certainly failing, hypodermically, by intravenous injection, as in cases of snake- bite. Strychnia, digitalis, and other drugs from which much was expected, have all proved fallacious ; a very small quantity of morphia {yi gr.), locally, is beneficial, relieving the pain and so diminishing one cause of the depression. Transfusion with blood or with a saline solution is of very little use, if any, in shock uncomplicated with hemorrhage. Possibly a certain amount of benefit may be derived from raising the limbs, surrounding them with cotton-wool, and then bandaging them, so as to diminish as far as possible the area over which the blood in the body has to be distributed. 152 GENERAL PATHOLOGY OF LNJURIES. DELIRIUM TREMENS. Delirium of various kinds is met with after injuries. Sometimes it is due to the anaesthetic, or to prolonged exhaustion and exposure, just as occasionally it occurs during the convalescence from protracted fevers ; in other cases fat-embo- lism or the absorption of some poison from the surface of a wound may be the cause, but the best defined and the most characteristic is that which is the result wholly, or in great measure, of alcoholism. Delirium tremens may occur without injury of any kind, but, as met with in surgical wards, it usually follows an accident, often one of a very trivial character, two or three days after it has been inflicted. Sometimes it can be traced to a pro- longed debauch, but it is more frequent in those who, like many brewers' dray- men, if they are never wholly sober, are never positively drunk. The first night is passed in comparative peace, although the patient may not sleep. Next morning the tongue is white, flabby, marked by the teeth, and exceedingly tremulous ; the face is flushed and anxious, the hands are strangely restless, the patient seems unable to control them or even direct their actions ; every movement is attended with characteristic tremor ; the appetite is lost ; the skin is cool and often moist ; the bowels are confined, and generally there is a ten- dency to nausea. Toward evening the symptoms grow worse ; the pulse becomes very rapid, wanting in volume, and frequently dicrotic ; hallucinations,- often of the most disgusting character, make their appearance ; the patient yields easily to control, but only for the moment ; the same idea returns again and again — it may be the sight or the sound of something that fills him with apprehension, or it may be something utterly unintelligible, referring in an indistinct way to his occupa- tion ; at the same time there is the most ceaseless movement ; the hands are never still, aimlessly turning the bedclothes over and over, in a curious, objectless, tremulous manner ; the patient lies down, starts up, turns around, looks behind, beneath, above him, anywhere, and does anything but remain quiet for one single instant. Sleep is out of the question. There is rarely any violence ; almost always, if spoken to gently and firmly, he will lie down ; but it is utterly beyond his power to remain in the same position, and all the while there is the most extreme terror, the horror of something unknown, not to be described. In this way the night is passed ; with morning the symptoms subside in a measure, although they do not disappear. The exhaustion is greater, the pulse feebler, the appetite absolutely lost, and although the hallucinations are not so prominent, the nausea, tremor, sleeplessness, and restlessness persist. The fore- head is bathed with perspiration, and the temperature is nearly alway subnormal ; in exceptional cases (which are invariably fatal) it rises rapidly in a way that is only paralleled in tetanus and injuries of the central nervous system. If sleep returns the following evening, all usually ends well and the symptoms gradually become less and less severe ; but if the patient's constitution is already wrecked by prolonged intemperance, or if the injury is a severe one, and sleep does not follow, the prognosis becomes very grave ; the prostration becomes more marked, the pulse assumes a running character, the beats being scarcely distin- guishable and the volume exceedingly small, the respiration becomes shalloAv and hurried, the skin is pale and dusky, the face cyanosed and wet with perspiration, and the strength fails rapidly toward the end. The prognosis, if the patient is seen for the first time, must be very guarded ; the condition of the pulse is the best guide, but the age, the state of the kidneys, and especially the extent of the injury, require very careful consideration. Treatment. — Sleep and food are the chief requisites. If a good night's rest can be secured, or if the patient can be induced to take a fair amount of food, recovery may reasonably be looked forward to. Usually in these ca.ses there is gastritis ; no food has been taken for .several days, and even for longer periods, and the appetite is completely lost. Strong beef-tea, with abundance of cayenne pepper, sometimes answers when nothing else will ; milk, with eggs beaten up, is TRAU.)rAriC DELIRIUM. 153 even l)ettcr, if the patient can be induced to swallow it; hut often he will take nothing at all, or only such things as, from their extreme pungency or acidity, will stimulate a corrupted apj^etite. l>romide of potash is sometimes given in very large doses, but without much avail : chloral is decidedly dangerous, as it tends to increase the vascular depres- sion ; opium, or, better, morphia injected hyi)odermically, deserves more reliance. One-third of a grain given in the alternoon, before the symptoms attain their full severity, and followed by a second similar dose in the evening, is often effectual ; but care must first be taken to examine some of the urine. If the opiate does not succeed, and the sleeplessness still persists, the head may be shaved, and cold water (half-a-dozen jugfuls) jjourcd over it ; or chloroform may be cautiously tried, the patient being kept under its influence for twenty minutes or half an hour. If these measures fail, if the patient will not eat and cannot sleep, and particularly if from the condition of his kidneys it is not advisable to administer opium, there is no alternative but to give stimulants. If the pulse is a running one, and they are not given, the patient will almost certainly die. In the vast majority of cases there is no doubt it is better to cut them off at once (though it is quite possible it makes the patient worse for the time), but I have seen many instances in which I am sure the free use of stimulants saved life. The best is bottled stout, of the heaviest and sleepiest description, and it should be given freely, without stint, until either the pulse changes its character or the patient falls asleep. The bowels should be opened as soon as possible ; the liver is almost always congested, and it may become necessary to administer nutrient enemata. Quinine and bitter tonics, or alkalies, with carbonate of ammonia, may be advisable for the gastritis and to improve the appetite ; tincture of capsicum is said to be of especial use ; but large doses of digitalis are too dangerous. [The use of beef tea is usually followed after a time by great relief, and where there is extreme weakness it may be combined with brandy or sherry. Of such a mixture the dose will vary from a few drops every ten or fifteen minutes to a tea- cupful every two hours.] In many surgical cases restraint of some kind is absolutely necessary, but w^herever it is possible, anything of the nature of a strait-waistcoat should be avoided. Of itself it is sufficient to induce delirium and a severe degree of fever. Patients who are suffering from delirium tremens are for the most part very easily controlled, so long as the attendant is firm ; and it is only in cases of extreme violence, or when there is a fracture which it is absolutely essential to keep quiet, that any tight restraining appliance is advisable. TRAUMATIC DELIRIUM. Traumatic delirium, in the strict sense of that term — excluding, that is to say, the delirium due to pyrexia, that which occasionally follows an anaesthetic, delirium tremens, and those forms which are caused by the absorption of poisonous alka- loids — is decidedly rare. Sometimes, however, a kind of delirium attributable to nothing else is met with, especially in old people ; although, as it is more usual after fractures, it is possible that the symptoms are due, in a measure, to fat-embolism. The delirium is not like that of delirium tremens ; it has not the same rest- less, busy character, and the hallucinations are not of the same di.sgusting descrip- tion. The patient is often exceedingly supicious, imagining that every one is wishing to injure him ; but when left to himself he remains quiet, watching every- thing perhaps, and his movements are not tremulous. The tongue is often furred and white, but it can be protruded without fibrillar contractions ; food is taken readily \ and though the patient's sleep may be disturbed, there is not the same distressing insomnia. Usually the symptoms subside of themselves in the course of a day or two, w-ith a moderate supply of stimulants ; but it sometimes happens that, they persist, and the mental disturbance is permanent. 154 GENERAL PATHOLOGY OF INJUR LES. TRAUMATIC FEVER. Every kind of fever that follows injuries has been described under this name ; strictly, it should be limited to that which results from them directly, and should be clearly separated from those which are due to septic decomjiosition and other secondary changes. Two varieties may be distinguished — the one caased by nervous irritation ; the other by the absorption of certain substances from the interior of the wound. (a) The neurotic form sets in almost at once, reaches its maximum within the first five or six hours, and then begins to subside again. Irritation of peripheral nerves, pain, mental emotion, and perhaps other causes appear to possess the power of increasing the production of heat, possibly by inhibiting the controlling influence of the heat-centre. In excitable children, and occasionally in women, the mere sight of the preparations for dressing a wound, the knowledge that the time for it has come, or even the apprehension of an operation, is sufficient to raise the temperature as much as two degrees. The same causes, acting with greater intensity, or under different circumstances, give rise to shock, a condition of general depression affecting the whole of the central nervous system. (b) The other variety, that which is caused by the absorption of certain sub- stances from the interior of the wound, sets in more slowly, and continues so long as there is anything to be absorbed. It is probably due to some of the products that are set free during the coagulation of the blood, as it has been shown that the injection of fibrin ferment can excite pyrexia, and that the height to which the temperature rises is to a certain extent dependent upon the amount of the extrava- sation. At the same time, other substances set free from crushed and bruised tissues may have some influence ; and the tension which is always present in the case of large extravasations may help, partly by its effect upon the nerves, partly by the way in which it assists absorption. As a rule, the fever subsides in the course of forty-eight hours, but it may last a week or more ; the temperature, which is of a remittent character, steadily falling after the first day. SUBCUTANEOUS INJURIES. 155 CHAPTICR II. LOCAL EFLECTS OF IXJURV. Injuries are divided into two classes, subcutaneous and open, as the latter are liable to complications from which the former are practically exempt. I. SUBCUTANEOUS INJURIES. Simple contusions only are dealt with here ; injuries of special structures are reserved for more minute description. Contusions are caused by blows from some hard, blunt object, or by violent squeezes. Blood may be extravasated into the skin, but the surface is not broken ; that constitutes an open wound at once. The soft parts beneath sustain the brunt of the violence ; the connective tissue with its delicate vessels first ; then the muscles, which may be crushed or torn ; veins, lymphatics, and, to a less extent, owing to their elasticity, arteries come next ; while nerves, as a rule, resist, how^- ever much they are stretched. • Contusions vary in degree from a trivial bruise to absolute crushing. Clini- cally, the number and size of the vessels torn are the most important features. In the slightest form — a wheal, for example, produced by the lash of a whip — there is no bruising perceptible, merely redness and swelling, with local pain, \vhich soon subsides. If it is more severe, a certain degree of ecchymosis follows ; some of the capillaries are ruptured ; blood is effused into the skin or the subcu- taneous tissue ; and, according to the structure of the part and the violence of the injury, swelling and discoloration make their appearance. In the worst cases, in which a large vessel has given way, or in which the tissues are soft and easily torn, the amount of extravasation may be enormous; the skin may be separated from the deep fascia of the limb by a layer of fluid blood extending over an immense surface, and the case may prove fatal almost at once from hemorrhage alone. A circumscribed swelling in the connective tissue is called a hcEmatoma ; usually it can be recognized at once by its soft fluid centre and its hard and firm margin. When the blood collects in some internal space it is known as a hematocele. CephalhcEinatoma occurs upon the head, either in the subaponeurotic or the subperiosteal layer of the scalp. The blood pours out until the tension of the extravasation is equal to that at the orifice of the ruptured vessel, then coagulation sets in, and after a variable time the clot breaks down, forming a thick, turbid fluid, darker than blood, but still reddening when exposed to air. The subsequent changes depend upon the amount of the extravasation, the tension, the nutrition of the tissues around, and the way in which the injured part is treated. Absorption is the rule ; the red corpuscles and the fibrin break down, the haemoglobin is set free and soaks into the loose cellular ti.ssue, the fluid serum is carried off by the lymphatics, and, when the amount is only small, the white blood-corpuscles wander away. If the extravasation is a large one, the leuco- cytes in the centre, too far separated from the living ti.ssues, share the fate of the red ones. Finally, the haemoglobin is removed and all traces of the injury dis- appear. In other ca.ses, however, absorption is not so perfect; a certain degree of organizatiofi makes its appearance round the margin, lymph is poured out by the tissues near, and a layer of granulation-tissue, which may become fibrous or even bony, is developed around it. When this takes place, the coloring matter dis- 1 5 6 GENERA L PA THOL O G Y OE INJ URIES. appears, tlie niiid in the centre grows paler and paler, and at length the blood- clot becomes converted into a cyst or, more frequently, a thickened, rigid layer of dense fibrous tissue without any central space. After a time this too disappears, probably undergoing fatty degeneration and absorption. Finally, if the tension is high (as when a large artery gives way), or the part is not kept at rest, or the tissues round are so badly nourished that they are unable to stand even the slight irritation of the extravasated blood, inflammation sets in ; and then, unless speedy steps are taken to prevent it, suppuration is very likely to follow, the pyogenic organisms finding their way to the injured part, either through the blood-vessels, or if blebs form upon the surface and the epidermis gives way, directly through the tissues. No material suits them better than extravasated blood, especially if the tissues round are injured by tension or are not kept at rest. Hsematoiiiata in the wall of the thorax and between the muscles of the abdominal wall seem peculiarly liable to break down ; the cephalhaematoma of infancy never does. Signs of Contusions. The degree of swelling naturally varies with the amount and situation of the extravasation and the looseness of the tissues. Pain, unless a nerve-trunk is struck, chiefly depends upon the tension. In some instances — when, for example, the testis is squeezed or the abdomen struck — the shock is very severe. If a large vessel is torn, the loss of blood may jjrove fatal at once, and even if it falls short of this, the hemorrhage is often exceedingly serious. The staining, if the bruise is superficial, soon shows itself; when it is deep it may not appear for weeks, and then in some far-distant part ; rupture of one of the deep veins of the calf, for example, causes discoloration behind the internal malleolus, and in the palm of the hand leads to peculiar purple crescents at the angles between the fingers. The color varies in the same way; under the conjunctiva it is a bright red; in the loose tissues of the eyelids, black; where the skin is thicker, it is blue or green, and when the extravasation is very deep it is lemon-yellow. As the stain dies out it passes through the same changes [giving in succession the colors of the blood- spectrum.] Traumatic fever is very general, and, in the case of large extravasations, not unfrequently severe for several days. If the bruise is superficial, the skin over it becomes hot and red, owing to the increased vascularity of all the tissues round ; more blood flows through the vessels, because there is more work to be done and a greater amount of repair is required. Provided the part is kept at rest, this soon subsides ; but if the tension is not relieved, or if any fresh injury is inflicted, inflammation .sets in, the swelling continues to increase, the pain becomes more severe, the skin becomes .shiny, perhaps (edematous, and then there is every prospect of suppuration. Treatment. — Slight contusions are best treated with cold or evaporating lotions ; lead lotion is especially useful if there is any redness of the skin. Arnica should not be employed at all ; its merit is due to the spirit the tincture contains, and it often causes an eruption. Where the extravasation is considerable, uniform, gentle compression, with many layers of cotton-wool, checks the increase, limits the hyperemia, and promotes absorption better than anything else. Even when the epidermis is lifted up and bullae are forming upon the skin, nothing answers better. The fluid should be drawn off through a minute puncture and absorbed with cotton-wool or thick blotting-paper, the epidermis carefully replaced, a little iodoform dusted on, or collodion painted over, and then cotton-wool carefully applied. In very severe cases, w^here there is risk of suppuration, aspiration often averts the danger ; there is no need to empty the cavity ; removing a small portion of the fluid relieves the tension ; the hypersemia begins to diminish at once, the skin loses its shiny, glazed appearance, and absorption proceeds unchecked. Of course, OPEN WOUNDS. 157 if a large artery has given way in one of the limbs, so that the collateral circula- tion is interrupted and the part below is cold and oedeniatous, other measures are required. Occasionally it hapi)ens that the contusion of the skin has been so severe as to kill it ; if the extent is only small and the dee])er structures are not badly injured, the slough should be allowed to separate of itself, and the resulting wound will soon close; but where, as in railway and tram-car accidents, the skin has been stripi)ed off from the subcutaneous tissue for some distance above the apparent seat of injury, and it is thought advisable to amputate, the line of incision must be carried well above, or the flaps are sure to slough. 2. orj:\ WOUNDS. Injuries in which the skin (or the mucous membrane) has given way, so that the deeper structures are exposed to the air. Wounds are described as incised, when inflicted with a sharp, clean-cutting instrument ; lacerated when the parts are torn ; contused when they are bruised ; axid punctured when caused by the thrust of a pointed weapon. Foisofied wownds, in which there is more than the simple division of the tissues, must be treated by themselves. Incised JVounds. — In these the injury is limited; on either side there is only a thin layer of tissue the vitality- of which has been destroyed. The symptoms are pain, from division of the nerves and exposure of the divided ends to the air ; bleeding, from the vessels that are cut, varying in ]>roportion to their size and im- portance ; and gaping, owing to the elasticity of the tissues. Skin retracts more than anything else, especially when the wound is transverse (except in such situa- tions as the palm of the hand, where it is bound down much too tightly) : arteries, if they are simply wounded, bleed most persistently, as the wound is held widely open ; if they are completely divided, they shrink together and retract, so that their ends can hardly 1)6 seen, and the amount of bleeding, except in the case of the larger ones, is comparatively inconsiderable ; veins retract less, but unless they are varicose, and hemorrhage is favored by position, bleeding is seldom serious from them. Muscles, when cut across, shorten at once, and often continue to shrink for some time. Fibrous tissues and nerves, on the other hand, retract but little ; there is no tension upon them. Contused and Lacerated Wounds. — The skin and the soft tissues are torn and crushed and, especially in the former, the injured area is often very much larger than it appears to be. The degree of gaping naturally depends upon the size, depth, and direction of the hurt; the pain is usually of a dull, aching character, not so severe as in the incised kind ; and the hemorrhage is less extensive. Cap- illary oozing may be present to a considerable degree, but large arteries rarely bleed in contused and lacerated wounds. The inner and middle coats break off" at a different level to the outer one, and they curl up together inside the sheath, so that sometimes not even a drop escapes. An arm may be torn off" at the shoulder- joint without any loss of blood from the axillary. The fear is that, owing to the amount of dead and dying tissue, decomposition may set in and open up the way for the whole series of septic processes. Pu7ictured Wounds. — These are caused by stabs with sharp-pointed iiistru- ments, such as bayonets and rapiers. The chief dangers are the very serious and concealed injuries that may be sustained by deep-lying structures, such as important vessels and viscera, and the fact that such wounds are nearly always valvular, so that proper drainage is impossible. Punctured wounds, as a rule, either heal at once, or lead to prolonged, deep-seated, and dangerous suppuration. 1 58 GENERAL PATHOLOGY OF INJURIES. Repair of Wounds. Wounds in all cases are repaired by the formation of lymph, which first be- comes vascular and then develops into a kind of fibrous tissue. Subsequently, where special structures are concerned, such as bone or muscle, further develop- ment may take place. If the amount of exudation poured out is very small, the wound is described as healing by xkv^ first intention \ if there is a considerable quantity, as when a cavity has to be filled up, union is said to take place by the second intention. Immediate union, which has been described in the tongues of animals after incised wounds, is merely a variety of the former, characterized by possessing the minimum of lymph ; union by the third intention and healing under a scab are only modifications of the latter. The changes that occur after the infliction of a simple uncomplicated wound do not differ in the least from those that follow a sprain or contusion, or any other form of subcutaneous injury. The hemorrhage ceases, partly from pressure, partly from the coagulation of the blood and contraction of the torn and bruised capil- laries ; all the blood-vessels round the injured area dilate, more blood flows through the part (so that the edges of the wound, if it is on the skin, become swollen and slightly reddened), more plasma pours out through their walls, and the cut surface on either side becomes infiltrated with leucocytes and coagulating fibrin. At first, shortly after its infliction, all the separate structures can be distinctly recognized in the wound ; in an hour or two they become blurred, the interstices between them and the surface over them are filled with the exudation, or, as it used to be described, the wound is glazed. If the two surfaces are now brought into apposition, and no irritant of any kind is allowed to injure them, they cohere and become glued so closely to each other that even after twenty-four hours it is almost impossible to detect the line. This is union by the first intention. The lymph that unites the surfaces becomes organized, fresh vessels form from the old ones on either side, fibroblasts gradually range themselves along them, the cells and fibres that have been killed by the accident, and the small quantity of extravasated blood still left in the wound, are absorbed and carried off by the leucocytes, and soon a very thin, delicate layer of vascular, newly-formed fibrous tissue is all that can be seen of the lymph that filled the wound. Meanwhile, the surface becomes covered with epidermis by the budding of the living cells on either side, and if the injury is inspected twenty-four hours after it has been inflicted, a faint red and slightly swollen line is all that is left. As organization proceeds, even this becomes less distinct ; many of the new vessels disappear, and gradually the color fades until it is as pale as the parts around. There is no inflammation after a single, simple injurj^ such as this ; the changes are identical with those that occur after a bruise, in which the extravasation has not been sufiiciently great to cause any tension ; there is no loss of tissue, except that which is killed in the original hurt, and the only changes that take place are the ordinary ones that are going on every day; the sole difference is in their rapidity and energy; there is a greater amount of wear and tear than usual, and the process of repair is carried on with greater energy. When the injury is more severe than this — when, for example, a definite portion of tissue is destroyed or lost — the process is exactly the same, always provided that no fresh irritant appears upon the scene. Suppose, for example, a cavity is left by the excision of a tumor, the surfaces of the wound not admitting of absolutely accurate adjustment. As before, the blood pours out, coagulation takes place, hemorrhage ceases, and all the vessels round dilate. As before, lymph pours out through their walls, and the leucocytes pervade every thing — the softened and swollen tissues on either side of the wound, the little fragments of dead material that are left clinging to them, and the extravasation of blood that fills the cavity. In this case, the amount of lymph thrown out is much greater, there is much more debris to be removed, and a greater amount of repair required ; but gradually it is C/CA TR rZA TION. 1 5 9 all done, ami as the vessels grow into tlie exudation from tiie dilated capillaries round, the whole wound is filled from all sides and from below with newly-formed vascular lymph, so called granulation-tissue. This is union by the second intention, and it onlyiliffers from union by the first intention in the amount of lym])h thrown out. There is no inllammation or suppuration, and there is no loss of tissue other than that caused by the original injury. The mere presence of e.xtravasated blood (always provided there is no tension and that it does not undergo decomposition) does not prevent union by the first intention, although it delays it ; there is a greater amount of dead material to be absorbed, and naturally the process is slower, exactly as it takes longer to repair the effect of an extensive contusion than that of a slight one. And the same may be said of tissue-debris : acertain amount of tissue is killed in every wound ; this is removed slowly by the leucocytes, which literally eat their way into it ; the larger it is the longer it takes, but so long as it does not cause tension or lead to decomposition, union by the first intention is the rule. The pedicle of an ovarian tumor, or a stump of omentum strangulated as tightly as possible and returned into the abdominal cavity, does not interfere with immediate recovery ; the lymph poured out by the tissues round it is able to deal satisfactorily with it. Healing under a scab is the same thing. Supposing the cavity, instead of being deeply buried, involved the surface, the blood that pours out from the injured vessels, and the lymph that transudes through their walls, coagulate and form upon the top, where they are exposed to the air, a coating which grows harder and drier the longer it lasts. Under this the lymph becomes vascular, as before, and if at any time the scab is removed, a smooth, pale, glazed surface is exposed, consisting of myriads of leucocytes, traversed by capillaries, and gradually becoming organized, the deeper ones into fibrous tissue, the superficial ones, where they are in contact with the already existing epidermis or epithelium, into flattened cells of the same character. If the scab is detached before the surface is sound all over, a peculiar transformation occurs : instead of remaining flat the topmost layer of the lymph is raised up in the course of an hour or two into myriads of little points, each consisting of a capillary loop, covered with a layer of leucocytes ; in other words, it assumes the typical character of granulation- tissue ; as soon as the restraining influence of the scab is removed, the newly- formed vessels, the walls of which are exceedingly delicate, yield to the influence of the blood pressure, and stretch rapidly upward in the direction of least resist- ance, raising up with them a little covering of leucocytes, so that the whole surface appears granular. When this occurs, the superficial layers generally melt away as pus ; but this is not essential, and must be regarded as a complication due to the incidence of pyogenic organisms. If two surfaces, granulating in this manner and perfectly clean, are brought together and held in accurate apposition, the granulations fuse, vessels pass from one to the other, and union soon becomes firm. This is sometimes known as union by the third intention ; it is chiefly of service in plastic surgery, or after extensive scalp wounds, in which the ordinary treatment has failed. Cicatrization. In a simple incised wound, the edges of which are brought together accurately, there is no difficulty in understanding the reproduction of the epithelial or epi- dermic stratum that covers in the surface ; the cells of the rete malpighii proliferate and multiply rather more rapidly than before ; while the old stratum corneum is thrown off" by the increased exudation beneath, and is quickly reproduced from the growing cells below. The same thing occurs when the extent of surface lost is greater ; but the perfection of reproduction becomes less and less the fiirther the cells lie from the edge of the wound. If there has been any loss of substance the cavity must first be filled up by the formation of vascular lymph. As soon as this has taken place, or while it is i6o GENERAL PATHOLOGY OF INJURIES. taking place, organization begins; the deeper layers gradually l^ccome converted into cicatricial tissue, and draw the edges of the wound together (in the case of a circular area, in which the contraction takes place from all sides toward the centre, the importance of this in connection with the healing of wounds is easily calcu- lated) : the superficial ones, on the other hand, are transformed into epithelium under the influence of the already developed cells at the margin. Without the presence of already existing epithelial or epidermic cells this is impossible; fresh epidermis never makes its appearance spontaneously at a distance from the edge. The method is the same whether the surface of the lymph is protected from all injurious influences or is exposed freely to the air; but the process is much more rapid in the former, and there is no waste. In the latter, owing to the incidence of the omnipresent pyogenic organisms, suppuration usually occurs ; many of the superficial cells are killed and lost as pus; and it is not until the ti.ssues gain the upper hand and are able to resist the attack that organization begins to make way ; then it advances equally from the margin, forming epithe- lium, and from the sides and base, forming fibrous tissue. By degrees, as the base contracts and the sides skin over, the area over which the pyogenic germs have power is reduced more and more until they are completely shut out. If at any time, before this has happened, some other irritant comes to their aid, healing stops; and if it is of any intensity, the whole surface of the wound may break down again. The appearance of a wound as it heals, under these conditions, is very characteristic. If the centre, where repair is not yet complete, has been covered by a perfectly dry scab or by some clean non-adhesive dressing, and this is re- moved, a pale, smooth, glassy-looking surface is exposed ; this is the lymph that has grown up to replace that which has been lost. At the margins it passes imper- ceptibly into the cicatricial epithelium ; the surface seems to become dry ; it does not reflect the light so readily ; then, a little further off, its color changes, be- coming rather more blue or purple ; and finally, it is plainly and definitely a layer of young epithelium, continuous with that of the skin around. As it grows older it becomes thicker, and allows less of the color of the parts beneath to show through. If, on the other hand, instead of being protected and compressed, the centre of the wound is exposed to the air, and suppuration has occurred, the appearance is altogether different. The color is a bright, florid red ; all the vessels are dilated ; and the surface is no longer smooth, but covered over with myriads of little points, each corresponding to a capillary loop, which has been stretched out in the direc- tion of least resistance, and has raised up on itself a covering of leucocytes. On this is a little thin pus, formed from the most superficial cells which have perished, but only sufficient to make the surface moist. Round it, and now seen very con- spicuously from the difference of its level and the smoothness and dryness of its surface, is the thin bluish rim of young epithelium, developing exactly as before. In the case of large granulating surfaces, although repair may advance rapidly at first, after a time progress becomes more and more slow, until often it cea.ses altogether, whether becau.se further contraction is impossible, or because the infective power of the epithelium is too feeble at the distance. In such cases, which are exceedingly common after burns, an attempt may be made to expedite matters by what is known as grafting. SKIN-GRAFTING. There are many ways in which this may be performed. The simplest — • epidermic grafting — consists in removing minute i)ortions of the skin from some other part of the body by means either of special grafting scissors or a sharp scalpel, and placing them on the granulating surface a short distance from the edge. Each of these grafts forms a new centre from which cicatrization spreads ; and it may not infrequently be noticed, if one is placed near the margin when healing has SKIN- GRAFTING. i6i become slack, that the cells on the other side, those which are growing from the already existing epidermis, suddenly wake up into activity too. It is not necessary or advisable to include the whole thickness of the skin ; it is quite sufficient if the cells which still retain their power of growth are used. No real wound should be left ; at the most, the spot from which the skin is taken should be reddened or marked with one or two dots of blood coming from papillae, the apices of which have been taken off ; and the size of the i)art that is used need be no larger than that of an ordinary pin's head. If possil)le, grafts should always be taken from the ])aticnt's own body, and from some part where the epi- dermis is not too thick; but if no objection is raised, the skin from an amputated limb may be made use of, or that which is removed in the operation for phimosis, especially as the vitality of thee])idermis is greater in the case of children. Grafting is of no use unless the wound itself is healing at the edges ; some- times when this is not the case — when the granulations are pale and uidematous — the grafts grow for a few days, but almost invariably they break down and disappear again ; and they should always be placed with the natural surface downward, about three-cjuarters of an inch from the margin, on that part of the wound, in other words, which is in other respects ready for cicatrization. Great care should be Figs. 22 and 23. — Drawing Illustrating the Cicatrization of Sores by Skin-grafting. taken not to make the surface bleed. The most satisfactory dressing is a single layer of gutta-percha tissue or oiled silk perforated with a number of minute open- ings, and covered with a considerable thickness of absorbent wood-wool. This may be left for a week or more, until the grafts are firmly set ; the excess of dis- charge, which might otherwise wash them away or displace them, being absorbed through the perforations. In the method advocated by Thiersch, actual portions of skin are used and the whole surface of the sore is covered over at once. It may be carried out in recent wounds, but it answers better in those which have been granulating for some little time, and in which the granulations are small and florid, a condition which usually follows the application of caustic or compression. The surface must first of all be thoroughly purified and washed with normal salt solution, compresses soaked in the same fluid being laid over the wound until the strii)s are ready. The most convenient situation from which to obtain the skin is the arm or thigh ; the epidermis is first thoroughly scrubbed with a solution of corrosive sublimate or iodide of mercury in iodide of pota-sh ; then the antiseptic is washed away with salt solution, and long strips are cut off with a sharp razor as wide as the part will allow. The limb must be held firmly from beneath with one hand, so as to put the 1 62 GENERAL PATHOLOGY OF LNJURIES. skin upon the stretch, and a shaving as long as it is thought advisable quickly taken from the upper surface. The subcutaneous fat should not be included, but the whole thickness of the true skin is necessary (of course, it is thinner at the sides) so as to take in the layer that contains the horizontal plexus of vessels. If the plasma can enter into these through the cut ends of the vertical ones through which they are sujjplied, the nutrition of the graft can practically be assured. .Strip after strip obtained in this way is placed upon the raw surface and pressed firmly into position until the whole is covered. A layer of protective, perforated with numerous large opening, is placed upon them, and over this compresses wet with salt solution, which are changed every day. As a rule the strips unite at once ; occasionally the granulations break through, and sometimes the edges are lifted up by the collection of the discharge beneath ; even then the whole area rarely perishes. [The method of I'hiersch is now generally adopted in America. The razor is used by a sawing motion, and thin strips of skin are thus spread upon the outer surface of the blade.] Frog's skin {Anna/s of Surgery, Feb., 1889) has been used in the same way. The same preparation and precautions are necessary, the skin of the back being carefully detached from the neck downward. The pigment-cells soon disappear ; but apparently the skin itself lives, and forms a thin pellucid covering, through which the deep color of the vascular lymph beneath can be seen. After a time it becomes denser and more opaque, but it does not appear to possess the same power of resistance as human skin. Wolfler has employed flaps of mucous membrane in the same way, obtaining them both from human beings after operation and from animals. Stricture of the urethra, for example, has been excised, and a graft of mucous membrane inserted in its place, with apparently good success ; and defects have been remedied in the eyelids and elsewhere. Complications of Repair. If the surface of the wound is irritated instead of being kept at rest, it becomes inflamed, and the inflammation continues so long as the irritant is at work. The process of destruction for the time the cause is acting is more vigorous than that of repair ; healing is delayed, the loss of tissue is greater than that due to the original hurt, and the wound increases in size, sometimes merely the surface melting away (suppuration and ulceration) ; sometimes, when the irritant is more intense, the base and edges perishing en masse (sloughing and gangrene). Open wounds are naturally more exposed to the action of the irritants than closed ones ; they are always liable to infection from the air and from contact with foreign bodies, and until recently inflammation was regarded as a necessary factor in their repair. It cannot, however, be too strongly insisted upon, that it is a complication, and an absolutely unnecessary one, caused by the action of .some fresh irritant. It does occur occasionally in subcutaneous injuries as well as in open ones, but it should not occur in either. The sole difference, why it is so rare in the one and so com- mon in the other, is that the former are protected from all external injurious agents by the skin, the latter are not. As soon as the irritant, whatever it may be, is removed, the inflammation ceases, and if the tissues have sufficient vitality left, the process of repair at once begins to make headway again. I. Simple inflammation. — This is the product of mechanical or chemical irri- tants, not generated by organisms living in the wound. Friction, want of rest, the tension of a tight suture, the presence of an irri- tating dressing (even when it is antiseptic), the accumulation of extra vasated blood or wound secretion, inert foreign bodies, and many other irritants of a similar nature may cause it. Repair advances more slowly or is stopped altogether, the area of redness spreads, the swelling becomes more marked, the temperature of the part rises, the pain becomes more severe, and the patient feels feverish. The gravity of the attack depends upon the nature of the irritant and the condition of COMPLICATIONS OF REPAIR. 163 nutrition. A tight suture will cause a rise of temperature of several degrees, and lead to a train of symi>toms of altogether disprojiortionate severity. A bullet or a piece of silver wire, ivory pegs, or other similar inert substances, may remain embedded in the body for years, especially if they are fixed in some part that is not exi)0.sed to friction or movement. If they are near the skin or loose in the muscles, the irritation usually leads to the production of a capsule of cicatricial ti.ssue. and not unfre(iuently, after remaining quiet for perhaps a number of years, suppuration suddenly sets in, the vitality of the tissues round becoming depressed by age or the addition of some slight injury. If the cause is removed, the inflammation subsides and repair proceeds ; if it continue, the vitality of the tissues is lowered, until at last they become too feeble to resist the assault of the pyogenic organisms, and suppuration follows. 2. Septic Inflammation. — Decomposition of the blood or lymph that fills the wound is a much more powerful cause. The micro-organisms of i)utrefaction are destroyed by living tissues; on the other hand, they grow and thrive in the fluid that exudes from them, especially when it is kept at the temperature of the body, causing either septic fever or sapnvmia. If the wound is a recent one, and all the strata of loose cellular tissue round the bones and between the muscles are open and filled with extravasated blood, difiiise inflammation of the most terrible description is sure to follow, and very likely prove fatal from the intensity of the fever before there is time for suppuration. If, on the other hand, the tissues are better nourished, or the poison is not so active, and death does not ensue in the first two or three days from the sapraemia, suppuration sets in, the germs finding the soil that suits them best in the already half-killed tissues, and one or more of the varieties of suppurative inflammation follow. 3. Suppuration. — The pus of acute suppuration always contains certain organ- isms ; it is believed, therefore, that it cannot occur without them, and that they are its cause. Ten or eleven different kinds are described as possessing this prop- erty, but only two, a staphylococcus and a streptococcus, are of common occur- rence. They kill the leucocytes and transform them into pus-corpuscles ; the tissues themselves, the walls of the vessels, and the plasma that pours out through them are destroyed, and converted by their peptonizing action into an albuminous fluid incapable of coagulation ; and, so long as there is any tension or any other irritant to lower the vitality of the tissues round them, they spread their process of destruction far and wdde. Over structures that are perfectly healthy they have no power. In children, therefore, and young and healthy adults, suppuration may be acute and severe, Avhen there is tension or septic decomposition to help the germs, but it is limited ; the nutrition of the tissues is too good for the micro- organisms to have any effect outside the immediate sphere of the other irritants ; in those, on the other hand, whose constitutions are wreeked by disease or intemperance, resistance is enfeebled, and the suppuration is only too liable to spread. That in the vast majority of instances these germs gain access through the wounds is absolutely certain ; suppuration is of common occurrence in open injuries, while it is the exception in subcutaneous ones. As, however, it does happen occasionally in the latter, and as some of the worst and most fatal forms of suppurative disease occur without a wound at all, it is clear there must be other modes of entrance, too. Sometimes their presence may be accounted for by the existence of cutaneous lesions in other parts of the body; but, in all probability, as they abound in the alimentary and respiratory passages, they enter through the mucous membrane and are distributed by the blood. It is only, however, when they meet with tissues that have been already injured in some other way — by cuts or bruises, tension, septic poisons, etc. — that they are able to cause coagulation- necrosis and suppuration. A certain amount of pus, generally very thick and viscid in character, is occasionally found when the dressings are removed from a wound, forming a thin layer over some part which the skin has failed to cover. It causes no rise of tern- i64 GENERAL PATHOLOGY OF LNJURLES. perature or fever, and the lymph beneath heals over rapidly as soon as the dress- ings are changed. Possibly, in many cases, it is not true pus (not the product of pyogenic microbes), but merely lymph which has perished, owing to its distance from its base of nutrition and its contact with a foreign body. In other cases, however, micrococci are present, having reached the part through the dressings or in some other way, and then the only explanation is that, owing to the thorough vitality of the lymph around and the absence of all other sources of irritation, they have been unable to effect more than the minimum of mischief. Suppuration of this description requires no .special treatment : its existence is usually unknown until the dressings are changed. Acute suppuration, on the other hand, accompanied by tension, is marked by very characteri.stic signs. There is often a chill at the beginning, or even a rigor; the temperature rises rapidly, the pulse becomes hard and frequent, the tongue is coated, the appetite lost, the skin hot and dry, the urine scanty and high-colored ; headache is always present, and, particularly in children, there is frequentlv more or less delirium. It is not material whether the suppuration is on the surface of a wound or deeply buried in the tissues ; in either case the symptoms are the same, although in the latter they are much more severe, owing to the higher degree of tension. Undoubtedly the chief reason is the absorption of the products of tissue- destruction, poisonous substances produced by the action of the pyogenic micro- organisms. Round the wound everything is swollen and tense, the skin is hot, red, glazed, and exquisitely tender ; often it pits on pressure, and there is oedema spreading up the inner side of the limb along the course of the great vessels, while the pain, especially at first, is violent and throbbing. Later, when the tissues round have recovered themselves and thrown out a protecting barrier of lymph, these local signs become less marked, and at the same time the severity of the con.stitutional symptoms diminishes ; but if, from any cause, the tension is allowed to return, the mischief at once becomes acute again. The w^orst complications are those which follow the combination of .septic decomposition, tension, and suppuration. If. in such a ca.se as that mentioned already, in which the loose cellular tissue is filled in all directions with extrava- sated and decomposing blood, a fatal result does not ensue in the course of the first two or three days from saprccmia, and if the patient survives sufficiently long for suppuration to occur under high tension, there is not one of the forms of suppurative inflammation that may not follow : diffuse inflammation of the cellular tis.sue is certain, but lymphangitis, phlebitis, osteophlebitis, pyaemia, suppurative arteritis, secondary hemorrhage, sloughing, and even gangrene may occur. Treatment of Wounds. In every case the first consideration is to stop the bleeding by measures suited to the circumstances. What these are, and how they are to be used, will be dealt with later on, in considering the injuries of vessels. The essential points are to make sure that the wounded surfaces are absolutely clean, to bring them into perfect apposition with each other, and to protect them from sources of irritation, whether friction, movement, tension, or the assault of living organisms. I . Cleanliness. Wounds are of two kinds. Some are inflicted by the surgeon in operating, others are accidental. In many respects there is a very material difference. (i) A wound inflicted in the course of an operation should not require cleans- ing, except from the blood that covers and obscures the surface. Of course, where old sinuses are present, as in the removal of sequestra, or when the wound com- municates with the inte.stine or the anus, the conditions are entirely different. Everything that comes into contact with the wound or with the skin near it TRKATMRXT OF WOUNDS. 16:^ shoukl be already clean. The operator's hands and arms should be well scrubbed with soap and water and a nail-brush. The skin round the wound should be treated in the same way, and then sponged with a five jjer cent, solution of car- bolic acid. The instruments should be kept for at least half an hour in a solution of similar strength. Special care should be taken about the sponges, which should be kept in carbolic lotion ; and nothing but a perfectly clean mackintosh or india-rubber sheet should be allowed near the wound. If these precautions are thoroughly carried out, there is no need to wash the wound out or to flush it with anything, unless it is desirable for the sake of checking oozing. Ovariotomy wounds, operations for hernia, excision of the breast, and amputation of limbs, for example, if the tissues are healthy and fairly well nourished, should heal at once by the first intention. Contused and lacerated wounds, if they are perfectly clean, heal in the same manner ; compound fractures by indirect violence, for example, very rarely suppu- rate; the dead fragments, which are always more abundant in such injuries, are quietly removed by the leucocytes ; but there is more risk. In a simple incised wound the amount of injured tissue is exceedingly small, the structures on either side retain their vitality and power of resistance unimpaired ; in contused wounds, on the other hand, the bruising is often considerable for some distance round, and there is always the fear, even if decomposition does not occur, that the pyogenic organisms may gain access to the jjart, as they sometimes do in subcutaneous in- juries, and finding structures a-lready damaged, cause suppuration. The amount, however, is never serious unless there is some further cause — tension, want of rest, or decomposition — continuing to depress the vital power of the tissues around. (2) Suspicious wounds and those which are known to be infected require an entirely different plan. It is certain that if the bacteria of putrefaction once gain entrance, and there is dead tissue or extravasted blood at the temperature of the body, they will produce a poison which causes very severe constitutional symptoms, lowers the vitality of the tissues, and renders them incapable of resisting the action of other germs. Steps must be taken, therefore, either to destroy the organisms or to re- move the material in which they grow, or preferably to do both. a. The first of these indications is fulfilled by thoroughly washing out the wound and scrubbing the skin round with an antiseptic lotion, using an irriga- tor or a piece of rubber tubing, and passing it down to the bottom of all the recesses. If it is in one of the extremities and otherwise conveniently placed, it is more satisfactory to immerse the injured part altogether in an antiseptic bath at the temperature of the body for two or three hours. What antiseptic should be used is to a great ex- fig. 24. tent a matter of personal choice ; the ideal one has not been found. Corrosive sublimate, either alone, with chloride of ammonium (sal alembroth), or Avith a minute quantity of hydrochloric acid, is very effectual. One part in a thousand is sufficient for general purification, one in five or ten for the irrigation ; but it should never be employed for large absorbing surfaces such as the pleura or perineum, or for complicated or extensive wounds in which there is any fear of its retention. As a germicide there is no doubt of its value, but it has many drawbacks. Dysenteric diarrhoea, vomiting, collapse, and even death have been known to follow its use ; in one case under my care (compound dislocation of the ankle-joint) salivation was caused before the odor of decomposition dis- appeared ; and it ruins any steel instruments with which it comes into contact. Further, it forms an insoluble compound with albumin, which is said to be almost inert, but this difficulty is to a great extent overcome by the addition of chloride of Irrigating Can lor thondighly Washing out the Recesses of a Wound. 1 66 GENERAL PATHOLOGY OF INJURIES. ammonium or hydrochloric acid. Lister has lately been experimenting with a double cyanide of mercury and zinc (of unknown composition^ which may prove more effectual. Carbolic acid possesses the advantage of being volatile, but it too is by no means perfect. According to Koch, instruments to be absolutely pure should be left for at least two days soaking in a five per cent, solution. One part in forty is the ordinary strength for cleansing wounds ; one in twenty for instruments, sponges, etc. Olive-green urine which darkens on exposure to light is not uncommon after its use ; headache, giddiness and sickness occasionally occur ; and instances of extreme depression with low temperature and fatal collapse have been recorded. Further, it distinctly tends to encourage oozing from the surface of a wound by its action upon fresh blood-clots, and the amount of discharge afterward is always excessive. Other substances are recommended from time to time, but with very few ex- ceptions they do not appear to obtain general recognition. Boracic acid is prac- tically non-poisonous, and may be used either as a saturated solution in water, or even dusted upon the wounded surface, but it is not nearly so effectual. Thiersch's solution is formed of two parts of salicylic acid, twelve of boracic acid, and one thousand of water. Hydronaphthol is strongly recommended as non-jx)isonous and as powerful as corrosive sublimate under the conditions of actual practice. It is very soluble in alcohol, but only slightly so in cold water. Salufer succeeds very well in the hands of some, and appears perfectly safe. Eucalyptus prepara- tions are very agreeable at first, but patients are apt to get tired of the smell. Chloride of zinc, which is stated to be almost inert so far as germs are concerned, is undoubtedly of very great value under special conditions. [Solutions of Bromine and Iodine have each an exceptional value in certain conditions.] Whatever antiseptic is used, unless it is intended to treat the injury by a con- tinuous bath, or there is some condition rendering it impracticable, it is most im- portant to keep the surface dry and check the amount of discharge as much as possible. Germs cannot grow without fluid. For this reason Gamgee preferred equal parts of spirit and water, a saturated solution of borax wath about one-eighth of glycerine and equal parts of water, glycerine, and methylated spirit, to the watery solution of any antiseptic. This is probably one of the chief reasons why iodoform has met with such favor. Its smell is exceedingly peculiar, very penetrating, and objectionable from its associations ; there have been many instances of serious poisoning, and even of death from its absorption ; it is by no means certain that it is a germicide ; yet as a matter of clinical experience there can be no question that it forms a most valu- able dressing for wounds. The hemorrhage is stopped ; the surface becomes dry : the amount of discharge is reduced to a minimum, and repair takes place rapidly, beneath the crust that forms, without suppuration or decomposition. It is chiefly used in the form of powder, but it may be dissolved in ether for special purposes, or formed into an emulsion with glycerine, or sprinkled over moist gauze, and then well rubbed into the meshes ; and it may be applied to quite recent wounds or to those that are already suppurating. Elderly people are said to be more liable to its effects than others, but, as in some cases very large amounts have been ased without any ill result, it is probable the susceptibility depends chiefly upon indi- vidual peculiarities. An erythematous rash, sometimes starting from the neighbor- hood of the wound, sometimes general, is tolerably frequent. Anorexia, head- ache, and great depression occur in the milder cases ; delirium, sleeplessness, and even convulsions in those that are more severe ; while in the worst of all the pulse is rapid and thready, the surface of the body cold, and the prostration extreme from the very first. It appears to be excreted by the kidneys as an iodide, and it has been suggested that poisoning only occurs when the action of these organs fails, possibly from the formation of some comjx)und with an albumin. b. The second indication is to keep the wound clean. Germs cannot live TREATMENT OF WOUNDS. 167 without tluicl, aiul have httlc or.no j)0\ver on tissues that are perfectly healthy. If the interior of the wound is kept dry, and the vitality of the structures around it is unimpaired, they are practically innocuous. Unfortunately cleansing a wound with an antisei)tic causes other effects as well. All antiseptics injure the tissues they touch to a greater or less extent, and increase the amount of fluid poured out (carbolic acid is probably the worst in this respect, iodoform the best) ; and many of them are used with water, which, unless it is thoroughly si)onged out (again an irritant, of some importance too, especially in connection with the jjcritoneum), adds still more to the quantity. In a simple in- cised wound, if the surfaces are brought together and pressure is properly applied, the amount of exudation is so small that it may be left to the natural i)rocess of absorption. Contused and lacerated wounds, in which the oozing has been com- pletely checked, may, if not too much handled, be treated in the same way ; or at most a little opening may be left at one angle, so that any great exce.ss of fluid can drain off and be absorbed by the dressing covering it. But a wound that has been thoroughly cleansed, and the surface of which has been sponged or washed with strong antiseptics, requires something more. If it is left open, the fluid that is poured out naturally can escape at once ; but if the skin is united over it, and no precau- tion is taken, the interior no longer remains clean ; exudation is more rapid than absorption ; fluid collects ; tension is set up ; inflammation follows, and if nothing is done suppuration is certain ; the germs gain access to the part, and destroy the leucocytes in just the same wdy as they sometimes do when a simple bruise is con- stantly rubbed or hurt. To keep such a wound clean, therefore, and to prevent tension and its con- sequences, either the edges of the skin must not be united, or, if they are, a system of drainage must be employed. The method in which this is carried out depends upon the way in which the surfaces of the wound are adjusted and held together. 2. Apposition of the Wound Surfaces. Want of cleanliness is altogether fatal to repair : the tissues cannot close the wound until by the production of vascular granulation-tissue they have ejected all injurious agents, at a certain sacrifice. Given cleanliness, the rapidity with which repair is effected depends upon accuracy of apposition. Irregular injuries with uneven cavities are gradually filled from the bottom and the sides, but the process, in comparison with those in which the surfaces are properly adjusted, is very slow, and the amount of cicatricial tissue much greater. Accuracy of apposition is effected by attention to position, pressure, sutures, and strapping. Position. — In operations, incisions are planned to avoid tension and to allow wounded surfaces to fall together of themselves. Natural folds are followed as far as possible, and gravity is carefully considered with regard to the attitude of the patient. In chance wounds, the position of the body and limbs must be arranged to suit the circumstances. A great deal can sometimes be effected by this, but it must be recollected that discomfort may cause fever. In many plastic operations the position of the patient has to be fixed, and this cannot be avoided. Pressure. — Properly ai)i)lied, this is of the greatest assistance. It keeps the deeper parts of the wounds together as well as the superficial ones ; prevents the formation of a cavity in which fluid can collect ; checks the tendency to effusion, and assists the absorption of that which has already been poured out. Every structure in the body exists under a certain degree of tension ; as soon as the skin is divided, this disajjpears ; and one object of the dressings applied to a wounded surface is to restore it to its natural condition until repair is com- pleted. The ideal dressing is perfectly soft, elastic, absorbent in the highest degree, and impregnated with something that will make it safe against putrefaction with- out renderinfj it in the least irritating. If these conditions are fulfilled, and if 1 68 GENERAL PATHOLOGY OF INJURLES. abundance of the material is used, an amputation wound, or such a one as is pro- duced in arthrectomy, may often be left a fortnight, or even longer, untouched, and only two or three dressings at the most are required. Absorbent cotton-wool, wood-wool wadding, treated with corrosive sublimate, prepared moss, and sponges wrung out of carbolic (the last especially if elastic pressure is required to stop haemorrhage) are the most useful. A strip should be laid on either side of the wound, some little distance from the edge, so as to press the deeper parts well together, and, as it were, force the actual line somewhat outward ; and then all the space round and in between should be thoroughly and carefully packed, especial attention being paid to the hollows between the bones. Over this a soft elastic bandage is placed, without reverses; or if a greater degree of firmness is required, torn strips of mill-board, soaked perhaps in plaster cream, as recom- mended by Gamgee, and then the bandage over these. The ease and comfort of this arrangement can hardly be surpassed. Immobility is perfect ; the patient feels that all is secure ; tension is prevented ; there is no cavity in which fluid can collect ; the small amount that is not taken up by the tissues is driven through the edges of the wound and harmlessly absorbed at once ; vascular dilatation cannot take place to excess, and the apposition of the injured surfaces is as exact as it is possible to make them. Strapping. — This is either employed in superficial wounds by itself, or in deeper ones as an adjunct to sutures, for the purpose of distributing tension and of immobilizing structures on either side. In operations on the breast, for example, one or more broad strips may be advantageously brought up from the region of the back to support the lower flap, draw it upward, taking the tension off the sutures, and keep it firmly pressed against the ribs. Sutures are of various kinds and various materials. Catgut of different degrees of thickness and hardened more or less in chromic acid, according to the strength and endurance required, is the most useful. Silver or iron wire possesses the advantage of being absolutely unirritating and of being easily fastened, but requires removal ; and the same may be said of silk. If properly prepared, and so arranged that no tension falls upon them, any of the.se materials may be left for weeks without causing the least irritation ; but wire and silk almost always require to be removed at last ; catgut removes itself. Silkworm gut, softened beforehand in carbolic lotion, so that it will tie more easily, is especially useful for plastic operations. Horsehair is occasionally em- ployed where there is no tension ; and in comparatively rare cases other materials are used as well. The method is still more variable ; the object is to secure accurate adaptation of the whole depth of the wound without causing tension upon it anywhere. In deep-seated or complex injuries this is only possible by means of buried sutures, which must necessarily be of catgut. Layer after layer of tissue is accurately adjusted and secured in situ, periosteum to periosteum, muscle to muscle, and fascia to fascia. The deepest sutures are fastened the most firmly ; the superficial ones are not so tight, so that if anywhere the amount of effusion Rowing to some accidental source of irritation) is in excess of absorption, the fluid may make its way in the direction of least resistance, toward the surface. It is only by means of this kind that large and complex wounds, those for example left by amputations, can be safely secured without drainage; but, of course, the surfaces must be per- fectly clean and healthy, fit and ready to cohere together at once. In the presence of suppuration or of decomposition, sutures used in this way could only lead to the most disastrous consequences. Deep sutures {sutures of support) aim at effecting the same result, but at the expense of tension and pressure upon, the skin some little distance off. Button sutures, for example (Fig. 25), are cut from pieces of stout sheet lead of various shapes and sizes. One of these is placed on either side of the wound, some little distance away; and while the two are brought together as closely as is thought desirable by the hands of an assistant, a stout silver wire is passed deeply TREATMENT OF WOUNDS. 169 across from one to the other, and fastened in a slit cut in the side of the lead. This relieves the edges of any tension by transferring it to a greater distance and spreading it over a wider surface ; but, though they are useful in such operations as excision of the breast, they do not secure nearly the same accuracy of apposition for the deeper parts. The same may be said of the quill sulure (Fig. 26), in which longitudinal rigid supports are laid a little distance from the edges of an incised wound and fastened to each other by deep ties of wire or some other unirritating material. Strong curved needles set in a handle are required for them : the skin and the deeper structures are transfixed, first, on one side, and then, in the opposite direction, on the other; if the needle is threaded before it is passed the loop is caught and drawn out, so that a double suture is left ; if not, it is threaded when the point projects through the skin on the further side and withdrawn, carrying the suture with it. As a rule such sutures cannot be left more than four or five days, but everything depends upon the degree of tension. Their chief object is to prevent any strain upon the superficial ones, and as soon as these appear secure they should be cut, even if they do not require it of themselves. The td.ed by treatment. It had never been more than an incli in width, and left the skin behind it quite supple. The ques- tion of diagnosis of this form from true lupus has already been alluded to. In its treatment the same applies as to gummatous ulcers, but it may be mentioned that oleate of mercury ointment (5, 10, or 15 per cent.) is often a very useful local application. In neglected or inveterate cases it is sometimes necessary to scrape the growth, or to cauterize it with the acid nitrate of mercury or actual cautery before healing can be obtained. If once thoroughly healed it shows no tendency to recur, unlike true lupus. 2. Tubercular Ulcers. Apart from the ulceration due to lupus, we have to consider the strumous form resulting from tubercular abscesses of the cutaneous or subcutaneous tissues. Although most common in early life, they may originate in elderly subjects (senile struma) and are in the latter case of very unfavorable prognosis. Glandular enlargement and abscesses are common complications, and pul- monary phthisis is, of course, not infrequent, The appearance of a tubercular ulcer is very characteristic ; dull, purplish con- gestion of the edge, extensive undermining of the .skin, thin, oily discharge, and pale, flabby granulations at the base usually leave no doubt as to the diagnosis. When they heal a thick scar is generally formed, often with small cutaneous " tags " along it. The treatment consists in destroying the Avail of the ulcer and sinus by scrap- ing or cauterization, and subsequently dressing the cavity with iodoform. Boracic fomentations, etc., cod-liver oil, residence at the seaside or in the country, good food, etc., are most important aids to recovery. 3. Chronic Inflammatory Ulcer of the Leg. The chronic inflammatory ulcer of the leg is seen especially amongst the poorer classes. The lower third of the leg toward the inner side is its usual site, and it often starts in some injury. The vitality of the tissues is previously lowered as a rule, however, by prolonged congestion from standing ; both varicose veins and eczema are its frequent forerunners. The patient often states that the ulcer commenced as a small pustule, or that intense irritation at one spot led him to produce an abrasion by scratching. A weak heart or chronic bronchitis may favor the obstruction to the return of blood, the presence of the ulcer increases the congestion, and thus a vicious circle is set up. The ulcer usually causes much pain and discomfort, though cases differ much in this respect ; not only the edge becomes callous, but the floor also, and if it has existed long the immediately subjacent bone undergoes condensing ostitis, to which may be partially due the aching pain felt. Steadily increasing, the ulcer may encircle the limb and spread upward over a large area, and at any time, from neglect of cleanliness, etc., it may take on sloughing action. The older the patient, as a rule, the less does the chance of healing become, though some very intractable ulcers are met with in young women in whom no constitutional cause can be assigned. Treatment in very inveterate cases must be merely palliative, and a variety of applications (such as the Ung. Zinci, the Ung. Acidi Boracici, weak carbolic lotions) may be tried in turn until one is found to suit the individual case. Am- putation of the limb is occasionally necessary, but should rarely be urged, since the low vitality of the tissues above often greatly impairs the result, and the risk to life in all elderly subjects is not inconsiderable. 196 DISEASES AND INJURIES OF SPECIAL STRUCTURES. A large number of these ulcers can, however, be cured, though, unfortunately, there is great likelihood of the scars breaking down again. The following meas- ures will be found useful : — a. Rest and elevation of the limb are most important and should l)e carried out as far as possible. b. Bandaging the leg from the foot to the knee, either with the ordinary linen bandage or with an elastic (Martin's) bandage. The latter cannot be used unless the ulcer is almost healed, and by its keeping in moisture some- times causes too great discomfort to be borne. An elastic stocking will often be of use in such cases. Carefully applied strapping above and below the ulcer is also beneficial. c. To clean a foul ulcer and to promote granulation there are few dressings more valuable than boracic fomentations, made by wetting boracic lint and applying one or two thicknesses of it under gutta-percha tissue. The dressing must be changed once or twice daily, according to the amount of discharge. d. The Ung. Resinae, Ung. Iodoform, Ung. Plumbi Subacetatis, and the two previously mentioned are of use according to the special indication, that is, whether stimulating or soothing applications are required. e. Skin-grafting and sponge-grafting are valuable if the granulations have been got into a healthy condition and the patient can be kept in bed for a i^^^ weeks. In using the skin-grafts they should be cut into minute pieces and only the epithelial layer employed. /. In a large number of cases tonics do good, the bowels should be kept regularly open, alcoholic excess forbidden, and if varicose veins are present, it is often helpful to limit the amount of fluids taken, so far as is judicious. There is one drug which has a very beneficial action upon inveterate ulcera- tion, especially in old people, namely, opium, the administration of which is said also to check the progress of phagedsenic or sloughing action. g. Blistering the edge of a callous ulcer was strongly recommended by Syme, and is occasionally useful. Some surgeons have advocated incising both base and floor of such ulcers, with a view to start a fresh granulating process. 4. Traumatic Ulcers. As already noted, a considerable proportion of the previous class of ulcers originate in some injury, often a very slight one, but we have to note some due to severe contusion of the skin of healthy individuals — really direct traumatic gangrene. This is especially likely to occur in regions where the skin lies imme- diately over a bone — for instance, the tibia or patella. An antiseptic poultice followed by some simple ointment is the best treatment, skin-grafting being advis- able if the ulcer is large. The limb should be carefully kept at rest during treat- ment if the ulcer is situated over a joint. In this class come the ulcers of artificial production, which may at first give rise to difficulty in diagnosis. A hysterical or idle girl, for the sake of exciting sympathy or notice, applies some strong chemical irritant to the skin, using great cleverness sometimes in concealing the cause of the ulcer which results, and in preventing it from healing. In one case I knew of a young lady who had applied sulphuric acid to the front of the left elbow, causing a deep ulcer, in which, for some time, the brachial artery lay exposed. The unusual situation of these facti- tious ulcers, their rapid formation, and the character of the patient will usually excite suspicion as to their true origin. 5. Malignant Ulcers. Rodeii-t Ulcer, Epithelioma, Fu7igating Sarcomata, Scirrhous Ulcers. — These need not be described here, as they come under the head of tumors. It may be mentioned, however, that epithelioma may supervene in the course of any in- Ny£VI. 197 tractable ulcer which has lasted for some years, antl that a ])articiilarly malignant form is liable to develop in old lupus patches, the patients being usually past middle life. NON-MALIGNANT GROWTHS OF THE SKIN. N/EVl. The essential feature of all angeiomata or naevi depends upon the presence of convoluted vessels closely packed together, commonly small veins and capil- laries, but occasionally arteries. One form consists in a widespread area of small vessels, such as is seen on the face — the "port-wine stain;" another (the true venous neevus) is situated more deeply and composed of much larger veins. The terms cutaneous and subcutaneous are used with reference to naevi, though no sharp line of distinction can be drawn. They may be met with on any part of the body, the head and neck being their most frequent site, and it is common to find more than one on the same subject. If sections be made of an ordinary cutaneous ngevus, it is curious to notice how slightly the lumen of the vessels shows in comparison with the thickness of the cellular wall. There is no doubt that after birth a neevus frequently increases in size ; on the other hand, with advancing years they may shrivel in part or entirely disappear. Sometimes they ulcerate — a curious fact considering their high vascularity. "Port-wine" naivi usually remain unchanged throughout life if untreated, and are by far the most resistant to treatment. A 7/iole is a congenital local hypertrophy of the skin, pigmented, and with usually abundant growth of hair on it. Moles are of little importance if seated on a part of the body naturally concealed by the dress, and even on the face are, if small, sometimes considered ornamental. But there is an undoubted tendency for them in advanced life to become the seat of melanotic sarcoma, and for this reason their excision should be advised. However, sometimes they are so large that re- moval by operation would leave an awkward wound, and here a plastic operation may be called for. They can also be destroyed by repeated cauterization, but the process is not so satisfactory as excision. One most curious growth allied to a mole is occasionally seen on the scalp — lobulated and softish projections of the skin with deep furrows between them, so arranged as strongly to suggest the brain convolutions. The treatment of ncevi consists principally in one or other of the following measures : — 1. The application at several parts of the naevus of the actual cautery (fine- point). This is most effective and leaves but little scar. It is well to proceed cautiously, and to do little at the fir^t operation rather than too much. 2. If subcutaneous and venous, the cautery point may be thrust in several directions through the nsevus, introducing it through only one opening in the skin. 3. Excision is suitable for small naevi, and is by some considered better than cauterization. 4. Electrolysis has of late been extensively tried, two needles being used as the poles, and both pushed into the growth at a short distance from each other. They should be introduced at several points. The method may be successful in leaving imperceptible scars, but it is an uncertain one and needs to be repeated several times, as a rule, before much improvement occurs. It is especially adapted for naevi of the face. Such measures as vaccination over the na^vus, the applitation of ethylate of sodium, and subcutaneous ligature are occasionally useful, especially the latter — but this has the drawback of possible sloughing of the skin. 198 DISEASES AND INJURIES OF SPECIAI STRUCTURES. Warts. — \PapiUoiiia.'\ [There are four varieties of the papillomata, viz. : wart, mucous tubercle, condyloma, urethral caruncle]. Warts are chiefly met with about the hands of young adults or children, and are composed of hypertrophied papillae covered with epithelium. Each papilla contains a central vascular loop, and, especially if scratched and irritated, is liable to bleed. They may occur in great numbers on the hands (especially the dorsum) and forearms, and may undergo simultaneous and rapid atrophy. In their treat- ment it is important for the patient to abstain from "picking" and irritating them ; perhaps the best local application is the glacial acetic acid, which, applied repeatedly with a small brush or point of wood, will soon cause them to shrivel and drop off. Nitric acid is more painful in its action and less certain ; nitrate of silver is useless as a rule. In elderly subjects single warty growths are met with, the tongue, lips, and scalp being often affected. They are much more serious than those of early life, from their liability to go on to epithelioma. This is especially the case with warts of the tongue and lips, and on this account it is usually advisable to excise them. The venereal form of wart {condyloma) is seen about the vulva, the prepuce, glans penis, and scrotum, in cases of gonorrhoea or vaginitis. They are especially prone to develop if there is phimosis and retention of the discharge, to the irrita- tion of which they are due. They may attain a very large size and have very vas- cular bases. Sometimes a neglected condyloma becomes wart-like, but true acuminate or pointed warts have no real relation with syphilis. In treating them the gonorrhoea should be cured, circumcision performed if there is phimosis, a drying powder applied, and strict cleanliness used. If they show no tendency to shrivel under this treatment they should be excised with scissors, and the bleeding checked if necessary with the actual cautery at a dull red heat. Salicylic acid is a powerful agent in softening warty and hard epithelial growths of the skin, and is of much use in treating corns on the feet. It may be applied in the form of plaster which is renewed daily, or as a cream made with glycerine. As soon as the softening process is complete the part should be soaked in warm water, and the overgrown epithelium pared off with a knife. Of course, injurious pressure should be removed so far as is practicable. [Clavus. — Corn. A corn is a callosity of the epidermis caused by pressure with friction where- by the skin becomes thickened and painful. The external surface of the corn is broad, its substance narrowing as it projects .inward, becomes conical, and much pain is produced. This conical point of the hardened epithelial cells is termed the " core " or " eye " of the corn, and it acts as a foreign body by being driven upon the true skin. ''Soft" corns are sometimes produced between the toes. They do not differ anatomically from the other variety, but by reason of being constantly bathed in the natural moisture of the part derived from the sweat glands are softened. The treatment consists in removing the pressure and paring off the thickened epidermis. Great relief will usually be experienced by painting the corn with the following application : — R . Ext. cannabis, indicse fl., ... grammes I Acidi salicylici, " 8 CoUodii, q. s. ad. . " 50 M. The collodion film thus produced may be removed together with a consider- able layer of epidermis, without pain, at the expiration of thirty -six to forty-eight hours. Another thick coat should then be applied and, after about the same time, again shaved off as before.] JDISEASES OF THE NAILS. 199 [Horns. — Cornu Cutancmn, Dcnnato-keras. Horns are outgrowths of the epithelial surface which may occur on almost any portion of the cutaneous surface, but are most frequent on the scalp and face. These growths resemble a clubbed toe-nail or finger-nail, and are sometimes grooved.* Horns are in general easily removed, but are occasionally found firmly attached to the periosteum. They should be extirpated as soon as recognized.] DISEASES OF THE NAILS. Like the hairs, the nails are liable to be invaded by the fungus of tinea ton- surans and of favus, both mycelium and spores being occasionally found in their substance. In association with eczema of the hands or feet the nails may become affected, the inflammation then chiefly involving their roots and causing secondary changes in the nutrition of the nails themselves. With severe general psoriasis, too, there is sometimes great thickening of the nail- substance, which becomes brittle and opaque, but in the slighter cases the nails usually escape. A form of dry, chronic onychitis is also met with, in w^hich no general skin disease exists. A very troublesome disease to treat ; arsenic given internally being the most likely measure to do good, combined with frequent soaking the affected finger-ends in a tar lotion. Syphilitic onychitis usually occurs during the secondary stage ; the nail-ends become brittle and irregular, this form occurring both in the acquired and inherited disease. Sometimes the nail-root is especially involved, becoming narrowed as though it were pinched laterally (see " Illustra- tions of Clin. Surgery," vol. 2, plate 81). Shedding of the affected nails may then occur, new, healthy nails ultimately taking their place. A peculiar and troublesome form of ulceration, creep- ing round the nail, and occasionally resulting in its com- plete detachment, is met with, especially in those who have to do ^vi^Yi post-ino7-tem work, surgical dressings, etc. It is, as a rule, decidedly painful, although it is not necessary in most cases to remove the nail for its cure, yet the finger should, if possible, be kept protected by an antiseptic dressing under oiled silk. Powdered boracic acid, or a pow^der containing equal parts of iodo- form, tannic acid, and oxide of zinc, will be found of service as a local applica- tion. The exfoliation of a nail as the result of a crush is too well known to need description, but it may be noted that frequently the process is very gradual and painless, and in such cases there is no need to hasten it by premature avulsion. Fig. 36. — Chronic Onychia. [* I removed a horn from the third finger of a female child at the Rush Medical College Clinic, in 1892. D. J. Hamilton mentions a case of a boy where the whole skin was covered with them from the crown of the head to the sole of the foot. Dr. Porcher, of Charleston, S. C, reported a case of a horn seven inches in length and two and three-quarter inches in diameter growing from the forehead of a negress aged about fifty-two. Dr. A. L. Sands, of Cold Spring, N. Y., removed a horn from the back of the head of a white woman aged fifty. This horn was six and a quarter inches long and three inches in circumference. It was of sixteen years' growth. Dr. Pausa, of Naples, in 1836, removed one six inches in length from the parietal scalp. Mr. Dalby, in 1847 {Lancet), removed a horn six inches in length from the head of a female patient. Dr. Souberbiele, in 185 1 {Am. Jour. Med. Set.), reported the extirpation of a horn eight to nine inches long, from the forehead of a woman aged eighty two. The most curious of reported cases, however, is that of Paul Rodnques ot Mexico, {Lancet, 1825), who was the subject of an enormous horn measuring fourteen inches at the base. This horn had three branches of which the central was largest. It was curved and descended several inches below the ear, thence turned forward on the cheek.] 2 00 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Fig. 37 — Onychia Maligna. A new nail is probably more likely to grow if the exfoliation is left wholly to nature. A slight injury is sometimes the primary cause of what is known as onychia maligna, an affection practically confined to children. The nail beconv-s loosened, altered in shape and much discolor- ed, the finger-end swells up and dis- charges a fetid pus from below and around the nail. So severe may the inflammation be in onychia maligna, if neglected, that the terminal pha- lanx is liable to necrose, and there is little or no tendency to spontane- ous cure. This may be due to the fact that its subjects are generally delicate or "strumous" children. With proper treatment recovery is usually very rapid. The diseased nail should be removed with forceps, and a dressing of iodoform, or of the liquor arsenicalis (one drachm to the ounce) applied. If these measures fail, a single application of the acid nitrate of mercury, or nitric acid, will usually sufficeto stop the ulcera- tion. Tonics, especially iron, are generally useful adjuncts to the local treatment. Ingrotving toe-nail is nearly always met with at the outer side of the great toe, and may be produced by the pressure of tight boots, or by cutting the nail too deeply away at its angles. Unhealthy granulations form around and bury the edge of the nail, and much discomfort is thereby produced. The treatment in the early stage consists in the removal of pressure from the toe and applying a few shreds of cotton-wool, charged with the astringent powder already mentioned, under the edge of the nail with a probe. Cleanliness and the daily repetition of this process will sometimes suffice. If it does not succeed the central portion should be scraped thin with a piece of glass and some thin lead-foil inserted under the angle. The nail itself should never be removed if it can possibly be avoided ; when it grows again it is even more distorted than it was before. The granulations, if very exuberant, may be cut away, and iodoform dressing applied ; but removal of the whole of the side of the fleshy part of the toe, though strongly recommended by some, is unnecessarily severe. [The removal of the entire nail with its matrix is occasionally necessary, and, although clubbed nail may result, yet the great relief furnished by the operation is a sufficient justification for its performance. Touching the site of the matrix with the red hot iron, after extirpation, may prevent the nail from being repro- duced.] INJURIES OF BLOOD-VESSELS. 201 CHAPTER II. INJURIES AND DISEASES OF BLOOD-VESSELS. SECTION I.— INJURIES. Blood-vessels may be contused or bruised ; ruptured, either partially or com- pletely ; wounded, or divided. When the external coat remains intact, as in lig- ature of arteries, and in some cases of contusion, and when, owing to the way in which a vessel is torn across, the coats are twisted together, no blood is lost. In every other case the immediate and most prominent symi^tom is hemorrhage, either externally or into the substance of the tissues. Hemorrhage may be capillary (coming not so much from the capillaries them- selves as from vessels too small to secure individually), venous or arterial. . Local Symptoms. Capillary hemorrhage is never serious except in patients with the hemor- rhagic diathesis. It is sometimes tolerably abundant from the walls of an abscess, the sudden relief of pressure causing the delicate capillaries in the granulation- tissue to give way; and after the application of Esmarch's bandage, when a limb has been kept anaemic throughout the course of a prolonged operation, it may be so considerable as to make the operator doubt whether there has been any real advantage to the j)atient ; but as a rule it stops at once on exposure to the air, especially if the part is raised at the same time, or with gentle compression. Ice- cold water may be poured over the exposed surface if this fails ; or better still, water at the temperature of 130° F., about as hot as can be borne with the hand. Carbolic lotion should not be used, as this tends to make the clot disintegrate again. In many cases, especially after amputations in which the bloodless method has been adopted, it is better to close the wound and trust to firm bandaging and elevation than to keep the patient waiting on the operating table ; but due provision must be made for drainage, or there may be a considerable degree of traumatic fever. Venous hemorrhage is recognized by the dark color of the blood and the steady character of its flow. Unless there is considerable pressure upon the cardiac side (as when a ligature is tied round the limb, and occasionally in hemorrhoids) the stream is always continuous, never in jets. Usually it comes from the lower or distal end, but when a large trunk is wounded, or a varicose vein, in which the valves are incompetent, gives way, the rush from the cardiac side may be so great as to prove fatal within a very few minutes. The slightest pressure, applied to the right spot, or merely raising the part so that it is not dependent, is sufficient to stop the flow at once ; but many instances are recorded in which, for want of this simple precaution, this accident has proved fatal. Arterial hemorrhage may be primary, at the time of the injury ; recurrent, within twenty-four hours ; or secondary, from any time after this until the wound in the vessel is healed. The distinction between the two last is of considerable importance. Recurrent hemorrhage is due to failure in the temporary closure of an artery ; the ligature by which it is secured has slipped, or pressure has failed, or as the heart recovers from the shock and beats more vigorously the clot has been washed out, and the contracted condition of the vessel's wall unfolded again by the internal pressure. Secondary hemorrhage, on the other hand, points to a failure in the measures by which permanent closure is effected. The wall of the artery is too badly nourished, from atheroma or from suppuration round it, for the exuda- 14 20 2 DISEASES AND INJURIES OE SPECIAL STRUCTURES. tion to become organized ; or the ligature has been tied so tightly that it cuts through before the protecting barrier of lymph is sufficiently strong to resist ; or the presence of a sequestrum or of some other foreign substance has caused ulcera- tion without repair. The symptoms, too, are different; the former is sarely sudden and is seldom serious unless the wound is loosely covered over with a thick layer' of absorbent material ; then sometimes it escapes notice until a very large amount has been lost and the patient's face is blanched. The latter, though it rarely occurs without giving a warning (some slight stain on the dressings the day before), may be of the most serious description, especially as it nearly always comes from the largest vessels, in which the pressure is very high. In primary hemorrhage from a wounded artery the blood is bright red, and comes in distinct jets, which, even in vessels smaller than the radial at the wrist, may shoot three or four feet. Occasionally, however, when the patient is anaes- thetized with nitrous oxide, or is partially asphyxiated from excess of carbonic acid, the color is darker, approaching that of venous blood ; and when the wounded vessel is concealed at the bottom of some deep cavity, the flow may apparently be continuous. Recurrent hemorrhage, when the opening is expo.sed, does not differ in any material way ; but sometimes in secondary bleeding after ligature of an artery in its continuity the blood wells up slowly in a continuous stream, coming from the distal end only, and having lost its force in the collateral vessels. When the blood, instead of escaping externally on the surface of a wound, pours into the tissues or one of the natural cavities of the body, the local symptoms are regulated by the size of the vessel, the pressure of the stream, and the readiness with which surrounding structures yield. Hemorrhage from small vessels is rarely important unless the number that give way is very great, as in some of the dorsal or lumbar haematomata. There is local swelling, which usually disappears again after a time, although it occasionally ends in organization or suppuration. If, however, the vessel is an artery of any size, and the tension is not checked, the tissues may become inflamed, or suppuration may set in, or the part may even become gangrenous from the collateral circulation being cut off. Hemorrhage into the pleural or peritoneal spaces, internal hemorrhage in the strict sense of the term, often causes no local symptoms. In other cases a certain degree of dullness can be made out in the dependent parts, and an alteration in the level of the fluid in different positions of the body, especially as blood when extravasated into serous sacs coagulates slowly ; but although this, when it does occur, is distinctive, its absence proves nothing. COXSTITUTIOXAL SYMPTOMS. The rapidity with which the blood is lost is almost as important as the quan- tity. When it pours out under high pressure from some great artery, the face becomes pale and livid at once; the lips are white, the extremities cold, the pulse low and quivering, and the respiration hurried and shallow, interrupted every now and then by yawns or deep sighs. The voice is lost, there are noises in the ears, the eyesight fails, nausea comes on, and the arms are tossed vaguely and wildly about over the head. If, on the other hand, the loss is more gradual, the face and lips become peculiarly transparent, like wax, the pulse is small and fluttering, the breathing quick and very irregular in depth, giddiness and faintness come on with the least exertion, and if the loss continues, dropsy makes its appearance, owing to the impoverished condition of the blood. In such a state the slightest further drain may prove rapidly fatal. Sudden hemorrhage produces a much more marked effect than oozing to the same amount continued over several hours ; and the consequences at the extremes of life are much more serious than in adult age. Even when the immediate effect is not fatal, recovery is often incomplete, the patient never really regaining strength, but dying, perhaps some months later, from some intercurrent trouble. INJURIES OF BLOOD-VESSELS. 203 Natural Arrest of Hemorrhage. The natural means by which hemorrhage is stayed are partly constitutional, partly local. 1. Constitutional. — The force of the heart-beat diminishes in proportion to the amount of blood that is lost ; in syncope it can scarcely be felt. Mean- while, before the strength returns, the blood has time to coagulate, and with good fortune this may prevent further loss. In the case of large arteries, however, it is seldom effectual; as the fainting passes off, the heart regains its power, and the bleeding begins again. Sometimes temporary cessation and recurrence alternate more than once before death ensues. It is said that the blood which is lost toward the end coagulates more readily than that which comes at the beginning, and this may help a little. 2. Local. — Owing to the structure of the internal and middle coats of an artery, the inner tube contracts as soon as it is divided and shrinks to such an extent that only a small orifice is left. This is due, in part at least, to its muscu- lar fibres. At the same time, owing to its great elasticity, the two ends retract and become separated from each other by a considerable distance, the inner part again shrinking very much more than the outer. If the vessel is put on the stretch first, so as to bring this elasticity into full play, as when, for instance, a limb is torn off, the orifice may contract and retract to such an extent that no blood at all is lost. As a rule, however, a certain amount pours out, and this flowing over the torn and irregular surface formed by the broken ends of the internal and middle coats and the interior of the sheath, coagulates and fills all the space round and inside the ruptured end with what is known as the external clot. Generally, but by no means invariably, an internal clot forms as well. The blood as it whirls round in the closed ends forms a conical-shaped coagulum, the base of which rests upon the ruptured coats, to which it is firmly adherent, while the apex, lying loose in the interior, reaches as high as the next largest branch. This, when it is present, must act to some extent as a buffer, saving the outer clot from the shock, but it is not essential to permanent repair. If, when the heart recovers, this combined barrier is sufficiently strong to resist the impact of the blood, the permanent changes begin. The vasa vasorum, the minute vessels in the sheath, and those which lie in the tissues, round, dilate ; more plasma pours through their walls ; the leucocytes pour out more rapidly and in larger numbers ; the torn ends of the fibres swell up and disappear ; and gradu- ally the external clot and the base of the internal one are invaded from all sides by the cellular exudation, and the fibrin and red blood-corpuscles are gradually replaced. The endothelium of the vessel itself near the torn end disappears as such and fuses with the growing lymph ; probably, except in the largest trunks, under the stimulus of injury it regains some of its lost power and begins active growth again. Possibly some of the leucocytes in the still circulating blood, where it whirls round and round the conical clot, help as well, gradually filling up the narrow cleft that lies between it and the wall. In any case, by the third day a button of firm, newly-formed lymph seals the end of the vessel, lying between the edges of the curved-in coats, to which it is firmly adherent. After a time this lymph becomes vascular ; new vessels form, some coming from the vasa vasorum in the thickened and softened coats, others springing from the cavity of the vessel above, many from the sheath as well ; and organization rapidly follows. The final change is the shrinking of the newly-formed tissue, the gradual obliteration of many of its vessels, and the contraction of the artery above the seat of division up to the origin of its next large branch. When an artery is divided in its continuity the changes are the same ; but repair is much less perfect at the distal than the proximal end, and secondary hemorrhage is much more common from the former than from the latter. In some cases, the two ends separate completely and retain no connection with each 204 DISEASES AND INJURIES OF SPECIAL STRUCTURES. other ; more frequently a fibrous band is left between them ; and occasionally a vessel is developed, and enlarged by slow degrees until it re-establishes a direct communication. \\'hether hemorrhage ceases spontaneously or not depends partly upon the size of the vessel, partly upon the character and direction of the wound. If the artery is torn in two, even the axillary at the shoulder may close completely with- out the loss of a drop of blood. In a case of clean division, as with a knife, the result is more doubtful ; an artery the size of the temporal (provided it is perfectly healthy) usually causes no trouble ; the brachial or the posterior tibial in the upper part of its course retracts sufficiently for a time ; but hemorrhage is almost certain to commence again as soon as the heart regains its power. In the femoral this almost always happens. A transverse wound which does not completely sever the vessel never stops bleeding of itself unless it is of the most minute dimensions ; the elasticit}' of the coats holds the wound open, and many of the worst cases of hemorrhage are traceable to the incomplete division of some comparatively small branch. Arteries that are either rigid from atheroma, or are contained in rigid canals, whether made of bone, fibrous tissue, or the dense cicatricial tissue met with after old suppurating wounds (such as septic compound fractures), naturally, if they are divided, cannot retract, and consequently bleed furiously. Treatment of Hemorrhage. The first thing always is to secure the bleeding point wherever it may be, and whether it is an artery or a vein. The subsequent treatment turns entirely upon whether this can be done or not. 1. If the Bleeding Point has been Secured. When the loss of blood is sudden, every care must be taken to keep the heart and brain as well supplied as possible. Any quick movement, particularly raising the head, might at any moment bring on fatal syncope. The patient should be laid perfectly flat, without a pillow, and with all the clothing loosened round the chest ; it may not be possible to remove it. The limbs should be raised, and they may be even iightly bandaged. Hot bottles and warmed blankets should be packed all around, and every attempt made to maintain the temperature. If the heart is failing, hypodermic injections of brandy or ether may be tried ; in other cases, very small quantities of hot brandy and water, not more than half a tea- spoonful at a time, may be given at frequent intervals by the mouth. Rectal injections of warm water are sometimes of great service, absorption taking place with very great rapidity, owing to the diminution of fluid in the vessels. Finally, if none of these measures suffice to maintain the action of the heart, intravenous transfusion with human blood or with saline solution may be tried. The blood of other animals, in spite of the fact that it is said to have succeeded, must never be used ; the plasma of the one destro3's the blood-corpuscles of the other, and, even if it does not cause general clotting, makes the destruction worse ; and milk does not appear to possess any advantage. Intra-peritoneal transfusion has succeeded in animals, but I am not aware of its having been tried in men. Where the loss of blood is gradual the same method may be adopted ; but instead of relying upon the temporary effect of stimulants careful dieting is required with easily digested food, and after a time very mild preparations of iron in small doses. If the loss has been severe, cases of this kind require watching for many weeks. 2 . If the Bleeding Point Cannot be Secured. In the internal hemorrhage this is, of course, often impossible ; and even when it is external it is a rule, in primary bleeding, not to interfere further, if the INJURIES OF ARTERIES. 205 loss has ceased when tlie wound is exi)osed. The injured part may be covered with iodoform under gentle pressure, and must be watched night and day ; ])ut it should not be explored. In cases of this kind great care is recpiired to prevent collapse on the one hand and avoid reaction on the other. The wound in the vessel is closed chiefly by coagulum, and the main hojje lies in this not being washed away when the heart regains its power. Accordingly, stimulants should never be given unless the case is desperate. Absolute rest, warmth, and small fragments of ice from time to time, to relieve thirst, are all that is possible at first. Later, if other conditions admit of it, small doses of opium (combined with gallic and sul- phuric acids) are very beneficial ; but the diet must be kept low ; the patient must not be allowed to rai.se a finger ; and even talking must be prohibited until there is a reasonable chance of the wound in the vessel having become sealed. The actual onset of secondary hemorrhage can nearly always be traced to cough- ing, laughing, straining at stool, or some other trivial exertion. INJURIES OF ARTERIES. Rupture. Rupture of an artery may be complete or incomplete, and may occur with or without an external wound. It is said to be com])lete when all the coats are divided at any one spot, not necessarily in their whole circumference. I . Incoviplete Rupture. The coats of an artery may be torn by a contusion, if the vessel is superficial, or is caught against the bone (the common femoral, for instance) ; or they may give way from ovet-extension, especially at the knee joint, and in the reduction of old dislocations. In the operation of ligature, jjartial rupture is often produced deliberately, with the view of effecting more certain closure. Owing to their anatomical structure, the internal and middle coats usually give way without the external (Fig. 28). If tied tightly wdth a narrow ligature they are cut as cleanly as if divided with a knife, and then they retract some little distance, but do not curl in far. On the other hand, in contusions, and when an artery is torn from over-extension, they not un frequently twist up together, and completely close the lumen. In disease, when an artery is rigid and calcareous, or is softened and thinned, partial rupture is not uncommon ; but the beha- vior of the coats of the vessel is entirely different, and usually the rupture sooner or later becomes complete. Partial rupture of an artery may end in its occlusion ; in imperfect repair with the formation of a traumatic an- eurysm ; or in complete rupture. In the first of these three the clot, as already descrilied, forms on and beyond the torn ends of the internal and middle coats, and gradually becomes replaced by vascular organizing lymph ; the artery is obliterated, although occasionally a small vessel forms subsequently in the band that joins the ends ; and the consequences depend upon the collateral circulation. If this is good, no ill result ensues ; if the walls of the vessels generally are rigid, and the heart's action w^eak, or if, owing to extravasation, dilatation of the neighboring branches is impossible, gan- grene follows. In the second, organization and repair begin, but the ^'^^-,38;— Laceration of thej^ter- process is not completed ; and under the influence of the jury, with a Coaguium (^5). 2o6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. blood-pressure the still unbroken external coat, the blood-clot that lines it, and the tissues outside it stretch more and more until they form the wall of a sac, in other words, a traumatic aneurysm. This is distinguished from the ordinary form (which likewise can usually be traced back to some violent strain) by the fact that the wall of the artery for the rest of its course is perfectly healthy. In the third case the remaining part of the wall gives way, either at once or later, after partial repair and the formation of an aneurysmal sac ; the rupture becomes complete. 2 . Complete Rupture. When there is an external wound the hemorrhage is usually profuse, and if the vessel is large, continues until either syncope sets in or the result proves fatal. Sometimes, however, when the artery has been violently pulled out, as when a limb is torn off, the internal and middle coats curl up so tightly that the blood does not escape. When there is no external wound the blood spreads far and wide in the limb, wherever the resistance is least, forming what is known as an arterial hcetnatovia. It is most common in connection with fractures, and the reduction of old disloca- tions of the humerus. If the rent is a large one, and the tissues round the vessel are loose and yielding, as in the case of the axillary and popliteal, the loss of blood may be so profuse as to cause syncope ; an immense, ill-defined swelling forms within a few moments ; the pain is extreme : the limb beyond becomes swollen, oedematous, and cold : and the pulse in the distal vessels ceases com- pletely. Pulsation can rarely be detected, except perhaps over a* limited area ; and, as a rule, there is' no bruit, or if there is. it is not conducted along the vessel, as in the case of an aneurysm. When, on the other hand, the opening is a small one, or the tissues immediately around it resist and restrain the outflow, the symp- toms are much more vague, and resemble at first those of traumatic aneurysm ; then, perhaps quite suddenly and after several days, the barrier gives way, and the full effect is produced at once. The diagnosis of an arterial hcematoma from an acute and deep abscess is sometimes very difficult, as there may be a considerable degree of inflammation round it. If a thrill, or bruit, or pulsation can be detected, it is clear at once ; but in any case of doubt, a puncture with a grooved needle is perfectly safe. Occasionally it is mistaken for a rapidly-growing malignant tumor. Treatment. — Simple occlusion of a large vessel as a direct result of injury is very rare ; the small ones maybe more commonly affected, but then the symptoms are too vague to be recognized. If it is noticed that the limb is cold and has lost sensibility and power, and that the pulse cannot be felt in the parts below without there being any swelling or extravasation to account for it, the diagnosis is very probable. The limb should be raised, wrapped thoroughly in cotton-wool without being bandaged, and carefully watched. If gangrene sets in, it will probably be of the dry variety, and if the access of moisture can be prevented a line of demar- cation will gradually form without any constitutional disturbance. One or two toes only may be lost, even when the popliteal is blocked. Traumatic aneurysm usually makes its appearance some time after the acci- dent, as a soft, pulsating swelling in the course of one of the arteries. It can readily be emptied by pressure upon the trunk above, and fills itself again in the characteristic manner. As the vessel from which it springs is perfectly healthy, it may be dealt with in almost any manner that is suited to the locality and size of the artery. When, for example, it occurs in the anterior tibial in connection with fracture of the leg (the most common form) it usually gets well of itself while the fracture is becoming firm. Afi arterial hcematoma is much more serious, whether it occurs at once or is secondary to the formation of an aneurysm. If the extravasation has ceased to extend and the circulation in the limb below is good, gentle pressure may be tried, partly to support the vessel, partly to assist absorption. If, on the other hand, the INJURIES OF ARTERIES. 207 swelling continues to increase there is no alternative, an attempt must be made to find the seat of injury and tie the artery above and below. The vessel must be compressed on the cartiiac side, a free incision made into the extravasation, all the clots turned out, and the seat of injury exposed. Then a ligature must be placed round it above and below, at a sufficient distance to ensure the wall being healthy, and if it is thought advisable the trunk may be completely divided in between. A director or a stout probe passed through the opening into the vessel renders its isolation from the blood-stained and thickened tissues round much more easy. In this way I secured the external iliac and the common femoral for a rupture of the intermediate portion of the artery, which only became complete four weeks after the receii)t of the injury that caused it. The presence of gangrene leaves no choice; amputation, if practicable, must be performed without delay. Wounds of Arteries. The effects of complete transverse division of an artery in a wound have been already described. The internal and middle coats contract and retract ; if the vessel is a very large one death ensues, in spite of this, at once. If not so large, syncope occurs ; the heart beats more feebly, and an external, and then an internal, coagulum forms. Sometimes this is not enough ; when the heart regains its power, bleeding recommences and soon i)roves fatal ; in most instances, fortunately, and probably in all when the artery is as small as the temporal and the walls are healthy, the combined resistance is sufficient ; lymph is poured out, and organization and permanent repair set in. Incomplete division, on the other hand, unless the wound is a minute puncture, does not admit of repair unaided. A transverse cut is held widely open by the elasticity of the wall, and a longitudinal one gapes with every pulse-beat. Prob- ably most of the cases of persistently recurring hemorrhage from small and medium -sized vessels are really due to the fact that the wall is only partially cut through ; complete division, allowing the coats to retract all round, is, in many cases, an effectual cure Arterial hemorrhage can only be mistaken when the blood wells up from the bottom of some deep cavity ; or when, some days after the complete division of an artery, repair fails at the distal end. When this occurs the flow is continuous rather than intermittent, but its steady persistence and rapidity rarely leave the question in doubt for long. Treatment. — The treatment of a wounded artery depends upon the size and position of the vessel, and upon whether the bleeding has already ceased or is still going on. In the former case steps must be taken to prevent recurrence ; in the latter, as the natural method of arrest is insufficient, provision must be made to assist and supplement it. Temporary Measures. — Hemorrhage must be stopped at once by pressure upon the bleeding point or upon the artery above. If the spot is the right one the amount of force that is required is exceedingly small. The subclavian can be controlled with the thumb pressing it down upon the first rib, the operator standing behind and somewhat over the patient ; the brachial is even easier, especially in the middle of the arm where it lies in the angle on the inner side of the biceps. In the lower limb very little is required for the femoral as it passes from beneath Poupart's ligament, and digital compression can easily be maintained for half an hour and more, if the operator stands well above the patient so that his arms are almost straight. In Hunter's canal a firm grasp can control it against the femur from the inner side, but it cannot be kept up for long. The tibials are only superficial for a short distance above the ankle ; in the upper part of the leg they are out of reach. Firm flexion at the knee or elbow diminishes the force of the stream below very considerably, and may, if carried far enough, stop it altogether ; but it is very painful. 2o8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. In thin people and in children the abdominal aorta can be felt beating just above and a little to the left of the umbilicus, and here it can be compressed with ease. If, however, there is much fat, or the abdomen is prominent, it is much more difificult, and sometimes it can hardly be managed even with Lis- ter's tourniquet. Tourniquets are required when com- pression has to be maintained for any length of time ; the simplest is Es- tnarc/i s, apiece of ^-inch rubber tubing twelve or eighteen inches long, with a hook at each end. No anatomical knowledge is required. It is simply stretched out and wound around the limb above the bleeding point, or in the case of the hip and shoulder arranged in a figure-of-eight with one loop in the axilla or groin, as the case may be, and the other held to prevent slipping. A small wooden block to fit over the artery is very useful for the femoral at Poupart's ligament ; it must be grooved on the upper surface to receive the band, and padded on the lower, so that the Fig. 39.-Petit's Tourniquet. whole prcssure may fall upon the right spot. There are, however, several disadvantages in connection with this. Nerves have been paralyzed by it, the prolonged compression and ansemia leading to Fig. 40.— Petit's Tourniquet Applied to the Brachial. Fig. 41. — The Same Applied to the Femoral. physiological interruption. It encourages sloughing, especially if applied to check primary hemorrhage before amputation. The amount of oozing that INJURIES OF ARTERIES. 209 Fig. 42. — Signoroni's Tourniquet. follows when it is removed is so great that, although it absolutely prevents loss of blood from large vessels (and so is of undoubted service when nothing better is at hand), it is sometimes question- able whether in the case of a large wound the real saving has been very considerable ; and it is intensely i^ainful. Accidents of this kind are much more likely to happen when the limb has been previously rendered bloodless by the use of Esmarch's bandage, but they have been known to follow the application of a single rubber band.-'^ Other kinds of tourni(|uets are only of use for special arteries. Petit' s (Fig. 39) can be employed for most below the axilla and the groin. The pad, or preferably a roller about an inch and a half thick, is placed over the main vessel, the band is buckled close to the limb and the screw turned quickly, so as to compress the artery as soon as the veins and avoid passive congestion. A bandage around the limb is advantageous, as it prevents the skin being dragged. SignoronV s (Fig. 42) is horse-shoe shaped with a pad at each end (one for pressure upon the artery, the other to give sufficient resistance) and a screw and ratchet in the middle, so that the arc can be opened or closed at will. It is chiefly of use for the femoral in the groin, the larger pad being placed well beneath the tuberosity of the ischium. Lister' s is made in the same way, but is of larger size and intended for the ab- dominal aorta. It should be placed upon the patient's right side, so that the vessel does not slip off the fourth lumbar vertebra, and should only be screwed up at the last moment, and with just enough force to interrupt the circulation. Davy s rectal lever is a smooth, round bar of wood which is introduced through the anus into the end of the sigmoid flexure, so as to cross the common iliac in the angle between the lumbar spine and the psoas. By raising the handle the vessel is readily compressed. It may be used for the right side as well as for the left, and to control the branches of the internal as well as those of the external iliac ; but great care has to be taken in introducing it, owing to the folds that are always present in the rectum. Perforation has been produced by it. In cases of emergency a tourniquet can be improvised at once out of a hand- kerchief tied round the limb and twisted tightly. A stone should be placed inside it to make a firm pad over the vessel. In wounds of the neck and in some parts of the trunk pressure with the finger on the bleeding point is the only temporary expedient of any good. Wherever it is possible and the bleeding is not too serious, the patient should be removed at once to a convenient couch or bed. This must be done with the greatest care, the patient not being allowed to raise himself or make the least effort. Then, as soon as a good light has been obtained, the clothing must be gently separated or cut over the seat of injury, all blood-stained bandages and wraps removed, and the wound thoroughly inspected. If the bleeding has ceased and does not return when the tourniquet is removed, the parts around may be quietly sponged and the wound itself dusted with iodo- form, but the clot must on no account be detached. Careful watch must be kept for recurrent hemorrhage ; a tourniquet may be placed on the limb ready to be screwed up at any instant. It is quite possible that when the heart regains its power, slight serous oozing will begin, and that very soon the coagulum will be [* Many of these objections may be removed by placing four or five layers of gauze between the tubing and the skin, before tightening.] 2IO DISEASES AND INJURIES OF SPECIAL STRUCTURES. washed away and the bleeding recommence ; but until this happens any interfer- ence is unjustifiable. The best hope lies in absolute rest ; if the clot is not dis- turbed organization may set in and gradually render the wound secure. Penna7ie?it Measures. — If the bleeding ]jersists, it must be stopped either by making use of some general remedy, such as heat, cold, or pressure ; or by isolating and securing the vessel. Which of these plans is to be adopted depends upon the size and position of the bleeding point. Cold. — Simple exposure to the air is sufficient to stop oozing from small vessels ; if a greater effect is desired, ice-cold water or ice itself may be used. It acts upon the muscular coat and consequently is of especial use when many small arteries have been divided. Heat. — Hot water (temp. 125° F. to 140° F. , practically as hot as can be borne with the hand) acts better than cold on tissues that have been exposed to the air for some time (as in prolonged operations) or rendered bloodless by Esmarch's bandage. The actual cautery is used where the structures are soft and spongy and the oozing persists without its being possible to define any one spot. It should be black or at the most dull red ; if it is brighter the tissues are burnt away and stick to the iron, so that when it is removed the bleeding begins again. When applied to an artery an eschar is formed, generally of all the coats, which curl up together, and an internal coagulum is deposited almost at once upon the injured tissues. The proce.ss is not instantaneous ; if the vessel is of any size the point of the cautery must be held in steady contact with it for some moments, or the closure is incomplete. Secondary hemorrhage is more common after this than after torsion or ligature. Pressure is of much wider application. General oozing that does not yield at once to cold or heat may be effectually checked by bringing the surfaces firmly together. It is by far the most convenient method for arteries of the scalp ; the occipital or temporal may be secured at once with a bandage ; indeed, care is required in applying a capelline one not to interrupt the circulation unnecessarily. In punctured wounds involving the deep palmar arch there is practically no alter- native, and nearly always, even when arteries are secured in other ways, pressure is employed to assist, partly for the sake of the support it gives, partly because of the control it exercises over the circulation. If the bleeding point is on one of the limbs and the hemorrhage is definitely arterial, the pressure must be applied systematically, and with a clear idea as to what is required. A well-padded, accurately-fitting splint is essential to offer a certain degree of resistance and to keep the part at rest. The whole of the limb beyond, and for some distance upon the cardiac side, must be carefully packed with cotton-wool and bandaged. A graduated compress made of many layers of lint, placed one upon the other and cut so as to form a cone, must be adjusted upon the exact spot ; the apex piece may advantageously be made of cork ; and then one or two small strips of strapping must be carried over the base to fix it securely in its proper j)lace. Further, a small longitudinal roll of lint may be adjusted over the course of the main artery above the wound and secured in the same way. Then, finally, separate bandages are to be placed over each of the compres.ses, so that the pressure upon one can be varied or removed without affect- ing the other. The limb should be raised after the bandages are in position, and the joint above flexed, so as still further to check the flow ; but very careful watch- ing is required for fear of gangrene. If no trouble of this kind threatens, and if the hemorrhage does not return, the dressing of the wound should be left undis- turbed as long as possible ; and when it is detached the lowest piece of the com- press should be left untouched. When the tissues have healed beneath, and the wound in the vessel is sound, it will come away of itself; and if the part is well dusted with iodoform and kept dry, there is no fear of any extensive suppuration occurring. The plan may be adopted for punctured wounds of the deep palmar or plantar arch. The amount of pressure is not so important as the exactness INJURIES 01 ARTERIES. 211 of its application ; very little really is required if it is on the right spot; if it is on the wrong one, either the bleeding continues or it causes sloughing. Pressure is also needed sometimes for other arteries which have been injured in parts that are peculiarly inaccessible. The internal pudic, for example, or some abnormal branch, may be wounded in lateral lithotomy in such a way that it can- not be secured ; or one of the intercostals may be punctured by a stab. A dilatable india-rubber bag may be used for these. It must be introduced into the wounded part, inflated by means of a tube, and then secured with a clip or stopcock. If this fails, digital compression for twenty-four hours may be tried, or some form of acu- pressure ; but it must always be recollected that often in these cases the vessel is only punctured, and that complete division may bring the bleeding to an end at once. If the artery lies in a bony canal (the descending palatine, for exami)le, which has been wounded in the operation for cleft palate) hemorrhage can only be stopped by plugging, using either a rounded splinter of wood, or, if the vessel is on the face of a stump, some wax or soap. Elevation causes marked contraction of the arteries of a limb, and is very useful as an adjunct, but of itself it has little or no power, except over the bleed- ing from veins and capillaries. It is still an open question, when there is distinct arterial bleeding from some deep-punctured wound, how far it is justifiable to trust to pressure. The alterna- Fig. 43. — Different Modes of Applying Acupressure. tive, enlarging the opening and trying to find the bleeding point, which may quite possibly lie on the other side of the limb (the posterior tibial, for example, has been wounded from the front), is often an operation of very great difficulty, and sometimes, from the circumstances of the case, simply impossible. Even when there is every assistance at hand, the attempt has often failed, and certainly, unless all the conditions for a prolonged search are favorable, pressure is advisable, at least as a temporary measure. The progress of the case will generally determine whether further steps should be taken or not. Acupressure is of great use in certain special cases. Occasionally, for example, an artery is imbedded in such dense cicatricial tissues that it can neither retract and close nor be isolated for ligature. I have on two occasions secured the posterior tibial in this way when everything else had failed. Or it may lie in an aponeurosis, so that it is practically under the same conditions ; or it may be so deep at the bottom of a wound, and close against the periosteum, that an extensive incision and prolonged dissection would be required to get near it. In such cases as these a curved needle may be passed beneath the bleeding point and a figure-of-eight ligature placed over the two ends, as in the twisted suture, or a straight needle may be passed beneath or over the vessel and then thrust into the tissues in a different direction, so as to close it by its pressure. The length of time it should be left depends upon the size of the vessel and the condition of the wound (Fig. 43). Eorcipressure is admirably adapted for securing with rapidity a number of 212 DISEASES AND INJURIES OF SPECIAL STRUCTURES. small bleeding vessels. Catch forceps are used with strong, bluntly-serrated ends ; the bleeding point (with as little of the tissue round it as can be managed) is seized, the blades clamped together over it, and left for a few moments while the operation is continued or others are being caught. On removal the crushed end forms a flat band which does not open out again ; the internal and middle coats, which are broken across by the pressure, curl up inside and a coagulum forms at once. It is as efticient as torsion for all small vessels and much more rapid, and in many operations (such, for example, as excision of the breast) enables the use of ligatures to be dispensed with altogether. Tof'sion. — When a limb is torn off the large vessels rarely bleed ; the inner coats of the artery shrink up inside to such an extent that the end is completely closed and a coagulum forms at once. Torsion acts on the same principle. It may be carried out in different ways, unlimited or limited. In the former the end of the artery is seized with a pair of broad- ended serrated forceps, clamped, and then twisted around as far as its natural connections allow, or sometimes twisted off altogether; in the latter the artery is drawn out in the same manner, but fixed with a pair of forceps placed upon it transversely about a third of an inch from the end, and this projecting part is twisted until it no longer uncoils itself (Fig. 44). There is no question as to the very great advantages that torsion possesses. It is better than forcipressure, for while the end is crushed in the same way into a flat riband, the internal and middle coats, instead of being merely broken off, are coiled up and rolled around together inside. There is no ligature to be absorbed (although now that catgut is chiefly used this is not so material), and temporary closure does not depend upon the security of a knot ; in other words, there is no fear of recurrent hemorrhage from this giving way. The end of the vessel, if suppuration occurs, sloughs off, it is true, but so it does with a ligature. If, on the other hand, the wound heals at once, it rapidly becomes organized into a cicatrix. For plastic surgery there is no doubt as to its superiority, for even catgut, however prepared, is a foreign body and diminishes the chance of primary union. The largest vessels can be secured with perfect safety, and even when they are diseased, if the surrounding tissues are caught and twisted up with the end, a conical cap is formed which is sufficient to resist internal pressure until (unless nutrition is exceedingly feeble) organization takes place. Ligature. — This is the only method of universal application (although in many cases torsion or forcipressure is preferable), and the only one by which an artery can be safely secured in its continuity. I. W/ieii the Artery is Already Divided. — If the vessel is of any size the end is seized with a pair of artery-forceps and drawn out from its sheath ; if it is small it must be separated carefully from the adjacent tissues, and the ligature tied firmly around it in a reef knot. An attempt should always be made to divide the internal and middle coats, but care should be taken not to cut the artery through ; the amount of force required is very slight. An internal clot begins to form almost immediately, and usually it reaches up the vessel as high as the next largest branch. Lymph pours out from the vasa vasorum and the capillaries in the tissues near ; organization begins, and, if the wound heals at once without suppuration, the end of the vessel, the sheath, and the tissues around it are welded together into an inextricable mass of cicatrical tissue. The fate of the ligature and of the portion of the vessel it surrounds depends upon the material and the way in which the wound heals. Fig. 44. — Effects of Torsion upon an Artery, showing the Incurvation and Laceration of the Inner Coats. From paper by Bryant, "Med.-Chir. Trans.," i86S. INJURIES OF ARTERIES. 213 Except in special cases, ligatures are made of finely twisted silk, soaked previously in a five i)er cent, solution of carbolic acid, or of catgut prepared with carbolic acid and kept in carbolic oil. It answers better if the catgut is hardened first, after Lister's plan, in chromic acid, as otherwise it is absorbed too soon. Silk, if the w^ound heals at once, is encapsuled in the cicatrix, the included por- tion of the vessel gradually becoming absorbed, owing to the pressure around it. Exceptionally, after lasting perhai)s many weeks, the ligature gives rise to a certain degree of irritation, cuts its way through, and comes out. Catgut, on the other hand, unless it is very old, disapi)ears completely, the length of time it lasts depending upon its age, thickness, and method of preparation. If it has been tied tightly, the included jjortion disappears too ; if loo.sely, it may remain unabsorbed, and then, at least in the case of an artery ligatured in its continuity, it becomes a source of weakness rather than otherwise. If suppuration sets in the ligatures, whether of silk or catgut, come away, cutting through the vessel, and the distal end sloughs. 2. Ligature of a Vessel in its Continuity. — When an artery has to be tied in situ the conditions are very different from when it presents on the face of a stump. In the latter case the end is seen and drawn down from the sheath into which it has shrunk, the internal and middle coats are divided, and the artery begins to contract, as well as retract, at once. It has, comparatively speaking, lost a great deal of its importance ; the femoral artery, for example, in a stump contracts almost immediately to less than half its previous diameter : the amount of tissue it has to keep supplied with blood is reduced, and though what is left has more work than usual, owing to the amount of repair, the blood-pressure falls propor- tionately. An artery tied in its continuity is under totally different conditions ; two ends have to be closed instead of one, retraction cannot take place in the same way, and the pressure is not in the least diminished : there is as much tissue to be supplied after the operation as there was before. The operation consists in exposing the artery at the selected spot (anatomical details chiefly determining where this may be), opening the sheath of the vessel, passing the needle around it with as little disturbance as possible, withdrawing it threaded, and then tying the ligature without lifting the artery out of its bed. Repair is very much slower at the distal end than at the proximal ; the inter- nal clot is always smaller, and is often absent ; retraction is much less complete, and secondary hemorrhage, when it occurs, nearly always comes from this, ^^'hy it should is not so clear ; the vasa vasorum are interrupted, but this alone will hardly account for it, and the arterial pressure on that side must be much lower than on the other. Many attempts have been made to diminish this liability. Compression with a ligature has been tried, the internal and middle coats being carefully preserved from injury ; and there is no doubt it succeeds in animals. A ligature that will last for some time without causing irritation is tied around the vessel, just tightly enough to close the cavity without dividing the coats ; a coagulum forms inside, organization follows, and, before the ligature has lost its holding power, the lumen is completely sealed. Silk may be used for this purpose, but, as it is always liable to cause a certain degree of irritation, a thick, round cord of specially prepared catgut is preferred. Barwell has made use of a flat band, cut from the aorta of an ox, with the same idea. Probably kangaroo-tail tendon is better still, as it pos- sesses great power of endurance, and can be secured more easily. In some cases a knot has been dispensed with, and the ligature fastened somewhat after the man- ner of a clove hitch ; for there can be no doubt that when ulceration of the vessel- wall does occur, it usually gives way opposite the projection it forms. But these results, however good they have been, have not yet convinced surgeons that (except perhaps in the case of the innominate and common iliac) compression is safer than division. Too great force, it is admitted, should not be used ; but a tight ligature is certainly safer. There is more to be said in favor of a double ligature with division of the 214 DISEASES AND INJURIES OE SPECIAL STRUCTURES. trunk between. If this is done, the ends retract at once (in the case of the femoral upward of half an inch) owing to the elasticity of the vessel ; and the condition is assimilated much more closely to that of ligature upon the face of a stump. Prepared silk, catgut, or kangaroo tendon may be used, and the ligature should always be tight. If there is no suppuration, the ends of the vessel and the portion of tissue included in the ligature are invaded by lymph and replaced by cicatricial tissue. The permanent clo.sure takes place by the organization of the little button of exudation that is formed in the base of the internal clot, between the retracted edges of the inner and middle coats, and in the short contracted space between this and the ligature. If suppuration does occur, and the ligature cuts through, the more perfect retraction undoubtedly diminishes the danger. Styptics are substances which either cause intense contraction of the vessels or hasten the coagulation of the blood. Perchloride of iron, turpentine, alum, subsulphate of iron, and matico leaf are chiefly recommended ; but, wherever it is possible, other remedies should be tried again and again instead. They altogether prevent union by the first intention, and cause a very great deal of inflammation. However, in some cases in which there is persistent rapid oozing, which nothing seems to check, they do succeed. The surface of the Avound must be rendered absolutely dry before any one of them is applied. Choice of Method, i. IVlieii the Artery is Exposed on a Stump. — Small vessels contract under the influence of heat, cold, or exposure, and if pressure is applied afterward give no further trouble. Forcipressure is useful for larger ones ; torsion or ligature for the largest. Styptics, acupressure, plugging, and other remedies are only employed under special conditions. Pressure and elevation should never be neglected. If the end of the vessel can be seen, it is safer to secure it with a ligature, even if it does not bleed at the time. Whether torsion or ligature is the better when the walls of the vessel are dis- eased is an open question. If torsion is used, sufficient of the tissues round must be included to form a cap over the end. If ligature, a broad and rather stout strand of catgut should be chosen, and some of the tissues round should be included so as only to compress the vessel ; a tight ligature would cut it in two at once. The great hope in these cases lies in early union ; the ligature or the twisted end of the vessel can be relied upon for a week or ten days. If union round the artery is fairly sound at the end of that time, it is probably sound inside as well, and the organ- ized coagulum will hold ; if suppuration takes place, or if nutrition is so feeble that organization fails, the end of the artery perishes, and secondary hemorrhage is only too probable. 2. When an Artery is Injured in its Continuity. — If it is exposed at the bottom of a wound, bruised but not divided, two ligatures should be placed upon it, one above, the other below, and the trunk severed between. When it is wounded, this rule is imperative, for if one end only is tied, the other bleeds profusely as soon as the collateral circulation is established, and though the stream may not be so forci- ble it is equally persistent. If it is not exposed and the hemorrhage is severe, a tourniquet must be placed upon the trunk higher up, and the wound enlarged by careful dissection until the bleeding point is found. If this is not done, it is impossible to be certain whence the hemorrhage comes. Tying the trunk of the vessel higher up, even supposing it were certain to be the right one, does not succeed ; either the collateral circula- tion is good, and then secondary hemorrhage occurs from the distal end ; or it is bad, and gangrene results. [The " Golden Rule " of Guthrie : " Tie both etids of the bleeding vessel in the wound, enlarging the Tvound if tiecessary."'] To these rules, however, there are a few exceptions : I. Punctured wounds of the tonsil, or behind the angle of the jaw with severe arterial hemorrhage. Exposure of the bleeding point by dissection is out of the question ; the common carotid must be tied in the hope of checking the hemor- INJURIES OF ARTERIES. 215 rhage. It has been reconiniended to tie the external too, just above the bifur- cation, with the view of cutting off a large amount of the collateral supply. 2. Punctured wounds of the deep })alniar and the plantar arches must be treated by pressure, as already described. 3. If the vertebral is injured, it is generally better to trust to packing from the bottom with iodoform gauze than to attempt ligature. The diagnosis, however, at the root of the neck is impossible without some exploration ; and it may occa- sionally happen that the artery can be secured there. 4. Very deep punctured wounds, in which it cannot be determined what has been injured or where it has been injured, are probably better treated l)y jjressure, at any rate for a time, especially if the light is not perfect and thorough assistance is not at hand. There is no telling, in such cases, if the operation is once begun, where it is likely to stop. 5. In cases in which one of the limbs has been disorganized from cellulitis, or a sequestrum has ulcerated into a vessel, amputation may have to be performed. These, however, are to be judged upon their own merits ; it is not merely the loss of blood or the risk of secondary hemorrhage, but the fact that the limb, if it were saved, would be useless afterward, that determines the operation. When an artery has been ligatured in its continuity, the greatest care must be taken to avoid gangrene. The limb should be wrapped in cotton-wool from one end to the other ; surrounded with hot water bottles (not too close) ; and slightly raised so as to assist the circulation as far as possible. Bed sores form in these cases with unusual rapidity, and healing is very protracted. Afterward, the wast- ing of the tissues, and particularly of the muscles, is often very considerable, and if the artery was an important one, and the patient past middle life, the size and strength of the part never thoroughly return, and it remains cold and liable to chilblains and chronic ulceration for the rest of life. If the collateral circulation fails from atheroma of the arteries, weakness of the heart, external pressure, or a great transverse wound dividing many branches, gangrene ensues. If it is of the moist variety, amputation must be performed ; fortunately, however, it is usually dry, and then the patient may escape with the loss of one or two fingers or toes, as the case may be. Defective Repair. Repair may prove defective at different periods and under different conditions ; in every case it leads to hemorrhage, which may be external (recurrent and secondary) ; or internal (arterial hematoma, traumatic aneurysm, arterio-venous aneurysm, and aneurysmal varix). I. Recurrent Hemorrhage. This usually occurs within the first few hours, rarely or never after four and twenty, and it is always traceable to failure in some of the measures upon which temporary arrest depends. A ligature may have slipped ; some artery may have been overlooked from its not bleeding at the time ; a clot may have been displaced by some accidental movement ; or an artery may have been injured without being opened. In any case, when the heart regains its power the hemorrhage returns, at first quietly and then seriously, especially if the wound is covered up with a thick layer of loose absorbent dressings. The treatment depends upon the amount. If there is merely slight oozing, an attempt may be made to check it by pressure, cold, and elevation. If this fails, or if the amount is serious, distending, for example, the flaps of an amputa- tion, the patient must be placed under an anaesthetic, the wound laid open, and the bleeding point secured as in primary hemorrhage, following the same rules. 2i6 DISEASES AND INJURIES OE SPECIAL STRUCTURES. 2. Secondary Heviorrhage. This is due to failure in the measures by which permanent arrest is effected. Either the amount of lymph poured out is insufficient, or it does not become vascularized and organized in time ; or, owing to the presence of some additional irritant, inflammation sets in, impairing the nutrition, not only of the newly formed lymph, but of the vessel-wall as well. Whatever it is, whether the artery is on the face of a stump or has been tried in its continuity, a slight amount of blood-stained discharge is noticed one day, usually about the time the ligature takes to cut through the vessel ; the next there is a little more ; and then suddenly, from some accidental exertion, coughing or straining at stool, there is a furious outburst. Fortunately there is nearly always a warning. Causes. — Secondary hemorrhage is due to the same causes that delay heal- ing of wounds in other structures. {a) Constitutional. — Pyaemia, septicaemia, renal disease, and other conditions that interfere with all reparative processes, strongly predispose to it. {b) Local — Malnutrition of the wall of the vessel, whether arising from athe- roma or because it has been separated from its sheath. Clearly, if the wall of an artery is already badly nourished, it is not likely to repair the results of an injury readily. The addition of some other ii'ritant is the most common cause of all. The ligature itself is one, although it may be very slight ; but with this already present only a little more is required, and that little is easily supplied. Want of rest is a common cause, straining, rough transport, or rough handling, for example ; the neighborhood of a large collateral branch with its constant pulsation is another ; but by far the most important is the presence of suppuration. If this occurs in a wound it always attacks the weakest tissues, those already injured by a ligature ; the wall of the artery becomes soft and yields, and organization in the inner clot fails. For this reason, secondary hemorrhage is much more common in wounds that are complicated by suppuration than in those that are repaired without. Premature yielding of the ligature is very serious. In animals no ligature is required ; it is sufficient if the inner and middle coats are divided so that they can curl up , or if a ligature is used, it simply need be placed round the vessel so as to compress it ; but in man this cannot be relied upon. If the ligature yields too soon, whether it is prematurely absorbed or the knot gives way, the outer wall loses its support before the internal organization is complete, and then there is always danger of the protecting barrier failing and secondary hemorrhage taking place. Treatment. — This depends upon whether the artery is on the face of a stump or has been ligatured in its continuity. {a) On a Stump. — Pressure and elevation should be tried first, but if it con- tinues the bleeding point must be sought and found, even if it is necessary to open up the flaps again and break down all, or nearly all, the union. The only excep- tion is when the stump is almost healed, and it is tolerably clear, from the effects of pressure, that it is either the main vessel itself or an immediate branch. In these circumstances the brachial may be ligatured for an amputation immediately below the elbow, the subclavian when the limb has been removed at the shoulder- joint, and the common femoral if at the hip. If the stump is sloughing (as it often is in these cases) the artery must be dis- sected up some little distance and tied well above the infected part. The actual cautery answers for the time, but if the vessel is of any size it cannot be relied upon. ib) When an Artery has been Ligatured in its Continuity. — Rest, cold, and pressure should also be tried here first, but if the warning is repeated, or if the loss is at all considerable, it is better not to delay further. It is true that some cases have lived through repeated hemorrhages and have recovered, but many more INJURIES OF ARTERIES. :i7 have dieil ; and there can he no (juestion, so far as the lower hnib at least is con- cerned, that the wound should be opened up (a tourniquet being i)laced on the vessel above), the two ends deliberately dissected clear and ligatured. In the upper limb, the artery (especially the brachial) has been tied nearer the trunk with occasional success, but the anatomical conditions here are very different. If this treatment fails, amputation must be performed. 3. Arterial Hicmatoina. This condition is exactly ecjuivalent to that of any artery ruptured subcuta- neously, and must be treated in the same way. There is no sac, simply a wide- spread extravasation with, if the vessel is a large one, interruption of the circula- tion and threatening gangrene beyond. If it is the axillary, an attempt may be made to turn the clot out through a free incision and tie both ends. If the femoral or the popliteal, and the patient is young and the rest of the arteries healthy, the same may be done ; but if the conditions are not perfectly favorable in other respects, aminitation is the only hope. 4. Traumatic Aneurysm. Sometimes, when repair is incomplete, a traumatic aneurysm forms in way as after partial rupture. Either the cicatrix or the injured coats are ciently strong to resist internal pressure, or they are not supported well enough from outside, and they gradually yield and stretch. It is only so long as the aneurysm is very small that the relation they bear to it can be traced ; as soon as it forms a perceptible enlargement the tissues that surround it, consolidated by the pressure and thickened by slight inflammation, constitute the outer part of the wall, while the inner surface, as in aneurysms that result from disease alone, is lined with laminated fibrin. The course, terminations, and signs of a trau- matic aneurysm are identical with those of the ordinary variety ; the difference consists in the condition of the rest of the wall of the vessel. As it is perfectly healthy quite up to the sac itself, ligature may be practiced in any part, near it or far from it, above or belo\v, that offers the best prospect of cure. Many of these, however, recover without opera- tion, under pressure or flexion. the same not suffi- FiGS. 45 and 46 — Aneurysmal Varix, 5. Arterio-venous Aneurysm. This and the remaining form, aneurysmal varix, are met with under the same condition, when an artery and a vein have been wounded at the same time and place and repair has not been perfected. In aneurysmal varix there is no sac, merely the direct communication of an artery with a vein ; the artery is somewhat dilated above, much contracted below, while the vein is enlarged, thickened, tortuous in all directions, and pulsates strongly. The limb below is usually wasted, but it may be enlarged IS 2iS DISEASES AND INJURIES OF SPECIAL STRUCTURES. and in a state of solid oedema. There is a peculiar jnirring or buzzing sound to be heard over it, propagated along the veins toward the trunk (Figs. 45 and 46). Arterio-venous aneurysm, on the other hand, has a sac, de- veloped chiefly from the tissues that form the channel of com- munication between the two ves- sels ; and the aneurysmal symp- toms are more marked, the venous ones less distinct (Figs. 47 and 48). The most common situation is at the bend of the elbow, owing to accidents during bleeding, but they may occur elsewhere, espe- cially from sword-thrusts. Aneu- rysmal varix should not be inter- fered with ; an elastic support may be worn to keep it in check, but nothing further. Arterio-ve- nous aneurysm, on the other hand, should be treated as an aneurysm, first by pressure upon the artery above and upon the vein, and then, if this fails, by ligature. Fig. 47. — Mr. Cock's Case of Arterio-venous Aneurysm. Fig. 48. — Aneurysm Laid Open. . The Laminated Clot in the Sac. INJURIES OF VEINS. \'eins, like arteries, may be bruised, torn, or wounded ; but except under special conditions, serious bleeding rarely follows. Contusions. — Thrombosis of a vein occasionally follows bruises, strains [and fractures], without any extravasation having been noticed. Probably the internal coat has been injured ; coagulation has taken place ; and the clot has continued to grow until it has filled the interior. Owing to the freedom of anastomosis, serious obstruction is unusual. Laceration. — Subcutaneous laceration of small veins is of common occurrence, but the pressure is so low that the vessels close and the hemorrhage ceases before a dangerous amount of blood is lost. If, however, the trunk is a large one, or a branch is pulled off from the side, and the tissues round are soft and yielding, as in the axilla, the amount of extrava.sation may be sufficient to cause gangrene or even to threaten life. Wounds. — Punctured wounds and small incised ones that run in the direction of the vessel should be sewn up with a continuous catgut suture ; the interior usually remains patent, but occasionally a coagulum forms and thrombosis occurs. If the wound is transverse, unless it is very small, the vessel should be tied above and below, and the division rendered complete. Small veins if cut in two collapse immediately. Large ones may cause a serious loss of blood from the proximal end ; and if there is any compres.sion on the cardiac side of the wound, or if the vein is varicose or dilated so that the valves cannot act, the hemorrhage may prove fatal within a comparatively short space of time. Ligature is only required in the case of the largest trunks, and then as a precaution \ but it can do no harm, and it does not cause phlebitis. Elevation, or the slightest degree of local pressure, is almost always sufficient. Gangrene of a limb rarely follows ligature even of the chief vein, owing to the freedom of anastomosis. Sometimes there is a certain degree of venous obstruction followed by tension and solid oedema, but it is by no means invariable. The axillary, for example, is not unfrequently ligatured in excisions of the breast without any ill consequence, so long as the lymphatics are not obstructed : and the same INJURIES OF VEINS. 219 may be said of the femoral. \\'hen the chief artery of a linib is wounded at the same time, the risk is greater, Ijut the external iliac artery and vein have been tied simultaneously without any bad result; and this has happened on many occasions in the case of the femoral. rrol)ably it is safer, when such an operation is recpnred, to delay it as long as jio.ssiblc with the view of encouraging the collateral circula- tion, but this is by no means essential, and, of course, is impracticable in the case of a wound. I'".NTR.\Nci£ ov Air into the Veins. This exceedingly dangerous accident rarely occurs except in connection with the great veins of the neck. In these the pressure during ins])iration is negative, and "the blood is sucked into the thorax. Under the ordinary conditions they are partly filled from l)ehind, partly closed by the collapse of their walls. If inspira- tion is very deep, or their coats are thickened, or if, as often happens while deep- seated tumors are being removed, they are held open by the traction upon the cervical fascia which invests them, and at the same time an accidental opening is made in their wall, air is sucked in with a peculiar hissing, gurgling sound, and the right auricle is filled at once with a bright, frothy mixture. The consequences depend upon the amount. If it is at all considerable death is instantaneous ; the frothy mixture cannot raise and close the valves, and the cir- culation comes to an end. Where it is not sufficient for this, the patient suddenly becomes pale and livid, the pupils dilate, the pulse is small and flickering, the respiration hurried and gasping, and the heart's action violent and irregular. As the air is dissolved this passes off, and gradually the heart begins to beat with reg- ularity again, but the danger is not all over, for sometimes, even after some hours, alarming symptoms suddenly return. Possiby this is due to the air having entered the pulmonary capillaries, but more probably to the shock. This accident usually occurs in operations about the root of the neck ; but it has been known to hapjjen in wounds of the axillary and even more distant veins. The greatest care must be taken in all operations about this region, especially as it is often necessary to exert a good deal of traction upon the structures, lifting them well up to see what is beneath. Any vein that is exposed and requires division should be ligatured first ; and, as Treves suggests, a basin of water and a sponge should be placed by the side of the patient's head, that at the least sign the wound may be filled at once. If the peculiar hissing sound that characterizes this accident is heard, either the finger or the sponge full of water should at once be placed upon the vein, regard- less of everything else, and the patient's thorax comj^ressed. Possibly by this some of the air may be forced l)ack again. Artificial respiration should not be employed, but every attempt should be made to keep ujj the action of the heart and to maintain a sufficient supply of blood to the brain, by the hypodermic injection of stimulants and by lowering the head and raising the limbs. 2 20 DISEASES AND INJURIES OF SPECIAL STRUCTURES. SECTION 11.— DISEASES OF BLOOD-VESSELS. Angeioma. Angeiomata are tumors composed entirely, or almost entirely, of blood-vessels. For the most part they are congenital ; many, however, are not noticed for a month or so after birth, and arterial ones may not make their appearance until much later. They may be composed of arteries, veins, or capillaries, or of all three together. Sometimes they consist merely of already existing vessels enor- mously dilated and varicose ; more often of newly-formed ones as well, and certain varieties are not unfrequently associated with other forms of congenital growth. Capillary angeiomata (cutaneous nsevi) have been noticed already among diseases of the skin. Venous angeiomata (subcutaneous or venous nsevi) may occur in conjunction with capillary ones, or independently, either in the subcutaneous tissue or in other parts. Some of them appear to be formed merely of dilated veins, others resem- ble rather the cavernous structure of the penis, being composed of irregular, thin- walled spaces in direct communication with arteries, and these may be associated with congenital lipomata, blood, and serous cysts, and occasionally with rapidly- growing sarcomata. As a rule, venous naevi form soft, irregular, but distinct masses, easily compressible, and filling up again as soon as the pressure is removed. Some few of the cavernous ones merit the name of erectile tumors, but there is very rarely any pulsation to be detected. Their color varies with their position. If beneath the skin they are blue, like veins ; if under a mucous membrane, bright red ; and their consistence varies, of course, with the amount of solid growth that is present. In many cases they remain stationary for years ; not unfrequently they degenerate or become cystic ; sometimes, after lying unaltered for a great length of time, they suddenly enlarge, ulcerate, and give rise to severe hemorrhage. Venous naevi must be carefully distinguished from meningocele or encephalocele when they occur at the root of the nose or at the angles of the orbit ; and if there is the suspicion of a doubt, the tumor should certainly not be touched. Various methods of treatment may be adopted, according to the size, posi- tion, and rapidity of the growth of the tumor. Probably, if in a part of the body in which they are not seen, and if there is no evidence of increase in size, the best plan is to leave them alone, certainly for a time. Excision is the most certain, and leaves an exceedingly small scar; the amount of hemorrhage is very slight. Electrolysis (using only the positive pole) is tedious but safe, and leaves no mark at all. The constant current should be used, four or six cells of Stohrer's battery. The negative pole is attached to a metal plate covered with wash-leather ; the positive to one or more steel-tipped needles, insulated for about half their length. These are introduced into the ngevus, jmrallel to each other. As soon as the current is turned on the blood begins to coagulate round them, and when they are withdrawn, a hard, dense track is left. If bubbles of gas make their appear- ance, it is a sign that the current is too strong. Where a rapid effect is desired the actual cautery is the most successful application. One perforation is made in the skin, and then the fine platinum point is thrust through the substance of the growth in various directions. If it is of the right temperature the pain is very slight and no blood is lost. [Electrolysis frecpiently fails, where the angeioma extends deeply into the tissue. The more superficial the angeioma the greater the probability of cure by electrolysis.] In other cases setons may be employed ; or threads dipped in perchloride of iron ; or portions may be ligatured subcutaneously ; .or the growth may be divided in various directions with a tenotomy knife, and pressure applied afterward. In cases in which extensive nsevi are associated with DISEASES OF BLOOD-VESSELS. ra]ii(lly-in(reasing solid growths in cliildreii, the outward application of strong lead lotion is of decided beneht, at any rate for a time. Injections should never be used, for fear of causing embolism. Artt-rial iX)i^cioma (arterial varix, cirsoid aneurysm, and aneurysm by anasto- mosis, are other terms descriptive of essentially the same condition) is, in com- parison with these, of very rare occurrence, and althougli it may be congenital in some instances, is seldom met with before puberty. It is known as arterial varix when only a single artery is involved, as cirsoid aneurysm if there is a mass together, and as aneurysm l)y anastomosis when the capillaries and venules are dilated as well. The most common situation for it is the scalp (especially round and above the ear), but it may occur in any part of the body. Sometimes it is stated to have developed from a nrevus ; in other instances it appears to have followed injury, and possibly may have originated as some form of arteritis ; in the majority no reasonable cause or explanation is forth- coming (Fig. 49). In its typical form it is composed of a mass of enormously dilated, tortuous arteries, twisted inextricably together, and covered with thin-walled pouches. It projects somewhat above' the skin (which is often dangerously thin over the most prominent ])arts) ; it is soft, lobu- lated, easily emptied by direct pressure, and to a less extent by pressure upon the trunk supplying it ; but it fills again at once, and its outline is very ill-defined, the branches that supply it only assuming their normal character some distance from the main body. A thrill and a distinct bruit can be detected over the main part, and followed along the vessels in the course of the blood-stream. By its pressure it gradually causes absorption of the structures round, cutting deep grooves in the bones, and rendering the skin so thin that it is in imminent danger of giving way. some nerve is accidentally involved. Spontaneous cure is unknown ; it may remain passive for years and then again begin to enlarge, or it may grow steadily the whole time. If the skin gives way the hemorrhage is of the most alarming character, and may prove almost imme- diately fatal. Excision is the only treatment that deserves any reliance. Ligature of the trunk supplying the tumor has failed far more frequently than it has succeeded, and renders subsequent operations more dangerous on account of the development of the collateral circulation. Pressure checks advance in some of the more chronic cases, but can do no more. Ligature en masse has answered in a few instances, although in one at least recurrence took place. If it is on the scalp, temporary ligatures may be placed on the carotids, or the trunks supplying the tumor may be compressed with hare-lip pins, and then, with the aid of one or two assistants to keep up digital compression while the ligatures are being placed and tied, the skin may be reflected from part of it, and the rest of the growth excised with the minimum of loss. If it is on the extremities the same plan may be tried, but in several cases amputation has been found necessary, sooner or later. Fig. 49. — Cirsoid Aneurysm of the Scalp. There is no pain unless 222 DISEASES AND INJURIES OF SPECIAL STRUCTURES. H.'EMOPHILIA. Haemophilia, or the hemorrhagic diathesis, is a peculiarity of constitution that is distinctly hereditary ; but though it may be transmitted by mothers to their sons, it is very rarely manifested except in males. Female children themselves are very seldom affected. Nothing is known as to its cause ; no definite change is found constantly in the walls of the vessels, and there is no apparent alteration in the blood. At first it coagulates as readily as usual, and though after a time it becomes thin and watery, the same thing occurs after profuse hemorrhage from people who are not bleeders. The aspect or appearance is not in any way characteristic, and before- hand there is nothing to tell whether a patient is a bleeder or not. The tendency to it is most marked in infancy and childhood ; if it does not develop then the patient, as a rule, remains free. In a few instances it seems to have spontaneously died out, and in all probability the tendency to it varies in intensity at different times. In some, the bleeding is spontaneous, coming from mucous or synovial sur- faces, in others it is traumatic only. The slightest injury may cause it ; bruises are followed by enormous extravasations in which the blood remains fluid for a great length of time, and the extraction of teeth is especially serious. It is said that trivial injuries are more often followed by bleeding than grave ones, but this is open to question. It is not arterial or venous, the blood simply appears to pour out from the tissues themselves in a ceaseless stream. Spontaneous hemorrhages are stated to be often preceded by symptoms of congestion, but they more usually occur without warning. When the joints are involved it is not infrequently taken for rheumatism, especially as there is a decided tendency for it to occur in cold and damp weather. The swelling is sudden, involving the peri-synovial tissues as well as the cavity of the joint and accompanied by ecchymoses. Permanent enlargement, and even ankylosis, may follow if the attacks are repeated. The mucous membrane of the nose and that of the gastro-intestinal tract are the most frequent seats, but in some the bleeding comes from almost every part. No si)ecial treatment is of any avail. Internal styptics have been used freely, and every kind of external one, without success. Not unfrequently the patient continues to lose blood until not a drop seems to be left, and then rapidly begins to recover ; but they rarely reach old age or even adult life. In the case of teeth, carefully applied pressure is the most successful ; a cork should be fitted into the holloAv, the cavity thoroughly packed, and then the teeth of the other jaw pressed tightly against it by means of a webbing strap around the head. In this way I have succeeded in checking it in several members of a well-known family. The actual cautery seems to be of no special use, and of course no measure that involves a wound should ever be attempted. [The editor has known one case of persistent hemorrhage that w^as due to long-continued use of sulphate of quinine.} DISEASES OF ARTERIES. Inflammation. Arteries, if subjected to long-continued irritation, become inflamed like other structures, the character of the inflammation depending upon the cause. It may commence in the intima (endarteritis), the media, or the sheath (peri -arteritis), and it may be acute or chronic, the exudation becoming absorbed, undergoing organization, degenerating, or being transformed into pus, according to the persistence and intensity of the irritant. I. Simple Traumatic Arteritis. The best example is that caused by a ligature ; the minute vessels in all the parts around dilate, lymph pours out, the amount depending very largely upon DISEASES OF ARTERIES. 223 the nature of the irritant ; some is absorbed, the rest becomes vascular and is organized into a cicatrix. If the ligature disappears without causing a sufficient degree of irritation, or if the tissues are so badly nourished that they are unable to carry out active repair, the cicatrix is very likely to be too weak and to yield to the strain that falls on it. Similar changes occur after wounds, bruises, ;uul the impaction of non- infective emboli. 2. Suppurative Arfcrifis. This may begin in the interior, from the presence of an infective embolus, or on the exterior, as peri-arteritis. In the latter case the organisms generally enter through a wound, but when, for example, there is a suppurating aneurysm, they must reach the part either through the blood-stream or the lymphatics ; the constant pressure and tension irritate the tissues and break down their power of resistance, and the pyogenic germs, which otherwise are innocuous, at once begin their work of destruction. In pysemic embolism, whether infarction occurs or not, the destruction is so rapid and so general that the changes in the wall of the artery cannot be distin- guished, the tissues melt at once into intensely infective pus. When, however, the suppuration begins in the outer coat, after ligature, for example, the course of events can be traced fairly well. The vasa vasorum dilate and become sheathed with leucocytes, the fibrous tissue melts away, the muscular bands split up, the endothelial cells perish and become detached, and at length, although the wall of an artery resists better than most structures, it is gradually eaten through or so weakened that it gives way. As a rule, before this occurs the- white corpuscles collect upon the inflamed wall and form a protecting thrombus. The subsequent course depends upon the intensity of the irritant on the one hand and the activity of nutrition upon the other. (rt;) If there is no additional cause at work, no tension, mechanical irritation, or absorption of septic products, the suppuration may cease, the tissues gaining the upper hand, and the wall of the artery remain intact, as, for example, usually occurs when a vessel is exposed upon the floor of a simple ulcer ; or the result may not be quite so good ; one part of the wall, for example, may be so weakened that it yields and forms an aneurysm, or the interior may be completely closed by a thrombus, or part of the artery may perish and slough, loss of blood being prevented by the sealing of the ends. {b) If, on the other hand, the vitality of the tissues is too much impaired for organization to be effectual (as in phagedtena), or if some other irritant appears upon the scene (especially septic decomposition), the germs prove themselves the stronger and the tissues give way. The wall of the vessel is softened, the clot disintegrates before it is organized, and secondary hemorrhage occurs. This accident may happen when a wound heals by the first intention, and even after it has healed, if the cicatrix is thin and weak and the structures around soft and yielding ; but it is much more common after suppuration, especially if the nutrition of the tissues is impaired, whether from pre-existing atheroma or from septic decomposition. A special form of embolic arteritis is met with in connection with ulcerative endocarditis. The vegetations detached from the valves sometimes cause suppu- ration, as in pyaemia ; but not unfrequently they merely give rise to a certain degree of softening and inflammation, by which the walls of the vessels are unduly weakened. In all probability a very large number of the aneurysms that occur in young children may be accounted for by this, the dilatation beginning opposite the embolus, not above it. 3. Syphilitic Arteritis. Arterial disease is of common occurrence, both in acquired and hereditary syphilis, especially in the brain. Probably the apparent frequency with which o 224 DISEASES AND INJURIES OF SPECIAI STRUCTURES. this organ is involved may be explained by the gravity of the symptoms that follow, by the fact that its vessels are easily examined, and by the anatomical peculiarities of their lymphatic sheath. Usually single vessels only are affected and often only small portions of them (Fig. 50). The exudation is similar to that ., which occurs elsewhere, with, however, a ,:--'i':--: ^^:^r:^^^'<.'-H^A-'- special tendency to fibroid transforma- tion ; it is doubtful if it ever calcifies. Sometimes it commences as a peri-arte- ritis, distinct gummata forming on the vessel and occluding it more or less by their pressure ; more frequently, how- ever, it involves the deeper layers of the intima, causing such an enormous degree of thickening that the interior of the vessel is almost closed. If the endothelial lining is involved as well, a thrombus forms over the affected part, and renders this complete. In the brain this may lead to white softening, from the blood- supply being cut off, or to aneurysm. In the most fortunate examples the exuda- tion is absorbed again more or less com- pletely, leaving, however, the vessel tortu- ous, inelastic, and weakened, so that it is always liable to give way. Similar changes are found in the vessels of gummata, and it has been sug- gested that the consequent diminution in the amount of blood they receive is the immediate cause of the degenerative changes they undergo as soon as they reach a certain size. »>. 1^ FlG. 50. — Syphilitic Disease of One of the Cerebral Arteries. The inner coat is thickened by fibrous tissue, and the lumen is much narrowed. (Bowlhy.) 4. Arteritis Obliterans. This name has been given to a peculiar form of inflammation, which some- times occurs in arteries during middle life. Nothing is known as to its pathology. It is exceedingly chronic in its course, beginning in the smaller vessels and steadily involving the larger ones, causing them first to become hard and thick, and then gradually closing them. It is often accompanied by very severe pain and usually ends in dry gangrene. When it occurs in younger subjects, especially in the arm, it is very liable to be confused with occlusion of the artery caused by deep-seated growths, especially cervical exostoses. 5. Gouty Arteritis. A few cases are recorded in which a moderately acute attack of periarteritis has occurred in gouty subjects past middle life, possibly, therefore — as syphilis, injury, and all ordinary causes could be eliminated — due to gout. It has been noted in the temporals with a certain degree of redness of skin and tenderness over their course, and in the brachial. Usually it ends in thrombosis and oblitera- tion, the ultimate consequences, of course, varying with the collateral circulation. Tubercular infiltration of the perivascular sheath of the cerebral arteries is of common occurrence, and certain facts render it probable that occasionally tuber- cular masses rupture into arteries and cause embolism (especially in connection with the bones), but no definite tubercular arteritis has yet been described. 6. Chrouic Arteritis or Atheroina. Chronic inflammation, with its consequence, atheroma, is very common in late adult life, although probably its beginning is laid at a much earlier period. DISEASES OF ARTERIES. 225 The larger vessels are chiefly affected, and those ])arts upon which the strain is greatest, the arch of the aorta for example, the origin of branches, the spot where the external iliac becomes the femoral, and generally the convexities of all the curves ; but the arteries of the brain, especially those at the base, those of the lower limbs, and, in the abdomen, the splenic, suffer almost as often. It can be traced to the effect of strains, sudden or long continued. It is more frecpient in men than women, it affects those esi)ecially who have to under- take sudclenly great ])hysical exertion, and it involves those parts of the vascular system which are the first to feel such effects. The pulmonary artery, for example, is always exemjjt unless there is some obstruction to the flow of blood through the lungs, causing hypertrophy of the right ventricle ; then it suffers equally. Alcohol helps to ])roduce it, and so do ])lethora and gout, for much the same reason, but it is doubtful if syphilis has more than an accidental connection. Bright's disease and arterio-capillary fibrosis are especially likely to be followed by it. Its first appearance is as a gray semi-translucent sjjot, slightly raised above the surface ; this grows larger and larger, coalesces with others like it, becomes more yellow in color, and at length forms a distinct elevation, elongated or circu- lar in shape, according to the part of the artery in which it is situated. It is caused by an inflammatory exudation into the subendothelial cellular layer, imme- diately under the lining of the vessel. Probably it begins here, partly because the texture is somewhat looser than elsewhere, partly because it is the first to feel the strain. The middle coat -is but little affected until the musadar fibres begin to waste, then it yields, loses its elasticity, and becomes rigid. The outer, on the other hand, is usually involved nearly as much as the inner. In some instances the exudation may disappear again, leaving the wall intact, but of this naturally there is no evidence. As a rule it either becomes fibrous, forming firm, slightly raised, yellow patches, still covered with endothelium ; or undergoes degeneration, either fatty or calcareous, or both together. Not unfre- quently the outer portion becomes organized, while the inner decays. The reason of the difference is probably to be found in the condition of the blood-supply. The vasa vasorum ramify in the outer and middle coats, but do not supply the sub-endothelial layer ; this is nourished chiefly or entirely by diffu: sion through the endothelium. When inflammation sets in, and the lymph- corpuscles increase in number, so simple a process as this is insufficient, and degeneration begins before new vessels can develop. On the other hand, in the outer layers, where the blood-supply is much more abundant, organization is the rule. Fatty degeneration is marked by a change in color and consistence. The patch becomes more yellow, it grows softer and softer, so that in extreme cases it is almost fluid, and then suddenly the endothelium gives way, and the contents — fatty molecules, cholesterin, and crystals of stearin — are discharged into the vessel. Fortunately they do no harm, beyond blocking up perhaps some minute branch ; but an atlieromatous ulcer is left, an excavated, ragged spot, often of considerable size, with the endothelium gone, the tunica media softened and weakened, and the integrity of the vessel only maintained by the thickened, inelastic outer coat, which is fused with the structures round. Calcareous degeneration is usually secondary to this, the fluid part disappear- ing, and the caseous debris left becoming infiltrated with lime-salts until it forms an irregular plate, lying in the wall of the vessel, exposed more or less to the blood-stream, and not unfrequently projecting into it at some point. The appearances produced by these changes are naturally very variable. The artery may be dilated along its whole course, or here and there ; not unfrequently it is elongated and tortuous, while the walls are rigid and inelastic, thickened in places and tied down by adhesions to the sheath, dangerously thinned perhaps in others. The inner surface is still worse ; in some parts there are firm, raised nodules of a grayish color, still smooth ; in others the endothelium has given way, leaving a ragged excavation with fringed and overhanging edges, lined with 2 26 DISEASES AND INJURIES OF SPECIAL STRUCTURES. caseous debris or calcareous plates, and in others again the irregularities are con- cealed beneath adherent thrombi. Rupture sometimes occurs in the arteries of the brain in which the adventitia is poorly developed ; elsewhere it is unusual, as the outer coat becomes thick enough to resist. The loss of elasticity and the destruction of the surface are soon followed by worse results. The walls stretch and yield, the vessels are thrown into curves and loops, so that what is known as a locomotive pulse is produced ; the parts beyond are ill-nourished and ill-supplied with blood, and as enlargement, of the collateral circulation is impossible, the least difficulty is liable to be followed by gangrene. It is by far the most common cause of aneurysm, sacculated as well as dissecting. If, as usually happens, one part of the wall becomes weak and soft from inflamma- tion, without an extensive degree of atheroma, the sacculated form is produced. If, on the other hand, degeneration occurs at an early period, so that the lining membrane ruptures before the coats are welded together, the dissecting one fol- lows, and the blood works its way down, between the layers of the wall, until it either bursts into the vessel again, or breaks the outer coat and pours into the tis- sues round. Thrombosis is even more common, the blood coagulating upon the irregular projections, and perhaps completely occluding the vessel. Embolism may occur, or the orifices of the small branches (the coronary arteries, for instance) may be closed by the contraction of the fibrous tissue round them ; or ruyjture may take place, or, in short, almost any of the troubles that can happen in con- nection with the blood-vessels or the blood supply. The importance of atheroma in the production of secondary hemorrhage cannot be over-estimated. Clearly, if the walls of the vessels are badly nourished and inflamed already, immediate repair after injury is hardly probable. Fortu- nately, the change is often local, and if, for example, the popliteal is diseased, the femoral in Hunter's canal may be sound. De(;eneration of Arteries. The coats of arteries are liable to degenerate and decay as age advances without any preceding inflammation, although naturally the tAvo are often asso- ciated, and the same thing is met with in younger people as a result of marasmus, anaemia, and exhausting illness. Fatty Degeneration. Fatty degeneration of the intima is not unusual in the aorta ; apparently it begins in the stellate sub-endothelial cells of the intima, and forms opaque yellow, sharply outlined patches, which may be distinguished from atheroma by the fact that they are superficial and scarcely raised. The deeper parts are quite healthy. It has no clinical, importance. When, on the other hand, it involves the media, especially in the case of the brain, the wall is so weakened that there is imminent danger of rupture. Calcareous Degeneration. This is especially liable to occur in the cerebral arteries and in the tibials of old people. It involves the middle coat chiefly, and appears to be a primary calcareous degeneration of the unstriped muscle-cells. They gradually disappear and are replaced by calcified rings, which fit so closely together and are so nu- merous that the arcery becomes converted into a calcified tube. Ultimately the intima is affected too, but this does not occur so early or so extensively as in atheroma ; the adventitia sometimes becomes hypertrophied so as to form a protecting sheath ; sometimes, on the other hand, it wastes away and nothing but these calcified rings is left. The effect upon the circulation is, of course, exceed- ingly grave ; the loss of elasticity impedes the flow of l)lood and prevents any DISEASES OF VEINS. 227 variation in the supply, the roughness of the surface increases the friction, the diameter is diminished by the increased thickness, there is always imminent dan- ger of thrombosis and embolism, and the establishment of a collateral circulation is usually impossible. As might be exjjected, it is the most important factor in the causation of senile gangrene, especially the dry form. In addition to these changes, the arteries of old ])eople are often immensely elongated and tortuous without there being any evidence of atheroma, fatty degen- eration, or, as it is often met with in those who are ninety years of age and over, of renal di-sease. In all probal)ility this condition is due to the gradually failing power of the muscular walls of the vessel, and to the loss of support from the struc- tures round ; for it is most marked in those whose limbs are greatly wasted. Usu- ally it is associated with a certain degree of fibrous thickening, so that the vessel is unusually distinct to the touch, but probably this is to be regarded as a com- pensative hypertrophy ; it is not the result of inflammation or of iniduly high vas- cular tension. DISEASES OF VEINS. Varicose Veins. Veins are described as varicose when they are hal)itually distended and dilated beyond their normal size. This is most common in the lower limb and in con- nection with the spermatic and hemorrhoidal plexuses (varicocele and hemor- rhoids), but it may occur in any part of the body. Causes. — Varicose veins are caused either by an increase in the blood-pres- sure or by a diminished power of resistance in the walls, or by both together. Increased blood-pressure by itself may give rise to the most extreme degree of varicosity, as seen in cases in which the inferior vena cava has been obstructed, and the front and sides of the abdomen are covered with tortuous masses of dilated veins, studded with pouches in all directions. More frequently, however, although it helps, as in pregnancy, heart disease, etc., it is only one of the exciting causes, and perhaps not the most important. Diminished power of resistance is pro- duced in various ways. Occasionally a vein becomes (and remains) varicose after some strain. In other instances the wall is weak- ened by inflammation, or suddenly loses 10. ^i.— some support to which it has been accustomed. Sometimes, as varicose veins are distinctly hereditary, there may be a congenital defect of structure, but probably in the great majority of instances the deficiency is really due to the feeble develop- ment of the muscular coat and to its being easily tired out. Varicose veins are especially common in those in whom the circulation is weak and the vascular tone defective. Long-standing obstruction, or any other cause that entails upon the muscular coat an unusual degree of strain for an unusual length of time, leads either to hypertrophy (as in a simple case of obstruction of the vena cava) ; or, if the nutrition is feeble, to dilatation with thinning in some parts, and fibrous thickening (so that the walls become firm and inelastic) in others. Varicose veins are rarely met with in children ; after puberty they become more common up to middle life, and then again the tendency diminishes. In spite of the effects of pregnancy, men are said to be more liable to them than women, and those especially whose occupations entail long standing or very great and sudden muscular exertion. The internal saphena vein suffers with exceptional frequency, from its length, the effects of gravity, the small amount of support it receives, as it lies outside the deep fascia, and the amount of blood discharged into it from the deep muscular and intermuscular veins. The narrowing of the saphenous opening is probably 2 28 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of no importance. Sometimes the whole length is involved, more often only parts of it here and there, the intermediate portions being altogether normal ; or the main trunk may be intact and the branches varicose, or only the minute tribu- taries, the venules in the skin, dilated. The deep veins of the leg (but not those of the thigh) are often affected to a greater extent than the superficial ones, and the disease may commence in them ; very often it shows itself first where the two sets of branches communicate with each other. The external saphena suffers almost as often, and not unfrequently the whole of the foot or ankle is covered with a network of tortuous dilated vessels, running apparently indiscriminately. In other parts of the body (except in connection with the testes, labia, and rectum) varicose veins are rarely seen unless there is obstruction of one of the great trunks. Varicose veins are not only dilated, but lengthened and thrown into loops and curves. In some places the walls are immensely thickened by the fresh develop- ment of fibrous tissue, so that when the vessels are cut across they remain gaping widely open with little or no tendency to contract. In other parts they are thinned and stretched, and so twisted up together that they form an ill-defined spongy swelling resembling cavernous tissue. The valves have often disappeared altogether or are reduced to shreds, which have no power of preventing regurgitation or sup- porting the column of blood. The skin is sometimes thickened, but more fre- quently it grows thinner and thinner, until the vein almost protrudes through it, and even the bones beneath may be grooved and cut into deep channels by the persistent pressure. Symptoms. — Varico.se veins, so long as the circulation and nutrition are good, give rise to very little inconvenience, merely a sense of aching or of weight after exercise. Occasionally, possibly because a nerve is pressed upon, there is more acute pain, and it is believed that deep-seated muscular varices are some- times the cause of painful cramps. The diagnosis rarely presents any difficulty, the color, shape, distribution, and the difference in tension according to position are sufficiently characteristic. There may be a distinct impulse in coughing, especially when the upper part of the internal saphena is dilated, and it is said that this condition may simulate femoral hernia. If, however, from any cause — age, ill-health, over-exertion, fatigue, etc. — the circulation begins to flag, the dilatation, the enormous weight of the column of blood, greatly increased in diameter and unbroken by valves, and the loss of vas- cular tone, soon produce, or help to produce, much more serious effects. Chronic congestion, with cjedema and more or less thickening and hypertroi)hy of the con- nective tissue of the part, is the first thing to happen. The red blood-corpuscles escape through the walls and cause deep pigmentation. The general nutrition of the tissues fails, chronic ulcers form, trivial injuries are not repaired, but leave behind them persisting sores ; the skin becomes irritated and eczematous, and at last — not so much because of the varicose veins themselves as because of the general failure of the circulation of which they are but one of the signs — the whole limb becomes more or less affected. Thrombosis is an exceedingly common complication, the blood coagulating in one of the outlying parts ; sometimes the clot is absorbed, more frequently it becomes organized or undergoes degeneration. Phleboliths produced in this way can nearly always be found in the prostatic plexus. Occasionally the skin over the vein gives way, and very serious hemorrhage results. Treatment. — i. Palliative. — All obstructions must be removed as far as possible. Tight garters are exceedingly injurious. In pregnancy the patient must rest as much as possible, or as is consi-stent with health, and wear a bandage or a stocking both during and for some time afterward. The bowels must be kept well open, and long standing and excessive walking avoided, although a reason- able amount of exercise, stopping short of fatigue, is decidedly beneficial. If the varix has made its appearance suddenly after exertion, the walls of the vein must be carefully protected from strain for some considerable time. The limb DISEASES OF VEINS. 229 should be kept at rest, in the horizontal position, for two or three weeks, according to the size of the vein, and then carefully supported. In the majority of cases all that can be done is to caution the patient against the evil effects of standing, etc. ; maintain the general health l)y means of tonics, combined with good food, Iresh air, and a fair amount of e.xercise, and sujjply some kind of sup])ort. Silk anklets, elastic stockings, and the appliances generally in use serve the i)uri)ose for which they are intencled very ill ; they produce the maximum of constriction when first applied, and then each week relax more and more until replaced ; they are usually much too tight, and generally cause con.sider- able wasting of the muscles. If worn once the limb becomes so used to their pressure that the patient can hardly be induced to leave them off. Bandages of thin flannel, domet, or perforated rubber are much better, as they can be put on with just sufficient pressure and no more, instead of an iron rule being followed in all cases alike. Upward friction and massage should be practiced every night when the ap- pliance is removed. If bleeding threatens, the part should be well bandaged and kept at rest ; if it breaks out (the usual situation is the lower third of the leg) the limb must be raised at once. The hemorrhage is exceedingly profuse, but it comes from the proximal or cardiac end, and raising the limb stops it instantaneously. If inflammation sets in and the veins become hard and painful, showing that they are filled with clots, the patient should be confined to bed, the limb placed in a slant- ing position on a leg rest, and' covered with lead lotion. 2. Radical. — In a certain number of cases the radical cure may be tried. As a rule, it is only advisable where the superficial veins are concerned, and where the part involved is limited in extent. Sometimes, however, it is beneficial in cases of varicose ulcer, in which the persistence of the sore appears to be depen- dent upon the vein. I have known an ulcer heal while the patient was in bed recovering from the operation, and remain sound for fifteen years afterward, although previously it was always relapsing. The choice lies between acupressure (with or without subcutaneous division), ligature, and excision. (a) Acupressure. — This is performed by passing a flat needle beneath the vein, while it is pinched up with the finger and thumb, and then twasting a figure-of- eight suture over the ends, protecting the skin beneath by means of a piece of bougie or quill. The needles should be about three-quarters of an inch apart, and the vein may be divided subcutaneously with a tenotomy-knife between them. They should not be left in for more than a week, and if any inflammation occurs this time should be shortened. Failure is not infrequent and there is always the risk of transfixing the vein. (/i) Ligature. — A small incision is made over the vessel, an aneurysm-needle passed round it and threaded with catgut. The ligature left when the needle is withdrawn is tied and the ends cut short. This method may be combined with the former, ligatures being placed in the intervals between the pins. ((t) Excision. — This is by far the most effective method, but it is only suited to a very limited number of cases. The skin is reflected from off the vein, the incision being as far as possible longitudinal ; the vessel is carefully isolated from the surrounding tissue, a double ligature (catgut) is placed round it at each end and round each branch, and the whole intervening portion excised. Where any great length of vein is involved this is, of course, impossible, but the comparatively isolated bunches of veins that are frequently met with on the inner side of the lower third of the thigh and leg can often be treated very satisfactorily. Thrombosis. A thrombus is a clot that develops inside the heart or one of the vessels dur- ing life. It is distinguished from a post-mortem coagulum by the fact that it is drier, harder, less elastic, and distinctly adherent to the interior. 2 30 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Red thrombi are formed in stagnant blood, white ones in that which is still circulating. The former are uniform all through, the latter are built up in strata, some of which are more colored than others. \'ery often the two occur side by side, a white one forming first and gradually blocking up the pas.sage until suddenly coagulation becomes complete. Causes. — Thrombosis is due either to some alteration in the wall of the vessel, to .some change in the blood, or to both causes together. It occurs chiefly in those parts in which the circulation is most feeble, beginning, for example, in the dilatations of varicose veins, or behind valves ; where, on the other hand, the stream is rapid and forcible, as in the central part of an aneurysm, it may be delayed for a great length of time. {a) The least change in the condition of the lining membrane is sufficient, whether due to injury, inflammation, or degeneration. The blood-plates are de- posited at once upon any surface that is not perfectly healthy, and then the fibrin begins to collect. Foreign bodies introduced into the blood-stream naturally cause this at once. Stagnation very probably acts in the same way. In typhoid, ad- vanced phthisis, and other exhausting diseases it is not uncommon for clots to form quietly, without any injury or inflammation, in the veins of the lower ex- tremities. These apparently commence behind the valves, in the layer of blood that under such conditions remains stagnant there, the endothelium of the lining membrane losing its vitality for want of a fresh supply, and causing the blood in contact with it to coagulate. Very possibly, hoAvever, in these conditions the composition of the blood is altered too. {b") It is an undoubted fact that certain conditions of the blood greatly favor coagulation, and also that certain substances introduced into the blood (includ- ing the fluids squeezed from some of the organs of the body) cause general intra- vascular clotting, but the extent to which this takes place in disease is quite unknown. In various forms of septic poisoning distant thrombosis is not uncom- mon, possibly owing to the destruction of blood-plates or colorless corpuscles, especially as there is usually at the same time failure in the force and vigor of the circulation ; but the subject requires further investigation. Thrombosis in arteries is rare except as a result of injury, inflammation, or atheroma ; in veins, on the other hand, it is exceedingly common, occurring both as a primary affection and secondary to injury or phlebitis ; in capillaries it can only occur when the wall of the vessel is gravely injured or actually killed. The changes that thrombi undergo vary according to their locality and cause. Venous thrombi occasionally continue to spread toward the heart, until at length they meet with a vessel in which the current is too rapid. In this way continuous clots of immense length may be formed, spreading through veins of larger and larger size, until at last the rounded end projects through a side open- ing into the cavity of one of the largest. Here it may stop and do no further harm, or it may be broken off and form an embolus, or, if the current fails in strength from any cause, it may reach the heart itself. This is especially likely to occur when they originate from poisoned wounds. 1. Resolution is not uncommon. Large masses of coagulated blood may melt away and disappear within twenty-four hours, as is seen not unfrequently in the rapid cure of aneurysm by means of E.smarch's bandage. If they last over this they are usually permanent. What becomes of the clot, how it vanishes, is not known ; of course, the channel is completely restored. 2. Organization. — This takes place in the same way as in an artery: lymph pours out from all the minute vessels around, and gradually replaces the clot. Whether the endothelial cells or the white corpuscles in the circulating blood help or not is uncertain. Then fresh vessels form ; fibroblasts develop along their course, and gradually the clot and the walls of the vein are welded together into a mass of fibrous tissue. In many cases the cavity is obliterated ; sometimes, however, capillaries communicating with the lumen of the vessel above and below enlarge and form a direct connection again ; or the clot shrinks to one side and DISEASES OF VEINS. 231 leaves part of the channel free. At any rate, it is not unusual to find, after some long period, that a blocked vein becomes pervious again, a few strands of fil)rous tissue being left across the interior or clinging to one side of it, showing the fate of the obstruction. In the case of aneurysms, in which there is often an enormous thickness of laminated clot, organization is a very slow proceeding, accompanied by shrinking and fatty degeneration. 3. Degeneration. — Large thrombi in the interior of a vein gradually become softer and softer in the centre, turning from red to yellow, and yellow to white, until they are filled with a fluid at first sight not unlike pus, but in reality con- sisting merely of ca.seating debris. The outer walls in contact with the still circu- lating blood usually form a firm casing ; occasionally they break down, and then the liquid contents are poured into the blood-stream, causing minute embolisms, and the thrombus is said to be canalized. Sometimes, especially in the case of the small thrombi forming behind the valves in veins and in the prostatic plexus, calcareous degeneration occurs instead, and what are known as phleboliths are formed — small rounded and often i^edunculated masses, enclosed in a fibrous sheath, and consisting mainly of phosphate of lime, with small quantities of sulphate of lime and of potash. 4. Infective softening. — If the micrococci of suppuration gain access to the clot, either through a local wound, through the wall of the ves.sel, or through the circulating blood, it becomes .soft and breaks down into a fluid apparently of the same character, but in reality altogether different. Each fragment of the blood that enters into the current carries with it the germs of suppuration ; wherever it becomes impacted, it cuts off the blood-supply, lowers the vitality of the tissues and renders them incapable of resisting the assault of the organisms it has brought with it : in other words, each embolus becomes the starting-point of a pysemic abscess. Consequences.— I . Inflammation. — Every thrombus causes a certain degree of inflammation of the wall, so that if the vessel is superficial, the skin over it becomes red and tender and the soft cellular tissue around infiltrated with lymph. If the cause is not an infective one, this ends in organization and repair, clearing up as the thrombus does ; if, on the other hand, it is infective, suppurative arteritis or phlebitis follo^vs, as the case may be. 2. Obstructiofi. — This differs very much according to the size and importance of the vessel. In the case of an artery the pulse ceases at once and the limb below becomes pale, numbed, and powerless ; even gangrene may set in (the dry form) if the collateral circulation is not good. When a comparatively small vein is involved, there is little or no difficulty to the return of blood, owing to the free anastomosis in most parts of the body ; but when it is an important one, such as the ilio-femoral, and any length of it is obstructed, the consequences may be very serious. This is of common occurrence after parturition (phlegmasia alba dolens) [and sometimes after fractures of the leg] ; the limb becomes tense, white, and painful, the vein can be felt as a hard, knotted cord, and the weight is so great that the patient can hardly move the part. Sometimes this clears up within a very short time, the clot apparently melting away. More frequently recovery is only partial ; the thrombus becomes organized, and either shrinks to the wall of the vessel, or is perforated by small anastomotic veinlets, so that the channel is opened up again more or less completely. Occasionally it persists without yielding at all, and then, especially if the lymphatics are involved as well, a condition of what is known as solid oedema sets in, often ending in what is practically elephantiasis. The skin and the cellular tissue become enormously and irregularly thickened by the growth of fibrous tissue, the natural texture of the part is lost, and the weight ma}- be so great that the patient is almost unable to lift it. In cases in which the anastomotic circulation is more free, as when the interior vena cava is obstructed by a thrombus, the collateral veins become hypertrophied, so that the skin over the front and sides of the abdomen is covered with great, tortuous masses. At first, perhaps, this compensates, but 232 DISEASES AND INJURIES OE SPECIAL STRUCTURES. when the obstructed vein is as important as the one mentioned, it rarely suffices for long, dilatation soon begins, the limbs become cedematous and swollen, the nutrition fails, and chronic ulcers appear. Finally, if spreading thrombosis occurs over a large area and involves the orifices of collateral branches, moist gangrene is very likely to ensue. 3. Embolism has been already mentioned as one of the remote consequences of thrombosis. It nearly always originates from venous thrombi and affects first the pulmonary circulation, but it may originate in the portal system. The conse- quences depend upon the size and the nature of the embolus. Embolism. Embolism is the impaction in some part of the blood-stream of a substance which from its size or nature cannot be driven further ; the substance itself is an embolus. Emboli are derived from many different sources. A fragment of a thrombus is one of the most common. An end may be bodily torn off, especially if it projects through a side opening into the cavity of a larger vein ; or the whole clot may undergo decay and disintegration, so that a mass of soft debris is dis- charged into the circulation at once. Vegetations are occasionally swept off from the cardiac valves, or calcareous or caseous fragments from an atheromatous ulcer. Malignant growths (especially carcinomata) sometimes perforate the walls of veins and sprout into the interior. Abscesses, whether due to pyogenic or tubercular organisms, may do the same, the coats of the vessel gradually softening until the endothelium ruptures without any protecting thrombus having been formed. Liquid fat is often forced in the blood-stream in cases of fracture, and in exceptional instances many other substances, even parasites, find their way in. Embolism may occur either in the systemic or the pulmonary arteries, or in the portal vein, the embolus originating, as a rule, in the venous system or the heart, and, of course, following the direction of the circulation. Wherever it originates, it is swept. along until it meets with some vessel too small for it to pass through. Usually this corresponds to the point of bifurcation. Then, if it is liquid, it splits up into finer ones ; if soft and yielding, like a recent clot, it moulds itself to the interior ; and if hard and rigid it becomes fixed and completes the obstruction by causing coagulation around. The immediate result is to stop the current through that branch. How this affects the area it supplies depends upon the size and nature of the embolus and the perfection of the collateral circulation. Instant death may, of course, ensue if one of the large branches of the pulmonary artery is blocked, or the middle cerebral. In other cases, however, every attempt is made to keep up the full supply of blood through the collateral branches. a. If these are fairly abundant and healthy, so that dilatation is possible, no ill result ensues ; there is a temporary blanching of the part, the pulse fails below and it feels cold and numb, but this soon passes off and is followed by transient hypereemia, in which all the vessels share. Later this general enlargement of the collateral supply gradually narrows itself down to one or two of the shortest and straightest routes, and everything is restored to its natural condition. /;. If, on the other hand, either dilatation is impossible, or — as, for example, in the case of the retina — there is no collateral circulation, the part gradually becomes starved out and dies. If it is in the interior of the body it undergoes fatty degeneration ; if it is on one of the extremities, dry gangrene. r. In certain organs (the lungs and kidneys in particular) what is known as infarction occurs. The collateral circulation is not sufficiently good to maintain the full blood-jjressure, but yet is developed to a certain extent ; the blood pours into the anaemic area(t'. ^. , from the capsular vessels in the kidney) with sufficient strength to fill the capillaries, but not sufficient to maintain its course. As a DISEASES OF VEINS. 233 result all the minute vessels become engorged, stasis sets in, the walls of the capil- laries perish, the red blood-cori)uscles i)ass through and fill all the interstices, and practically, at length, the whole area is absolutely solid with blood, forming what is known as a hemorrhagic infarct. In the lungs this is seen in its most charac- teristic form, a conical mass of tissue, black and hard ; the base of the cone abutting in the pleura, the apex corresponding to the embolus, and the size depending upon that of the blocked vessel. In the case of an ordinary non- infective embolus this slowly undergoes fatty degeneration, a zone of hyperaemia forming round it, and the lymph-corpuscles invading it from the exterior, and quietly absorbing it until nothing but a depressed cicatrix is left. The effect of an embolus, however, depends not only upon its size and the arrangement of the blood-vessels, but upon its nature. So long as it is absolutely imirritating (the fragment, for example, of a simple thrombus), the inflammation it excites is merely sufficient to cause organization of the clot that forms round it and seal it to the side. In ulcerative endocarditis, however, the vegetations that are detached from the valves are often so irritating that the walls of the arteries in which they are impacted become soft and yield before the blood-pressure, so that an aneurysm is formed. And in suppurative phlebitis, when pyogenic micro-organisms have gained access to the interior of the clot, and have caused it to break down into a puriform infective fluid, the consequences are more serious still. Wherever the debris is carried, it brings with it infective germs, which find in the engorged and lifeless mass of tissue the soil that suits them best ; as a result, the whole affected area melts away at once into the most intensely infective pus, and a true pya^mic abscess is developed. Inflammation of Veins. Inflammation of veins may begin either in the tissues round (periphlebitis) or in the interior from the endothelial surface. It is nearly always acute ; the chronic form, corresponding to the atheromatous degeneration of arteries, is seldom met with except in the thick-walled dilatations of varicose veins, and, owing to the difference in the blood-pressure, does not possess the same degree of significance. I. Simple Acute Phlebitis. This is due either to injury (ligature, contusion, etc.), the presence of a throm- bus, or to some morbid condition of the blood, of which gout, rheumatism, and syphilis are the best known. If a thrombus is not already present, one is formed as soon as the inflammation begins to affect the endothelial lining. The changes that take place are those already described in thrombosis ; the wall of the vein becomes thickened, softened, and more vascular, a greater amount of lymph is poured out, the endothelium changes in appearance, though whether it takes an active share in the production of the exudation is not known, and the thrombus itself, the coats of the vein, and the tissues around it are infiltrated with masses of lymph-corpuscles. The effect is the same whether the thrombus is primary and the cause of the inflammation, or whether it is secondary, the attack beginning from the outside as periphlebitis. As soon as the irritation subsides the lymph is in part absorbed and in part converted into fibrous tissue. The thrombus, as already described, may either be absorbed, undergo organization, or decay in the centre and ultimately be canalized. Sometimes the cavity of the vein is restored completely, more frequently it is obliterated for a time, and then subsequently, as the clot is organized or canalized, regains its normal shape and size to a greater or less extent. Symptoms. — When the vein is superficial it can be felt as a hard, knotted cord, standing out under the skin and surrounded by inflamed cellular tissue. It is exceedingly tender to the touch, but, unless the periphlebitis is very acute, and the vein quite under the surface (as in the case of a varicose internal saphena) the skin is seldom much reddened. There is often a very considerable degree of pain and stiffness, especially on movement, or when the limb is allowed to hang down ; 16 234 niSEASES AND INJURIES OF SPECIAL STRUCTURES. and sometimes there is very considerable constitutional disturbance. In the case of the deeper veins the diagnosis chiefly rests upon the deep-seated hardness and tenderness, the peculiarly clumsy appearance of the part, the sense of weight and pain when the limb is allowed to hang down, the relief as soon as it is raised, and the evident distention of the more superficial vessels. (Generally a certain amount of superficial cedema can be detected on the distal side of the obstruction, round the malleoli, for example, in cases of phlebitis of the deep veins of the leg. Gouty, rheumatic, and syphilitic phlebitis can only be distinguished by the other symptoms that accompany these disorders ; they have no certain distinctive character of their own, although the gouty variety is occasionally metastatic. They all have a decided tendency to symmetry, they affect the superficial veins rather than the deep ones, and the lower limbs much more frequently than the upper. Recurrence is exceedingly common in the gouty variety, and may continue in the syphilitic form all through the secondary period, but it is seldom that permanent obliteration is caused by either. Treatment. — Rest is absolutely essential until at least all trace of inflamma- tion and tenderness has disappeared. Serious extension of the thrombus and detachment of outlying fragments, causing embolism, are rare accidents, consid- ering the very large number of cases of phlebitis of varicose veins of the leg, but they do happen occasionally, and every precaution must be taken to avoid them. Elevation is no less essential for the sake of the return circulation and to relieve tension. Cold lead lotion, as a rule, causes the inflammation to subside within a few days ; but in cases of gout, and where the arteries are atheromatous, belladonna (equal parts of the extract and glycerine) and warmth should be used instead. The bowels should be kept well open ; the diet should be light, without stimulants, and if there is any evidence of gout, rheumatism, or syphilis, appro- priate remedies should be employed. Afterward, when all the inflammation has subsided, the patient may be allowed to get about with a support, and if the leg is much wasted, or has a tendency to remain cold and oedematous, massage may be used to improve the circulation. 2. Suppurative Phlebitis. This, too, may originate either as a periphlebitis or in the interior. Examples of the former are often seen in diffuse inflammation of the cellular tissue ; the pyogenic organisms rapidly destroy the coats of the veins, spreading along the loose cellular tissue round them, and causing them to slough or melt away into the purulent fluid that fills up every interstice. As the endothelium is approached coagulation takes place, and although the thrombus shares the fate of all the rest of the structures, fortunately, in the vast majority of cases, it extends sufficiently far and sufficiently rapid to act as a barrier and prevent the poison spreading far and wide in the circulation. If it fails, or if it is broken down, general pyeemia is almost certain. This is of common occurrence in acute suppurative osteomye- litis, and in otitis media, infective inflammation with thrombosis, spreading along the coats of the veins into larger and larger trunks, until at length the puriform clot that fills the vessel gives way and is scattered all over the body, causing metastatic abscesses wherever it comes. Acute spreading phlebitis of the same character, and ending in embolic pyaemia in the same way, may begin in the interior of a vein as well as round it. This, of course, unless pyaemia has already developed, can only take place after the cavity of the vein has been opened. Usually, under these circumstances, the vessel either collapses at once or a coagulum forms and extends up to the next set of valves or the next large branch. If, however, septic decomposition sets in before organization has taken place, and lends its aid to the micrococci of suppu- ration, the clot melts away at once into an infective puriform fluid, and there is every chance of a widespread distribution of infective emboli all over the body, even before the rest of the tissues succumb or the diffuse cellulitis assumes alarm- ing proportions. ANEURYSM. 235 SECTION 111— ANEURYSM. An aneurysm is a circumscribed tumor developed in connection with the interior of an artery, and containing either fluid or coagulated blood. Aneurysms have been classified in various ways : by their cause (traumatic and idiopathic, or spontaneous) ; by their shape (fusiform, sacculated, and dissecting), and by the share the wall of the vessel takes in their construction (true and false). Some of these distinctions are very important. All aneurysms are in a certain sense of the term traumatic, due either to one single sudden strain or to the continued effect of slighter ones ; but the term traumatic aneurysm is reserved for those cases in which a perfectly healthy artery has been injured in some accident, and either the wall, or the cicatrix, or the coagulum that closed the wound, has expanded into a sac. There is a very great difference in the matter of prognosis and treatment between this variety and the so-called idiopathic or spontaneous on^, in great measure, if not entirely, the result of disease. The terms j-ar^z/Az/^^/ and ///x//(?r;« almost explain themselves; the former is applied to those cases in which a pouch is developed from one side of an artery ; the latter to those in which the whole circumference of the artery is stretched more or less. As, for example, in aneurysms of the arch of the aorta, no distinct line can be drawn between the two, or between the latter and what is known as aneurysmal dilatation. Dissecting aneurysm, on the other hand, is a very distinct variety ; it can only occur in the larger arteries, and results from an early rupture of an athero- matous abscess in the wall. If this occurs before the coats are welded together by inflammatory exudation, the blood may make its way down between the lavers of the wall for long distances, and ultimately break either into the interior again or outside. In the former case it may give rise, for a short distance, to the appear- ance of a double aorta. Aneurysms used to be described as true, when all the coats of the artery were to be traced in the wall, or, according to others, when one of them could be. This, of course, is only possible when the aneurysm is fusiform in shape or exceedingly small in size, and the distinction is not worth maintaining. An aneurysm sometimes ruptures, suddenly or gradually, producing the same effect as if the artery had given way — an arterial haematoma. A diffuse aneurysm is a contradiction. Idiopathic or Spontaneous Aneurysm. Idiopathic aneurysm is due to the yielding of a weakened part of a vessel under the influence of the blood-pressure. Causes. — (a) All forms of inflammation predispose to aneurysm by the way in which they weaken the wall of the vessel. Atheroma is the most common, especially in its earlier stages, when the muscular coat is infiltrated with lymph and weakened, without as yet any considerable degree of degeneration. If at a later period the floor of one of the ulcers yields and gives way, the adventitia is usually sufficiently thickened by that time to render it secure. Dissecting aneurysm must, of course, be due to atheroma. Embolism is not infrequent, especially in young subjects, not because of the obstniction it causes (for then aneurysm would frequently follow ligature), but owing to the softening and inflammation of the vessel at the injured spot. In other cases it is a form oi peri-arteritis. either syphilitic, as in the vessels at the base of the brain, or suppurative, when, for example, small aneurysms form on branches of the pulmonary artery in the wall of phthisical cavities. 236 DISEASES AND INJURIES OF SPECIAI STRUCTURES. {p) Injury acts both as a predisposing and an exciting cause. Its effects are best seen in the case of the popliteal, the inner and middle coats of which, even when it is healthy, maybe ruptured by over-extension of the knee. Probably one reason why aneurysms are so common in this artery is that even when this does not take place, the walls are ea.sily injured in the constant and violent flexion and extension to which they are subjected. In a few instances an aneurvsm has developed in an artery that has been subjected to long-continued compression. {/) The immediate cause is the blood-pressure. If the coats of an artery are weakened by injury or inflammation, they gradually yield before it, especially if it is raised by hypertrophy of the left ventricle. Bright' s disease, chronic alcoholism; plethora, or other causes. In many instances the first commencement of an aneurysm is traced to some sudden exertion, which either, as in the popliteal, directly ruptures one or more of the coats of the vessel by over-extension, or pro- duces practically the same result by the immense increase in the blood pressure that attends sudden and violent muscular efforts. This serves to explain why aneurysms are so much more common in men than in women (with the exception of those of the carotid, which are equally frequent in both), and particularly among those who are exposed to sudden strains. Further, it gives a satisfactory reason for the extreme frequency with which the popliteal artery and the arch of the aorta suffer in comparison with others. Aneurysms are most common between thirty and fifty years of age, when the arteries are diseased, and the heart and the muscular system have not lost their vigor. Soldiers and sailors are especially liable to them, partly from their occupa- tion, partly, perhaps, because of syphilis, although the share that this takes in the development of aneurysm is probably not a large one. [The influence of climate is a constant but as yet imperfectly understood factor in the production of aneurysm.] Mode of Formation. — Fusiform and dissecting aneurysms are only met with in connection with the largest arteries. The former are caused by a uniform expansion of all the coats, so that the cavity of the vessel is increased in diameter and somewhat lengthened. The outer coat usually becomes thickened and strengthened by the addition of fibrous tissue formed from the lymph that is poured out in its interstices ; the inner may be unaltered, although it is usually in a more or less advanced stage of atheroma ; while the middle always degenerates, the muscular fibres becoming further and further separated from each other and ultimately disappearing altogether. Dissecting aneurysm, which, singularly enough, is more common in women than in men, is rare at all times, and is only met with in the aorta. Sacculated aneurysm may arise by itself from the side of a vessel, or as a further development from a weakened spot in the wall of a fusiform one. So long as it is small, the adventitia, thickened and more densely fibrous than elsewhere, can be traced over it, and it may appear to be still lined with intima ; but even in small ones the middle coat is wanting, and in those of moderate size, and still more in large ones, no distinction of coats can be made out in any part. The sac-wall is formed of fibrous tissue, partly the product of inflammation excited by the constant pressure, partly the residue of the structures which it has displaced, turned on one side, and caused to atrophy. Even bone and cartilage waste away before an aneurysm, but as they resist longer than most other structures, portions of them are occasionally found in the wall, projecting into the sac. The lining membrane may be smooth and shining, or covered with calcareous plates and irregular from atheroma, but it cannot be separated from the fibrous wall. Fusiform aneurysms rarely contain any clot, or, at the most, a small thrombus formed upon a projecting calcareous plate. Sacculated ones, on the other hand, are seldom quite empty and may be completely filled. It varies in character and appearance, according to its age, and whether it has been formed from stagnant or circulating blood. The oldest part, that which lines the sac wall, is hard, dense, and yellowish-white ; inside this are generally many layers, more or less coherent, ANEURYSM, 237 some colored and others not. but less firm ; and inside these again very often a loose, soft, and recent coagulum. No sharp distinction can be drawn between them, although the extremes are exceedingly different. The one is known as laminated ox active clot, containing very few red corpuscles. As the blood whirls round in the interior the platelets are whipped out from it and deposited upon the irregularities of the surface until they are welded together into a coherent mass by the fibrin that they form. This is repeated again and again, and layer after layer is thrown down, some quite colorless, others, when the circulation is slower, con- taining a few red corpuscles, until in successful cases the whole interior is filled. Even when this does not happen the wall is rendered immensely stronger wherever the layers are formed, and as the size of the cavity diminishes the expansive power of the blood pressure diminishes too. The loose red coagulum formed from stagnant blood is called in distinction passive. Its behavior is always very uncertain ; sometimes it melts away and dis- appears, so that an aneurysm that felt quite solid one day may the next pulsate as strongly as ever ; sometimes, on the other hand, it shrinks and becomes organized, or under the impact of the blood stream is flattened out into a colored lamina. It is not, therefore, so useless as its name implies. The future destiny of the lami- nated clot cannot be regarded as certain. The white corpuscles it contains undergo fatty degeneration and the longer it lasts the thinner and harder it becomes, until at length in old cases it disappears altogether, probably undergoing fatty transforma- tion and absorption. There is no proof that it becomes organized, its density is too great. Sacculated aneurysms may attain an enormous size ; not unfrequently more than one is present, and in any case the heart and every artery in the body that is accessible should be carefully examined before the treatment is determined. Symptoms. — The first appearance of an aneurysm is a soft, elastic, circum- scribed, and pulsating swelling in the course of one of the large arteries. Its fea- tures vary according to the amount of clot it contains. At first it is filled with fluid blood, but by degrees, as fibrin is deposited, it becomes firmer and harder, until at length in some cases it is absolutely solid, and presents all the characters of a solid growth. The pulsation varies in the same way. So long as the contents are fluid and the cavity communicates directly with an artery, this is characteris- tic ; the sac becomes tense with each beat of the heart and expands in all direc- tions ; it is not merely the lifting up and falling down of the ma.ss, as when a solid growth rests upon the wall of a vessel, it is an expansile pulsation, and this pecu- liarity can usually be recognized at once by placing the fingers one on either side of it, or one above and the other below. As, however, it becomes solid this is lost. At first there may be some pulsation communicated to the tumor from its resting upon the artery ; but even this, when the vessel is thrombosed, disappears, and it remains perfectly motionless. The difference in the tension, which is no less marked a feature, depends upon the same cause. If the limb is raised, the artery contracts, and so long as the con- tents are fluid the pulsation and the tension in the sac diminish ; if it is allowed to hang down, the effect is just the reverse. If the artery is compressed upon the cardiac side the pulsation ceases, the tumor shrinks in size, and may even become perfectly empty and collapse. When the finger is raised, it fills again in two or three beats, expanding forcibly in all directions. In nearly all cases, so long as the blood circulates through the cavity, a bruit is heard all over the tumor, synchronous with the beat of the heart, and very often a thrill is felt. These, of course, vary very greatly, not only in different cases, but at different times in the same, as they depend upon the position of the orifice and the amount and situation of the laminated clot deposited inside. Care must be taken in investigating this not to compress the artery against a subjacent bone, as a distinct bruit can be caused in this way even when the vessel is perfectly healthy. In internal aneurysm, on the other hand, or where the tumor is inaccessible, 238 DISEASES AND INJURIES OE SPECIAL STRUCTURES. these signs may Ijc wanting altogether, and then the diagnosis must be made i)artly from the effect upon tlie pulse, partly from the pressure sym])toms. The pulse in the parts below is always modified, the force of the heart is lost in stretching the sac, and little or none of this is returned, owing to the absence of elastic recoil. If the aneurysm is a large one, especially if it is near the centre of the circulation, compensative hypertrophy of the left ventricle sets in ; if it is further away the collateral circulation enlarges, but in any case the pulse below is wanting in strength, the sphygmographic tracing shows the wave is lower and less marked, and the tissues beyond are ill supplied with blood. In some instances the wasting and loss of strength produced in this way are ver)^ characteristic. An aneurysm, by its immense and constantly varying pressure, always causes a certain degree of inflammation in the tissues around. In most cases this is merely sufficient to develop the fibrous capsule, but sometimes, especially in the axilla and the groin, where the enlargement is very rapid, suppuration sets in, and the whole sac sloughs out. In addition, it often gives rise to very important signs by the way in which it interferes with the structures near it. Bones are absorbed, being hol- lowed out or perforated, as in the case of the sternum, without of necessity a trace of inflammation ; cartilages are treated in the same way, although the)- resist longer ; muscles become reduced to flattened, fibrous bands ; veins are obliterated ; nerves stretched and expanded into ribands, and in certain situations other organs, such as the oesophagus, trachea, or thoracic duct, compressed and prevented from work- ing. The symptoms caused in this way are naturally of the most varied character. Intense neuralgic pain, referred to the distribution of the nerves and worse at night, is one of the most common ; spasmodic contraction, paralysis, wasting, hyperaesthesia, and alteration in the electric reaction may occur. The sympathetic in the neck may be pressed upon, causing vaso-motor and pupillary changes. The recurrent laryngeal maybe paralyzed, giving rise to a peculiar and most significant tone of cough. There may be the most intense pain from pressure upon the cords of the brachial plexus. In short, there is scarcely a symptom due to nerve irrita- tion or compression that does not occur sometimes in connection with aneurysm. Immense congestion, with dilatation of the veins, redema, and even moist gan- grene may be caused by pressure upon one of the great venous trunks. Dyspnoea and dysphagia may occur from partial occlusion of the trachea or oesophagus. And even in some very rare cases the artery itself may be so compressed by the aneurysm springing from it as to cut off the circulation through it, and so effect a permanent cure. Progress and Termination. — Aneurysms, especially fusiform ones, that partake rather of the character of aneurysmal dilatation, and those which occur in old people who lead (luiet lives, occasionally last for many years unchanged. This, however, is exceptional ; as a rule, if left to themselves they either undergo spontaneous cure or prove fatal from rupture of the sac, suppuration, pressure upon some important organ, or, especially in the case of large thoracic ones, syncope. I. Spontaneous cure may be produced in various ways. {a) The sac may gradually be filled with laminated clot, until at length the artery itself is occluded, or there is merely a narrow channel left, running down through the centre of the tumor. A certain amount of active clot is present in all cases of sacculated aneurysm, forming, as it were, in the eddies of the blood-stream ; if this is diverted from time to time into different directions, so as to fill up one part after another, or if the circulation through it is rendered very slow and uniform by some accident, such as the development of the collateral circulation, the pressure of the aneurysm upon the artery above, or the formation of a fresh aneurysm upon the same trunk higher up, it sometimes happens that the whole sac is obliterated and cure effected (Fig. 52). When this occurs the tumor becomes smaller and harder, the characteristic expansile pulsation ceases, although, so long as the artery is unobliterated it may be lifted up and down with each beat, and the bruit and thrill disappear. At the same time the collateral vessels can sometimes be detected ; and not unfrequently ANEURYSM. 239 their enlargement is attended witli a certain amount of aching pain. Finally, the whole sac shrinks to a small, hard nodule, sessile upon the artery. (/') The distal orifice of the sac may he suddenly ])lugged by a detached frag- ment of clot. In this case the aneurysm rapidly becomes filled with stagnant blood, which coagulates, forming a loose, soft clot, and then gradually shrinks under the pressure e.xerted upon it by the displaced tissues around. If the coagulum extends into the orifice of the artery, the cure is likely to be permanent, organiza- tion taking place in that part of the recent clot which is in contact with the intima of the vessel, the rest being ultimately absorbed. Rapid cure of this kind is usually attended with a severe degree of pain for a short time, the limb feeling exceedingly tense and full, and the part beyond cold and numbed. Ultimately the collateral circulation enlarges and the sac shrinks up as before. ((•) Suppuration may occur. The loose cellular tissue round the sac becomes more and more inflamed ; the outline of the tumor disappears ; the skin over it becomes hot, red, and cedematous ; the size of the part increases rapidly; there is a. The cut edge of the arterial coats where healthy. aa. The coats in the diseased and occluded part of the artery. Their substance is dispersed and blended with the new fibrous tissue, b, which fills the vessel, yet not so much diffused but that they can still be traced to the mouth of the aneurysm (opposite the upperc). c. The aneurysm sac, composed of laminated clot and compressed tis- sue welded together in- definitely. d. Scarcely laminated clot, filling the hollow of the sac. The vein, with two valves in its lower part, is seen close behind the artery . Fig. 52. — Section through an Aneurysm of the Popliteal Artery, Cured nearly two years before by Digital Pressure. The aneurysm is not dissected out, but left embedded in the popliteal fat, e, e. The arterj' is occluded with the aneurj-sm. intense, throbbing pain, with high fever, and then suddenly the skin gives way over it, and pus mixed with sloughing shreds of fibrin, chocolate-colored masses of the broken-down blood-clot, and perhaps fresh arterial blood, pours out. Suppuration has taken place round the aneurysm and it has sloughed. If the walls of the artery above and lielow have been able to resist the action of the pyogenic micrococci, and form and organize a thrombus in their interior, hemorrhage may never occur and the cure may be permanent ; if, on the other hand, as too frequently hajipens under the.se circumstances, the nutrition of the tissue fails, organization lags behind, the clot softens and melts away under the influence of the blood-pressure, and the gush of arterial blood may prove instantaneously fatal. 2. Enlargement. — The pressure in the interior of an aneurysm increases in proportion to its cubic contents. Partly for this reason, partly, perhaps, because after a certain time the tissues round it resist less well, it is not uncommon to find, after it has reached a certain size, that the rate of growth becomes much more rapid and the wall exceedingly thin. In these circumstances, if it does not prove fatal from syncope, suppuration, or pressure upon some organ essential to life, rujiture occurs sooner or later. 240 DISEASES AND INJURES OF SPECIAL STRUCTURES. The way in which this takes place and the symptoms to which it gives rise vary with the situation. Hemorrhage into a serous sac is usually rapidly fatal, a great stellate opening forming and admitting a full rush of blood. When it occurs on a mucous surface, on the other hand, days may pass before the final outburst, the orifice being very minute and becoming plugged with a coagulum which only allows a certain amount of leakage from time to time. Rupture on the cutaneous surface is still more rare, unless preceded by inflammation and suppuration. The tumor may render the skin red, tense, and shining, or may even raise the epidermis up in the form of a blister, so that bloody serum soaks through and forms a scab on the surface ; but unless suppuration occurs, or a slough is formed, external hemorrhage is, comparatively speaking, a rare form of death. In the majority of cases of rupture the sac gives way subcutaneously, and the blood is extravasated into the cellular tissue. A small amount usually escapes at first, causing some increase in the size of the tumor, then it coagulates and forms a wall around itself. After this it may remain quiet for several days, or may cause suppuration, or may, in very exceptional instances, lead to the development of a new and stronger sac. More frequently it is only the prelude to a more extensive hemorrhage which pours in all directions into the cellular tissue around, causing the most intense pain, and leading to complete cessation of the circulation in all the parts below. The patient may faint at once and become collapsed, partly from the loss of blood, partly from the shock and pain ; the limb beyond becomes cold, oedematous, and pulseless ; the region of the aneurysm is immensely distended ; all bruit and pulsation disap- pear, and if speedy steps are not taken moist gangrene is inevitable. An aneurysm that is enlarging very rapidly, especially in one direction, is sometimes described as leaking ; either the sac has already given way, or it is in imminent danger of doing so, and there is the greatest risk that actual rupture, which in an aneurysm of any size is hopeless so far as the limb is concerned, and always places life in very serious jeopardy, may occur at any moment. In the case of ruptured popliteal aneurysm, the appearance of the limb is not unlike that produced by deep-seated suppuration ; the skin all round the back of the joint is red, tense, and oedematous on pressure, and the pain is most acute and throbbing, and the history may be that of a rapidly forming abscess ; but the cessation of the circulation in the limb below, the coldness and oedema of the part, and the loss of sensibility in the toes, point unmistakably to some grave interrup- tion in the blood-supply. Moist gangrene in such cases is inevitable. Diagnosis. — i. In its earlier stages, while it still pulsates. {a) Aneurysm may occasionally be confounded with a form of aneurysmal dilatation chiefly met with in the innominate and the abdominal aorta in young women. The dilatation and the pulsation are often exceedingly well-marked, but the age and sex, the effects of tonics, especially iron, and the evidence of other nerve troubles are usually sufficient to make the diagnosis certain at once. As the dilatation disappears again completely there can be no serious morbid lesion in the wall of the vessel. {F) Fluid tumors, bursee, hydatid and other cysts, and chronic abscesses in the neighborhood of large arteries or on their walls occasionally present great dilifi- culty. If, however, they pulsate they do not expand in the way that an aneurysm does, and though they contain fluid they cannot be even partially emptied by pressure upon them. A bruit or thrill is exceptional, though it may be produced if the artery is compressed or bent irregularly. {/) Pulsating sarcomata are usually found in early life or in localities in which aneurysm is either very rare or practically unknown, and even when they do grow from such places as the back of the knee joint the diagnosis is seldom difficult. The pulsation is not expansile ; the bruit, when there is one, can only be heard over a limited area ; the tumor cannot be emptied either by direct pressure or by compression of the artery above, and even if it can be reduced in size, it refills slowly, not with the rapid bound of an empty aneurysmal sac. In some instances, however, when the tumor is intra-pelvic, a positive statement is often im- ANEURYSM. 241 possible without examining the case more than once and watching the manner of its growth. 2. Aneurysms that do not pulsate, whether this arises from their being already filled with laminated clot or from some peculiar anatomical relation to the artery from which they spring, are exceedingly difficult. All the ordinary signs fail com- pletely, there is no pulsation or bruit, the tumor cannot be emptied, it lies in the region of an artery, but it cannot be separated from it or lifted off it. In short, in all such a most guarded opinion must be given until the case has been watched some little time. If it is a cured aneurysm it will slowly tend to become smaller and smaller ; if it is not cured, but merely prevented pulsating by some accidental condition, it will either cure itself or some day pulsation will suddenly make its appearance. 3. Ruptured and suppurating aneurysms can usually be recognized by the complete and sudden obstruction to the circulation in the part below. Even if no history can be obtained, the coldness of the distal portions, the oedema, numbness, and cessation of the pulse, should at once arouse suspicion. In any case of doubt the introduction of a grooved needle can do no harm, but both the patient and the oj^erator must be prepared for any measure that is necessary. Suppuration may be distinguished from simple rupture by the intensity of the local signs of inflamma- tion. Treatment. — Aneurysms may be treated in many different ways, according to the conditions under which they are placed, but the idea is the same in all, to bring about one or other of those changes by which spontaneous cure is effected, viz., the deposit of laminated clot, the rapid coagulation of the contents of the sac, or the exclusion of the aneurysm from the circulation, as in suppuration. I. The Deposit of Laminated Clot. This may be accomplished either by increasing the amount of fibrin in the blood, or by rendering the circulation through the sac as slow and as uniform as possible. Of these two the first is at present entirely beyond our power ; nothing is known that can increase or diminish the amount of fibrin without at the same time causing even more serious changes, and it must be remembered that an increase in the quantity of fibrin is not the same thing as increasing the readiness to coag- ulate. The circulation through the sac may be controlled by constitutional or local measures, or by both together. {a) Constitutional Treatment. — Rest, in the recumbent position, is of the utmost importance ; it lessens the force of the heart-beat, reduces its frequency, and keeps it uniform. The sudden enlargement of an aneurysmal sac can often be traced directly to some comparatively trivial exertion. The diet must be restricted. In many instances it is of advantage to adopt Tufnell's system. The patient is placed on a well-made hair mattress, with a water cushion, and forbidden to raise hand or foot for any reason. The diet is reduced to eight ounces of solids and six of fluids per diem (six ounces of bread with a little butter, two of meat, and six of milk), and is maintained at this level for some weeks. The patient, of course, becomes extremely emaciated and feeble (it is necessary to take great care that he does not catch cold), but the number of heart- beats can be reduced to forty-two or forty-four in the minute ; and not unfrequently it happens while this is going on that, owing to the slowness of the current in the aneurysm, many fresh layers are deposited on its wall. Moreover, the improvement is not only maintained, but often becomes much more marked when the diet is gradually raised again. In patients who are feeble and anaemic already, this, of course, is not advisable. Not unfrequently with them a more generous diet, com- bined with iron, reduces the frequency of the heart-beat, although it may some- what increase the force ; stimulants, however, should always be avoided. The bowels must be kept well open ; if the arterial tension is high, repeated -42 DISEASES AND IXJ CRIES OF SPECIAL STRUCTURES. saline purges are recommended, and even venesection. Opium is of great use in controlling pain and procuring sleep. Other drugs are recommended from time to time, but it is difficult to show that any improvement that takes place during their administration is actually the result of their influence. Iodide of potash, for ex- ample, has a distinct effect upon the blood-pressure, and relieves the nocturnal bone-pain so common in some forms of internal aneurysm, and, moreover, is some- times of benefit when there is a decided history of syphilis : but it certainly tends to diminish the coagulability of the blood. [Post-mortem dissection has shown the consolidation of the contents of the aneurysmal sac too frequently to admit of a doubt that potassium iodide does exercise a materially curative effect on the larger aneurysms.] Digitalis may modify the action of the heart, but it also tends to raise the arterial pressure. Aconite and belladonna may be given with better reason. There is no proof that either ergot or acetate of lead has the least effect. (b) Local Treatment. — The simplest method is to raise the part if it is one of the limbs, bandage it. and apply gentle pressure over the tumor. This, however, is rarely enough, except in the case of the anterior tibial or other small vessels. Sometimes these are injured in fractures, and then an aneurysm may develop and be cured while the patient is lying in bed with his limb in splints. Whatever method is finally adopted, bandaging and elevation always form part. I. Compression of the Main Artery on the Cardiac Side. — This may be digital or instrumental : in either case the object is to diminish the stream of blood flow- ing through, so that the fibrin may be deposited on the walls. It is not necessary to occlude the artery completely, all that is required is to prevent pulsation in the sac ,: and this is especially to be remembered, as many cases in which this plan has failed have been given up because the patient would no longer stand the pain, and in one or two inflammation of the wall has been caused, and a second aneurysm has developed later on. The patient must be placed in a comfortable position, and the skin .shaved and powdered well with French chalk. Digital compression is to be preferred wherever it is possible, but it can only be carried out where the artery is superficial and rests against a bone, as in the case of the femoral at Poupart's ligament, and at least three people are required. Two fingers should be placed upon the vessel, care being taken not to include the vein, and a weight of about four pounds (suspended by a pulley from somewhere overhead) allowed to come down and rest upon the dorsum of the last two phalanges. Pressure, carried out simply by muscular exer- tion, is exceedingly exhausting, and can only be kept up for a short time. With the aid of a weight it can be maintained with perfect uniformity for half an hour without changing and without fatigue. When a change is made, the vessel should be secured above or below with the other hand, so that no pulsation can take place in the aneurysm, and the grasp should not be relaxed until the new-comer is certain that he has secured the vessel. One hand should be kept upon the aneurysm the whole time, to make sure that there is no pulsation. The number of hours this treatment has to be maintained depends a great deal upon the thoroughness with which it is carried out. Usually compression is continuous for the first twelve or fifteen hours. If the tumor l:)ecomes solid in that time it is probably filled to some extent with laminated fibrin, but much more with recent soft coagulum, and the limb must be elevated and firmly bandaged with a compress over the whole length of the artery for twenty-four hours more, for fear of the contents being washed out again. At the end of that time it is fairly safe, although no precaution may be relaxed until the tumor has begun to diminish distinctly. If no change is de- tected, it should be left for a few days and simply bandaged : perha])s at the end of that time a certain amount of fibrin will have been laid down and it is certainly better to allow the patient time to rest. Even when every precaution is taken con- tinuous compression becomes very painful, especially if there are any enlarged glands round or near the vessel. At the end of a week a second attempt may be made, following the same plan, or shorter sittings may be tried for four or six ANEURYSM. 243 hours a day, until the cure is complete. When this is successful, the fibrin is deposited in laminx, but it may be a week before there is any distinct solidifica- tion. If it ha.s been tried well and it does not succeed at the end of that time it should be given uj). Instrumental compression is carried out on the same plan, chiefly with Carte's tourniquet, which has the advantage over others of greater elasticity of pressure and of a double pad, so that the point of compression can be varied without moving the instrument. In some parts of the body (the abdominal aorta, for example) only instrumental compression is possible ; but in most, if it can be managed, the digital plan is to be preferred as less likely to injure the artery and more easy to adjust. Opium is not unfrequently required to allay irritability and to procure sleep. Sometimes, as in the case of the abdominal aorta, an anesthetic is necessary. If compression fails or the patient will stand it no longer, the artery must be tied, but not at the spot at which it has been compressed, for in all probability the coats of the vessel are somewhat thickened there, and perhaps matted together by adhe- sive inflammation. It appears from statistics that ligature after compre.ssion is not so favorable as immediate ligature — what this may be due to is not certain ; there is no doubt that the collateral circulation enlarges from the effect of continued pressure, and that this, while it checks the tendency to gangrene, at the same time maintains, perhaps too well, the current through the sac ; but it must be remem- bered that the cases are not like fresh ones, they have already failed once. Compression is the plan of widest and most general application ; it avoids the necessity for a wound and the risk of secondary hemorrhage ; but it can only be employed in certain cases (fortunately, the majority) ; it must never be used where, from the presence of oedema or venous engorgement, there is reason to fear obstruction to or pressure upon the main vein of a limb, or where the sac is enlarg- ing rapidly and in danger of rupture; and it must be admitted that sometimes, perhaps from want of intelligence on the part of the patient, it is exceedingly difficult to carry out thoroughly. 2. Ligature of the Artery on the Cardiae Side, at a Distattce from the Aneurysm ; the Hunterian Operatio7i. — The object is to allow a slow stream of blood to flow through the sac and deposit layers of fibrin upon the walls, not to cut off the circulation completely, and fill the cavity with a loose, soft coagulum. Additional advantages of ligature at a distance from the sac over ligature close to it are that the operation is easier, the best part of the vessel being selected ; that the artery is much more likely to be healthy ; that the sac is less interfered with, so that there is less risk of suppuration ; and that the collateral circu- lation is likely to be better, and the danger of gangrene less. The immediate effect of tightening the ligature is to stop the pulsation in the aneurysm. The blood pressure begins to fall at once, the tissues around resume their normal position, the tumor diminishes in size, and its outline becomes less distinct, ■when compression has been tried before ligature, and the collateral circulation is already established, coagulation does not take place at once; the current is not shut off completely : from the first it flows through in a gentle, continuous stream, and under its influence fibrin is deposited in layers on the wall until the sac is filled and the artery blocked above and below. In some cases slight but distinct Anel's Hunter's. Brasdor's. Wardrop's. Fig. 53. — Diagram Showing the Different Operations for Aneurysm. In most cases, however, especially 244 DISEASES AND INJURIES OF SPECIAL STRUCTURES. m w^ pulsation can be detected, the stream is so strong ; not, as a rule, for two or three days after the operation — not, that is to say, until the collateral vessels are thoroughly expanded ; then growing more and more marked, and finally, as the walls become thicker, fading away again. In a successful case the sac diminishes in size, until at the end of three or four weeks it is small, shrunken, and hard. The artery is obliterated at the seat of ligature, and again opposite the aneurysm ; in between it not unfrequently re- mains pervious (Fig. 54). After the operation the patient should be placed in bed with the limb arranged in an easy position, wrapped in cotton-wool and slightly raised. It may be surrounded with ^j. hot-water bottles, but none should touch it. Ligature is liable to certain risks from which compression is more or less exempt. \d) Secondary hemorrhage may occur, or the ligature mav give way, or soften prematurely, leaving an artery bruised and partly divided, exposed to the full effects of the blood-stream. Not unfrequently, in spite of careful selection, it is very difficult to make sure of finding a part of the artery that is absolutely healthy. (J}) Pulsation may return, either from some aberrant branch or because of the development of the collateral circu- lation. If this is only slight it need not excite alarm, but if it continues, and particularly if after lasting four or five days it becomes more marked, the prospect is not good. Some- times, even then, if the limb is kept carefully bandaged it subsides of itself ; but if it does not, as soon as the wound in the artery is sound, means must be taken to make the blood that is in the sac coagulate. Probably, if other things are suitable, Esmarch's bandage is the best ; with such perfect development of the collateral vessels there can be little fear of gangrene ; in other cases flexion, pressure on the artery ^' between the aneurysm and the seat of ligature, or above the latter point, and possibly even ligature of the artery higher up, may be required. Amputation is the last resource if the sac continues to increase in size and threatens to give way. {c) Gangrene may occur. The aneurysm itself is no inconsiderable obstruction, although, if it has formed slowly, the collateral supply round it has usually had time to enlarge ; the tissues beyond are frequently ill-nourished, the heart is often dilated rather than hypertrophied, and the vessels in many cases are atheromatous. Ligature of the main trunk under conditions such as these easily leads to gangrene ; and Fig. 54.— The Femoral and if the vciu is prcsscd upon or injured, or the sac has begun to leak, or there is any inflammatory cedema, is almost sure to do so. Usually it is of the moist variety and amputation is inevitable ; sometimes, when it is dry and very slow in its course, a line of demarcation forms, and only a part of the limb is lost. (d) Suppuration round the sac. This was not an uncom- T^r artrryTetween^ihe ^0^ occurrence whcu the artery was tied near the aneurysm, ligature and the sac is in a great nicasure owing to the extent of the manipulation. patent. -(Bowiby.) Sometimes, especially when the sac has rapidly enlarged, or has been much handled, it happens even when the operation is performed at a distance. If the sac has ceased pulsating it should be left as long as possible until the skin shows signs of giving way ; with good fortune the Popliteal Vessels, five years after ligature of the superficial femoral for the cure of a popliteal aneu- rysm. The vessel has been occluded by the ligature at a, and again at the seat of aneurj'sm. The aneurj'sm itself is represented by a small ANEURYSM. 245 ends of the artery may become sealed, and turning out all the clots would only increase the chance of hemorrhage by opening them up again. If, however, pulsation continues, there is no hope but in amputation, plugging, or placing a tournitjuet upon the artery higher up, laying the whole open from one end to the other, turning out all the sloughs and broken-down clot, and securing everything that bleeds as far from the surface of the wound as possible. Afterward, and in any case, watch must be kept night and day until the wound is healed. 3. Distal Ligature after Wardrop'' s Method. — This is ordinarily classed with Brasdor's, and as a matter of history was a deduction from it, but there is an essential difference between them. In Bra.sdor's the whole circulation is cut off, the aneurysm is left full of clot, and complete obliteration is aimed at. In Wardrop' s the whole circulation is not cut off, large branches are left either between the seat of ligature and the aneurysm or arising from the sac itself; and these branches begin at once to increase in size, so that whatever benefit is derived from the operation, and in some instances it has been shown to be very considerable, it cannot be due to immediate obliteration of the cavity. As a matter of practice it is reserved almost entirely for aneurysms at the root of the neck, whether springing from the subclavian, innominate, or aorta. The benefit some of those springing from the arch itself have derived is very remarkable, although in some of the earlier cases the operation was performed under the erroneous impression that the innominate was concerned. As at first practiced, the carotid and subclavian were ligatured simultaneously with a view of diminishing the amount of blood flowing through ; but that this cannot be the correct explanation is clear from the fact that in some cases as much benefit has been derived from ligature of the left carotid only. The result must be due either to a coagulum projecting back into the sac, and acting as a nucleus for the deposit of laminated fibrin, or to the fact that the direction of the stream is changed and the pressure transferred to parts which not only have not been so much weakened, but which even may have been strengthened by the deposit of fibrin upon them while they were lying out of the direct flow. Possibly there is something to be said for both views. II. Rapid Coagulation of the Contents, such as is produced naturally zc>he?i an embolus is dislodged and blocks the distal orifice. The natural method of cure may be imitated in many ways, with varying success ; but with the exception of one (the use of Esmarch's bandage) it is only employed under special conditions when ligature or compression is out of the ques- tion. Constitutional treatment must, of course, be maintained at the same time. I. Esmarcli s Bandage (Reid' s Method). — The aneurysm is filled with blood and the circulation arrested above and below. An elastic bandage is applied to the distal part of the limb, either beginning at the end and carrpng it up to the sac or leaving the fingers or toes, as the case may be, and commencing only a short distance below. The sac is then allowed to fill, the bandage either carried over it very lightly or made to skip it altogether, and applied firmly again to the part above. If there is not sufficient room, an elastic strap may be used, or an abdominal tourniquet, as the case requires. The bandage is usually applied for about two hours (I have known half an hour suc- cessful, but this was a very exceptional case) and then digital or instrumental compression kept up on the trunk above for twelve hours more, in order to protect the clot at the entrance of the vessel from the impact of the blood. In a successful case the whole of the sac is filled with a coagulum which extends into the artery and occludes it. The hope is that this, if not displaced, will become organized where it is in contact with the intima, and be replaced by fibrous tissue ; while the rest of the coagulated blood, lying out of the current, will either be absorbed or dry up. Possibly it may become organized too. An anaesthetic is absolutely necessary the whole time, as the proceeding is very 2 46 DISEASES AND INJURIES OF SPECIAL STRUCTURES. painful. If the aneurysm is on one of the limbs, this should be raised and care- fully wrapped with cotton-wool before the constriction is removed. The chief advantages of this method are its simplicity and rapidity. It suc- ceeds best, naturally, with small aneurysms in young subjects free from cardiac disease or extensive atheroma, and should not be used for large ones or those on the point of rupture. At the same time it is practically the only plan admissible for some aneurysms of the abdominal aorta and its branches. Failure is not infrequent, the aneurysm appearing perfectly solid when the bandage is unwound, but becoming completely empty by the next day in spite of the precaution of pressure upon the supplying trunk. If this happens once it is nearly sure to happen a second and a third time. If, on the other hand, the coag- ulum remains firm for twenty-four hours the cure is likely to be permanent. A considerable amount of ecchymosis is often noticed round the sac, but it does not appear that there is any unusual danger of gangrene. The bandage has been kept on for upward of three hours and a half in a case of popliteal aneurysm without any ill effect. Rupture has occurred on one or two occasions from the tension to which the sac has been subjected, and there is always the possibility, if there is any cardiac disease or atheroma of neighboring vessels, of throwing too great a strain upon them, but, provided the cases are carefully selected, it is as safe as any other method. Where it is possible the elastic strap tourniquet should be avoided, and two or three turns of a broad rubber bandage made round the part instead ; the sharp construction of a rubber band has l)efore now caused paralysis of a nerve by com- pressing it against a subjacent bone. The other methods for obtaining rapid coagulation are of very limited appli- cation. 2. Manipulation. — An attempt is made to detach some of the clot from the interior, and plug the distal orifice with the embolus, as in the natural method. The artery should be compressed upon the cardiac side during the manipulation. This has succeeded in a few instances in which there was practically no alternative ; but it should never be tried at the root of the neck if there is the least suspicion that the carotid is involved. 3. Flexion. — Aneurysms at the knee and elbow may be compressed, and the pulsation stopped by extreme flexion of the joint, but the process is painful, un- certain, and only advisable under special circumstances, when, for example, pulsa- tion has returned after ligature. The limb must be bandaged as high as the aneurysm, flexed until pulsation ceases, and then fixed for some hours, the patient meanwhile being kept under the influence of morphia. Afterward the same pre- caution must be adopted as in Reid's method. 4. Brasdor" s Operation or Distal Ligature of Trunk ivithout Leaving any Lnter- ve?iing Branch. — This is only possible in aneurysm of the root of the common caro- tid, all other large arteries having too many branches. The cavity is filled at once, as in embolism, but the blood-pressure soon falls ; the tissues around expand again, the sac diminishes in size, and the blood that it contains probably coagulates at once. Sometimes the coagulum extends down into it from the seat of ligature. For aneurysms in that particular situation it is exceedingly suitable. 5. Distal compression has been tried in imitation, but, except in a few an- eurysms of the abdominal aorta, it is of" very little service. It throws the whole strain upon the sac without anything like the same certainty of coagulation. 6. Introduction of Foreign Bodies into the Sac. — Of these, iron wire seems to afford the best prospect. As yet it has only been used in desperate cases of inter- nal aneurysm, so that it must not be judged too harshly. In one or two it has been partially successful, but in spite of this it cannot be recommended until all other methods have been exhausted. The wire must be sufficiently fine and flexible to coil up in the interior of the sac without exerting any degree of internal pressure ; and especial care must be taken to bury the ends as effectually as possible. Usually it is passed in through ANEURYSM. 247 one of Southey's trocars, the puncture being sealed with strong carbolic acid or the actual cautery. In the most successful case (I.oreta's, one of abdominal an- eurysm, in which the sac became consolidated and the patient lived for 92 days afterward) only six feet were employed, and probably in some of the first the amount was unnecessarily great. I' ndoul)tedly it causes coagulation of the blood, but the result is usually fatal from rupture of the sac at some weak spot, or from inflanmiation set up by the necessary manipulation. It has been proposed to connect the wire with the positive pole of a battery and pass a continuous current through ; but coagulation, in all the cases yet re- corded, appears to have been induced with sufficient rapidity without this. 7. Galvano-ptincturc. — Coagulation may be started in the interior of an an- eurysm by means of galvano-puncture, provided the part of the wall selected is not too thin, or the sac extending too rapidly; and possibly the clot so formed may change the direction of the stream and lead to the deposit of fresh layers over the weaker parts. The difficulty is that, especially in the case of thoracic aneurysms, for which this is chiefly used, it is almost impossible to form a definite idea as to the size of the orifice of communication, the direction in which the aneurysm is spreading, or the course of the blood-stream through it. Still, in some cases of sacculated aneurysm springing from the arch of the aorta, a very decided im- provement has been effected with very small risk. Unhappily, accumulation of fibrin on the front of the sac (often the only part accessible) may be attended with, or may actually cause, rapid extension in some other direction, unknown and unsuspected. Fine trocar-shaped needles are the best, insulated up to the neck with vulcan- ite ; silk causes too much irritation, and sealing-wax or simple rubber does not adhere sufficiently. They are attached to the positive pole only ; the negative, which should never be introduced into the sac, is connected with a large zinc plate, covered with wash-leather and soaked in salt solution. The patient can rest his hand on this and interrupt the current at any moment ; but as the strength never should exceed five or six milliamperes, there is no pain or shock to cause any alarm even when the aneurysm is close to the heart. Two or more needles are introduced parallel to each other, well into the interior, until their ex- ternal ends distinctly vibrate ; then the current is turned on and continued until the movement ceases and the tissues around feel hard. The needles should be left in for an hour or so afterward, in order that the clot mayattain some degree of firmness and become fixed. Nothing, or at most a little blood-stained serum, exudes from the punctures, but it is as well to cover them with collodion. By repeated applications of this kind, I have succeeded in keeping in check an aneurysm of the aorta that had already caused partial absorption of the sternum, and with such success that for some time the pulsation disappeared from the inter- costal spaces. Unhappily, sudden excitement one day caused a rapid extension of the tumor, and the skin became so much stretched and thinned that nothing further could be done. 8. Acupuncture. — In one or two cases, this has been tried with at least tem- porary benefit. Three pairs of long, fine darning-needles were introduced into the sac, so that each pair crossed in the cavity. They were left in for five days, by which time they had caused a considerable degree of clotting ; and this gradu- ally increased until at length the sac became almost solid. III. Exclusion of the Aneurysm. This takes place when suppuration occurs round an aneurysm and the sac sloughs out. What is known as the old operation is carried out on the same plan ; a free incision is made into the sac, all the clots turned out, and the artery tied above and below. With the aid of tourniquets, the primary hemorrhage can be fairly well controlled ; but as the artery in idiopathic or spontaneous aneurysm is almost certain to be extensively diseased on either side, the risk of secondary 248 DISEASES AND INJURIES OF SPECIAL STRUCTURES. hemorrhage is vet}' great ; and even if this does not occur, gangrene is exceed- ingly likely to follow. Practically it is reserved for traumatic aneurysm, embolic aneurysm of the upper limb in young p>eople, and cases in which, after ligature of the artery, the sac has become inflamed and is beginning to suppurate, without the pulsation having ceased. IV. Amputation. This may be required if moist gangrene sets in : for rupture of the sac ; .sup- puration with threatened hemorrhage ; or disease of a neighboring bone or joint. If secondary hemorrhage occurs from the seat of ligature, an attempt may be made to secure the two ends of the artery iji situ ; but if it is clear that the walls of the vessels are seriously diseased, it is probable that amputation at once, if it is prac- ticable, gives the patient a better chance of life. Traum.\tic Aneurysm. The formation of traumatic aneurysm has been already described ; an artery is injured and the cicatrix yields ; or one of the coats is torn through, and the others are unable to stand the strain ; or there is a wound plugged withacoagulum which gradually stretches under the influence of the blood-pressure ; in any case a circumscribed sac containing fluid blood forms in connection with the interior of the vessel and grows larger and larger, the wall, as soon it attains any consid- erable size, being formed of fibrous tissue thrown out by the inflamed and irri- tated structures around, and lined with laminated clot. Its progress and terminations are similar in all respects to the idiopathic form ; it may become filled with laminated fibrin, or with loose soft blood-clot ; it may cause suppuration around ; it may leak by slow degrees and then suddenly rupture into the cellular tissue ; sometimes even it forms a communication with a vein (arterio-venous aneurysm) ; or it may at length end in gangrene of the part. As a rule, the simpler methods of treatment succeed ; a bandage is often enough, if the part is kept at rest ; or, if this does not answer, Reid's method, digital compression, or flexion may be tried. If these fail and the aneurysm is superficial, the old ofjeration may be resorted to without hesitation, as the walls of the vessel are healthy ; but if it is deeply seated proximal ligature (the Hun- terian method) should have the preference. Rupture or even leakage, unless of the most trivial description, leaves no alternative ; then it is simply a question of a ruptured artery, and it must be treated as such. Special Aneurysms. Aneurysms at the Root of the Neck. !Many forms of aneurysm are met with at the root of the neck, and the differ- ential diagnosis is often very difficult. Roughly, they are divided into three classes, although .sharp distinctions are seldom possible, and the dilatation is rarely limited to one part. 1. Those confined within the thorax. These spring usually from the first part of the arch of the aorta, occasionally from the third. They may be sacculated ; but very often, even when a sacculus is present, it is only secondary to a wider fusiform enlargement. 2. Those that pulsate in the episternal notch, or behind the sterno- clavicular articulation or the stemo-mastoid, so that part of the outline of the sac can be felt. These include sacculated aneurysms of the transverse portion of the arch ; those that spread from the aorta into the base of the innominate ; and aneurysms of the innominate itself, involving more or less of the carotid or subclavian. Aneurysms springing from the left extremit)' of the arch, and spreading in the direction of the ANEURYSM. 249 left carotid or sulxlavian, occasionally jircscnt in this region, l)ut only in their later stages. 3. Those that lie entirely ont of the thorax, the finger being able to feel the under surface of the sac. 'I'hese must be either carotid or subclavian ; even the high innominate form (so called to distinguish it from that which spreads upward from the aorta) descends too far. The diagnosis of these different conditions rests upon the position and extent of the tumor with regard to the surface of the body, the evidence of pressure upon structures near, and the alteration in the pulse-wave. Thorough examination must always be made of the heart, to ascertain whether there is any mitral or aortic regurgitation, and of the other arteries. Any surgical o]jeration that is undertaken must be of the most serious description, and should never be attemi)ted unless other conditions are favorable. Fusiform dilatation, aortic disease, atheroma in other vessels, hypertrophy or dilatation of any of the cavities of the heart to any serious extent, and renal disease, are practically final, so far as active treatment is concerned. Even taking the small number of cases left, those in which there is merely a sacculated aneurysm springing from an otherwise healthy vessel, active surgical treatment cannot be recommended until rest, diet, and simpler methods have been thoroughly tried. How long they should be kept up before adopting further meas- ures depends upon the amount of improvement in each individual case. A certain degree is almost invariable at hirst if a patient who has been engaged in hard man- ual labor is laid up in bed and kept on low diet ; the heart beats less quickly and less forcibly ; the tension in the aneurysm falls ; the surrounding tissues empty it to a certain extent by their pressure ; and the pulsation becomes less distinct. If this continues, nothing better can be wished for, and it may be hoped that the sac will gradually become solid. Too often, however, it is only temporary ; all the symp- toms return even after a patient trial for months, and without the patient undertak- ing any exertion. For such as these, if the other conditions already enumerated are favorable, it is sometimes possible to adopt a more active line with benefit ; but the proportion they bear to the whole is exceedingly small. I. Aneurysm of the first part of the arch. This lies for the most part to the right of the middle line, causing an area of dullness that corresponds chiefly to the second rib and the second interspace, although it may reach as high as the sterno- clavicular articulation. Protrusion of the chest- wall takes place comparatively early, and is soon followed by the formation of a distinct swelling which pulsates visibly and sensibly. Over this region the heart-sounds are heard with abnormal loudness, the second especially. The heart itself is often displaced outward. There may be evidence of pressure upon the right bronchus, air not entering freely into the lung, or upon the superior vena cava, causing congestion of both arms and both sides of the head. The pulses are equal, carotid as well as radial, but the pulse-wave is slightly lower and more sloping than natural, and the down-stroke prolonged and undulating. If rest and diet fail and the other conditions are sufficiently favorable, the choice lies between galvanopuncture, acupuncture, the introduction of foreign sub- stances, simultaneous distal ligature of the right carotid and subclavian, and liga- ture of the left carotid. Of these the first three have never strengthened the sac sufficiently to enable the patient to lead an active life again, even for a time, and the last of them is very likely to end in embolism. Perhaps galvanopuncture is the best, especially if the current is kept up for some hours and the needles are retained until the clot is firm ; but it has not yet been proved that the coagulum is capable of resisting for any length of time the immense force that must fall upon it in the first part of the aorta. The last two have each succeeded once or twice, although it was not known at the time that the aneurysm was situated in the first part of the arch. Ligature of the left carotid perhaps affords the best hope ; it is not so serious an operation as the other, and if the rest of the aorta is not dilated, and the heart 17 250 DISEASES AND JXJURIES OF SPECIAL STRUCTURES. is not diseased, there is a possibility of its proving successful. The condition of the other carotid must, however, be carefully investigated first. 2. Aneurysms that pulsate in the episternal notch. This is the most difficult class of all : it does not follow by any means that a tumor originates upon the side upon which it projects. {a) The area of dullness and the locality of the pulsation rarely reveal much. If there is a distinct band of resonance opposite the level of the second costal carti- lage, it is probable that the first part of the arch is intact, but it is not common to find this even after the fullest inspiration. Also, if the pulsation is limited to the region of the right sterno-clavicular articulation, the aneurysm probably involves the innominate artery, but it does not show that the dilatation is limited to this, and it does not exclude those varieties of sacculated aneurysm which ascend from the arch in front of the other vessels and pulsate in exactly the same locality. (J)) Pressure signs are more useful. Veins are often obstructed, the superior cava when the first part of the arch is concerned, the right innominate if the aneurysm extends upward along the innominate artery, the right internal jugular if the first part of the subclavian is involved, and the left innominate when there is a pouch projecting upward from the transverse part of the arch, along the innominate or independently. This last condition, in which the tumor, pulsation, and accent- uated second sound of the heart are most distinct upon the right side, and the congestion upon the left, is very suggestive. Nerves do not suffer so often. The left recurrent laryngeal is first irritated and then compressed in aneurysms of the distal portion of the arch, causing a peculiar paroxysmal cough with a high, squeaky voice, and in the later stages aphonia. The right suffers in the same way when the first part of the subclavian or the innominate is dilated. In every case of suspected aneurysm the condition of the vocal cords as regards position and movement during phonation should be carefully examined. The sympathetic is not affected unless the aneurysm assumes a particular direc- tion or becomes very large. Vascular dilatation, increased sweating, and con- traction of the pupil are the chief symptoms. Compression of the trachea or of one of its divisions may occur in almost any of the forms \ the tone of the voice is not affected ; the breath-sounds are changed ; there is a loud, harsh blowing, often audible on both sides, even when only one is involved ; violent fits of spasmodic coughing, ending in the expectoration of thick, ropy mucus, are of common occurrence, and the expansion of the chest is often unequal. In other cases the oesophagus, the lower cords of the brachial plexus on one side, the sternal end of the clavicle, or the sterno-clavicular articulation are affected as the growth increases in size, and give important indications as to the direction in which it is extending. (t) The condition of the pulse affords even more valuable evidence than this, although it must always be remembered that the right subclavian sometimes runs an abnormal course, and may be compressed by an aneurysm springing from some other vessel. It is not, however, the absence of pulsation, so much as the character, the peculiar, low, sloping, aneurysmal curve, that is important, and, to obtain satisfac- tory evidence of this, tracings must be taken from both radials and both carotids. If those obtained from the two sides are approximately equal, the aneurysm proba- bly involves the first part of the arch, though it is by no means certainly limited to it ; if the right are affected, but not the left, the arch itself must be nearly intact ; if the let't without the right, the innominate must be sound ; and the same with regard to the radial and carotid on either side. If rest and diet fail, distal ligature is the only active treatment advisable for any of these, although one case of innominate aneurysm is stated to have been cured by distal compression of the subclavian and carotid. Galvano-puncture or the introduction of foreign bodies does not offer the least prospect of success. ANEURYSM. 251 Those cases, however, only are suitable for it in which the tumor is distinctly- limited in size, and in which the presence of fusiform dilatation of the aorta, hypertrophy and dilatation of the left ventricle, etc., can be excluded. The choice lies between simultaneous ligature of the right carotid and subclavian and ligature of the left carotid. The former is to be preferred, if from the condition of the pulse and the right venous congestion the symptoms point definitely to the innominate ; the latter probably under other conditions. 3. Aneurysms of the right side of the root of the neck, lying outside the thorax. These are either carotid or subclavian. The reason for classing them here is the extreme difficulty of distinguishing them from the high innominate form. In aneurysm of the first part of the subclavian the swelling appears first behind the clavicle, pushing that bone forward and causing a rather elongated area of pul- sation. Paroxysmal cough with alteration in the tone of the voice from pressure on the recurrent laryngeal, venous congestion and oedema of the side of the head and neck from compression of the internal jugular, and weakening of the radial pulse are the chief distinctive signs. When the base of the right carotid is involved the shape and position of the tumor and the direction of the pulsation are different ; there is no pressure upon any nerve or vein, no dullness in the first intercostal space, and nothing in connec- tion with the trachea, cesophagus, or recurrent laryngeal, until the tumor reaches a considerable size. On the other hand, the facial and temporal pulses are dis- tinctly different from those on the opposite side. If these two sets of symptoms occur together, even if they are only slightly marked, it means that the distal end of the innominate is involved ; that practically it is a case of innominate aneurysm (the high form in distinction from the low one, which spreads upward from the aorta), and, as already described, that it can only be treated by rest and diet, or by simultaneous double distal ligature. Aneurysms of the Carotid. The point of bifurcation is the most common situation, but almost any part, except that which lies inside the thorax on the left side, may be involved. The internal carotid is seldom affected, although a few cases are on record, and most of those in connection with the external are traumatic, and extend along its branches. It is peculiar that aneurysms of the common trunk are nearly as fre- quent among women as among men. Two varieties are distinguished, the high and the low ; the latter is almost, if not quite, confined to the right side. Symptoms. — In addition to the ordinary signs, the presence of a circum- scribed fluid tumor with characteristic pulsation and bruit, there are others caused by pressure upon neighboring organs and by interference with the cerebral circu- lation. Among the former may be classed dyspnoea, spasmodic coughing, and hoarseness from pressure upon the trachea, larynx, or recurrent laryngeal, dys- phagia from the sac projecting into the pharynx or oesophagus (this is more com- mon when the internal is affected), contraction of the pupil and other symptoms from paralysis of the sympathetic, and neuralgia from pressure upon the cervical nerves. The latter are due either to loss of arterial tension in the vessels of the brain, in the same way as in the facial and temporal branches of the external carotid, or to obstruction to the flow in the internal jugular. Giddiness, syncope, noises in the ears, dimness of vision, headache, and violent throbbing are not unfrequently present, and in addition there is always the risk of embolism, with paralysis of smaller or larger centres, from some fragment of clot being detached. The diagnosis in many cases is exceedingly easy ; in a few, however, it is a matter of the greatest difficulty. Aneurysmal dilatation is not at all uncommon at the bifurcation and at the origin of the right common trunk, and if noticed suddenly for the first time, or if it accidentally becomes more prominent from wast- 252 DISEASES AND INJURIES OF SPECIAL STRUCTURES. ing of the tissues around, it may cause considerable uneasiness. Probably the cases in which carotid aneurysms are recorded as having lasted unchanged for years were really examples rather of fusiform expansion than anything else. At the root of the neck, even if the diagnosis of aneurysm is certain, it may be impossible to prove that the carotid only is involved ; aneurysms of the subclavian, the innominate, and even of the arch of the aorta, may simulate it perfectly, so far as position is concerned. Glandular enlargements are usually lobulated and multiijle, and the only difficulty occurs when the artery runs through the centre of a mass of them. A few cases of cysts lying on the artery are on record, but the character of the pulsation is different, and although fluctuation is distinct the contents cannot be emptied out of the sac by pressure. Vascular growths of the thvroid, which occasionally pulsate, move up and down with deglutition, and can be traced into connection with the isthmus. Abscesses and pulsating malignant growths rarely give rise to trouble ; the shape of the swelling, the relation it l:)ears to the vessel, the absence of expansile pulsation, and the effects of distal and proximal compression are sufficiently distinctive. When the aneurysm is situated on the internal carotid, pressing against the tonsil and causing it to project into the pharynx, it may be mistaken for an abscess. Spontaneous cure is very rare. Some cases remain quiet for a long time without enlarging, but the general tendency is for the tumor to increase until it ruptures into the pharynx, trachea, or externally. Suppuration may occur round it, especially after ligature, and embolism of the cerebral arteries, leading to hemiplegia, has happened in several cases — once, at lea.st, while the tumor was being examined. The only treatment possible is compression or ligature, proximal or distal. The common carotid may be compressed with the fingers against the trans- verse process of the sixth cervical vertebra, or above this by grasping the artery behind the sterno-mastoid, between the finger and thumb, the patient's head being bent over to the affected side so as to relax the muscle. Instrumental compre.ssion is rarely successful. In any case, even when the greatest care is used, it is almost impossible to stop the flow of blood for more than two minutes, and often not that long at first, vertigo, faintness, and a sense of .sickness coming on almost at once. Whether this is due to the interruption of the circulation or in part at least to the irritation of the vagus and sympathetic is uncertain. It is more important that after a number of sittings a certain degree of tolerance is established. If this fails proximal ligature must be tried if there is room, distal if there is not. Neither is very successful, and it has been proposed, especially in traumatic cases fwhich, however, are too rare to enter into the question), to resort to the old operation. There is some rea.son, however, to believe that recent results are a good deal better. Suppuration of the sac, and hemiplegia and convulsions from cerebral anaemia, are not unusual consequences. Occasionally pulmonary conges- tion and hypostatic pneumonia occur, possibly from interference with the blood- supply of the base of the brain, but more probably from injury sustained by the vagus or the cardiac branches of the sympathetic. Aneurysm of the external carotid presents no special features. The artery itself should always be secured in preference to the common trunk, if it can pos- sibly be managed, as this avoids one of the most common causes of death. Some- times it is necessary to tie one or more of the branches as well, owing to the special freedom of the collateral circulation. Aneurysm of the extra-cranial portion of the internal carotid can only be treated by pressure or proximal ligature. Aneurysmal varix occasionally occurs in the neck, as a result of stabs and other wounds, involving an artery and a vein. It is most frequent in connection with the common or internal carotid and the internal jugular ; but it has been known to form between the common carotid and the subclavian vein, just where they cross. The immediate effect of such an injury is an enormous extravasation of blood ; if this does not prove fatal, or end in suppuration, the orifices in the ANEURYSM. 253 vessels lying opposite each other may unite and prevent further loss. The symp- toms are those already described, violent pulsation in the veins with dilatation and hypertrophy, palpitation arising from the une([ual pressure in the auricle and the unusual character of the l)lood, and headache, giddiness, noise in the ears, etc., from interference with the cerebral circulation. In most cases there is a distinct thrill along the course of the vein ; and a whizzing or purring noise can nearly always be heard, more or less, over the whole of that side of the head. Not unfrecpiently it is very distressing to the patient, even preventing sleep. Treat- ment should be palliative only. Okiuiai, Aneurysm. Orbital aneurysm is a clinical term used to describe certain pulsating tumors of the orbit, attended with exophthalmos, without implying the invariable presence of any single pathological lesion. In those past middle life it may originate spontaneously or after some slight exertion, or at any age from such accidents as fracture of the base of the anterior fossa of the skull, gunshot injuries, or penetrating w'ounds of the orbit. U.sually the symptoms appear within the first few months, often within a few days. At first there is merely a loud buzzing or roaring sound audible to the patient, then the conjunctiva becomes congested and perhaps chemosis follows. After a while the eyeball projects and begins to pulsate, the ocular muscles lose their power, the pupil becomes fixed, the hollow under the orbital arch is filled up, and a soft, pulsating mass makes its appearance at one angle of the orbit, usually the upper and inner. The veins of the eyelids, the bridge of the nose, and the forehead soon become distended and tortuous ; a distinct thrill and a loud, rasping bruit are perceptible over the swelling ; a large pad of infiltrated mucuous membrane pro- trudes between the lids ; the pulsation of the eyeball becomes more and more distinct, and in many cases the transparency of the media is destroyed. Before this occurs it may be noted with the ophthalmoscope that the disc is unduly prominent and the retinal veins enlarged. Small hemorrhages, too, may be present. Finally the opposite eye and orbit may become affected in the same way, and in extreme cases the dilatation of the veins may extend over a great part of the face. The noises in the head and the bruit cea.se as soon as pressure is applied to the carotid on the corresponding side ; if it is kept up the globe recedes and the pulsa- tion diminishes or stops altogether. It has been clearly demonstrated by Rivington that the pathological lesion underlying this condition is probably always a communication between the internal carotid artery and the cavernous sinus, sometimes caused by injury, sometimes due to the rupture of an aneurysm or the giving way of the floor of an atheromatous ulcer. The immediate effect is the rush of arterial blood, under high pressure, into the ophthalmic vein, causing at first merely pain and a peculiar buzzing noise audible to the patient ; but later, as the vein becomes enlarged and distended, and as with its increasing size the pressure in its interior becomes greater and greater, giving rise to the exophthalmos and the signs of aneurysmal varix extending on to the face. The communication between the two cavernous sinuses explains the fact that one eye may become affected after the other. Aneurysm of the ophthalmic artery may cause exophthalmos, but cannot produce a pulsating tumor at the angle of the orbit or the distention and thrill in the veins. The venous sinuses of the cranium notunfrequently become throm- bosed, but do not of themselves lead to the development of pulsating tumors, although they may cause some degree of proptosis with passive congestion of the eyeball, dilated pupil, restricted movements, and diminished vision. Aneurysms of the internal carotid (unruptured) may project into the cavernous sinus without giving rise to the essential symptoms of this disorder. The rare examples of erectile and cavernous tumors met with in the orbit might produce something of the same 254 DISEASES AND INJURIES OF SPECIAL STRUCTURES. character, but without pulsation or bruit. Cirsoid aneurysms undoubtedly could, but it has never yet been found in this locality, and Rivington suggests that in many cases, in other parts of the body, especially where it has followed injury, it is really a form of aneurysmal varix itself rather than true cirsoid aneurysm. The greatest difficulty occurs with pulsating sarcomata growing from the back of the orbit. For a time at least they may cause symptoms of an almost identical character, but the bruit is usually absent, and when it is present is of a very different description ; and extension of the grow^th always takes place very rapidly. Treatment. — The only treatment at all satisfactory in its results is compres- sion or ligature of the common carotid. The former has seldom been tried, owing to the difficulty of maintaining it for more than a minute or two ; but probably it deserves more attention than it has received. The latter has been very successful both in the traumatic and, though to a less extent, in the spontaneous variety. In one or two instances both vessels have been tied, though not at the same time, owing to persistence or recurrence of the symptoms. This may have been cau.sed by the clot being wa.shed away before organization had rendered it sufficiently firm, or by unusual freedom of communication between the two cavernous sinu.ses, or by the blood having found its way into the orbit through other veins as well as the ophthalmic. Vision is lost in a large number of cases, chiefly from ulceration of the cornea and collapse of the eyeball. This may sometimes be checked by early operation, certainly it is favored by delay ; but it is impossible to predict what will result in any given case, as the ligature of the vessel itself under these circumstances may so interfere with the circulation through the eye as to impair the transparency of the media. Aneurysms of the Subclavian. These, like aneurysms of the carotid and innominate, may be divided into two classes : those which are limited to the third part of the arter\% that which descends beneath the clavicle, terminating at the lower border of the first rib ; and those which implicate the first part, whether they are limited to this or extend over the rest as well. Like aneurysms elsewhere (with the exception of the carotid), they are much more common in men than in women, and, for the most part, occur upon the right side. Subclavian aneurysms rarely attain large size before rupture takes place. They usually form an elongated swelling behind and above the clavicle, with all the characteristic signs of aneurysm, pulsation, bruit, etc. The pressure symptoms vary according to the locality ; when the inner part is concerned, the recurrent laryn- geal nerve and the internal jugular vein are compressed ; when the outer, the sub- clavian vein, the external jugular, and some of the cords of the brachial plexus. In general, the prominence is chiefly upward, but occasionally the sac enlarges in the direction of the pleura, and it may become adherent to it ; and sometimes the phrenic nerve, the trachea, and the oesophagus are compressed. Enlarged glands may, as in the case of the carotid, surround the vessel and lead to a certain amount of difficulty in diagnosis ; and chronic abscess may occur in connection with them or with other structures, and produce at first sight a closely similar appearance ; but the effect of compression upon the artery or upon the sac is conclusive. The difficulty of determining how far inward the dilatation extends is often very great, especially on the right side ; but, as a rule, the comparison of the pulse in the branches of the carotid on the two .sides is enough to determine whether the innominate is involved or not. Spontaneous cure is said to have occurred in a few cases from embolism. As a rule, the sac enlarges very slowly for a time, and then suddenly gives way, causing an immense extravasation, which may prove fatal from pressure, or may burst into the pleura, the trachea, or externally. The treatment of subclavian aneurysm is most unsatisfactory. Proximal liga- ture, unless the aneurysm is really axillary rather than subclavian, is practically ANEURYSM. 255 hopeless. Ligature of the innominate or of the first part of the siil)clavian on the right side has proved ahiiost invariably fatal from secondary hemorrhage ; while on the left side ligature of the corresponding trunk is out of the question. Proximal compression is ecpially impossible, except in the case of some rare anatomical abnormality. Distal ligature has not proved any better, i)robal)ly owing to the very large collateral l)ranches coming off from the sac itself or its immediate vicinity. Am- putation at the shoulder joint has been performed on one or two occasions with the view of meeting this, but without sufficient success to justify repetition. Rest and diet should be thoroughly tried in every case first. If they do not succeed, and the sac contains sufficient fibrin, direct pressure with manipulation affords the best hope, always provided the carotid is not involved. Under other circumstances, prolonged galvano-puncture would prol)ably answer better ; or an attempt might be made to procure solidification by the introduction of a short length of iron wire ; but the prognosis in all such cases is very grave, and the risk of suppuration setting in very great. Axillary Aneurysm. This is chiefly remarkable for the rapidity of its development and the fre- quency with which it can be traced to a definite injury. As might be expected, it is much more common among men than women, and nearly always occurs upon the right side. Any part of the artery may be involved, and it may project downward into the axilla, inward toward the thorax, so that the ribs become absorbed ; or upward under the clavicle, raising the shoulder. The movements of the arm are naturally restricted, the head is inclined to that side, the elbow is abducted, and not un frequently there is great pain running down the arm from pressure upon the brachial plexus, or oedema from occlusion of the axillary vein. Spontaneous cure is very rare, if it ever happens. If left to itself the sac rapidly enlarges and either becomes inflamed and suppurates (to which it is espe- cially prone) or ruptures into the loose cellular tissue of the axilla, the shoulder joint, or the thorax. The treatment, if the aneurysm is limited to the axilla, is comparatively .simple. Compression of the third part of the subclavian should be tried first ; but after a short time it usually becomes exceedingly painful, and if it is kept up is not with- out danger to the brachial plexus. If it cannot be borne, Esmarch's bandage may be used under an anaesthetic, the circulation above being controlled with a rubber cord arranged round the axilla in a figure-of-eight, as high as possible ; or a liga- ture maybe placed round the third part of the subclavian. When, however, the clavicle is pushed up by an immense tumor, and it is doubtful how far the aneurysm is subclavian and how far it is axillary, the question becomes much more difficult. Rest and diet may succeed, but usually the tumor continues to increase unchecked. Direct pressure and manipulation are not suitable, owang to the thinness of the sac and the rapidity of its growth, while galvano-puncture and the introduction of foreign substances are almost sure to excite inflammation and very possibly sup- puration. The best chance lies in ligature of the subclavian as far away as pos- sible, dividing the scalenus anticus, and drawing the phrenic nerve inward out of the way, if it appears necessary. Any branch that comes off from the main trunk near the seat of ligature should be tied too, to diminish as much as possible the risk of secondary hemorrhage ; but the operation is one of extreme difficulty, and, owing to the manipulation necessary, is very likely to be followed by inflammation either of the sac or of the pleura and its contents. Aneurysms of arteries below the axillary are rare except as a result of embo- lism or injury. There is nothing special either in their symptoms or their treatment. 256 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Abdominal Aneurysm. Fusiform, dissecting, and sacculated aneurysms are described in connection with the abdominal aorta and its branches. The last is the most common and is the only one capable of treatment. It may occur at any part and may either involve the roots of some of the large branches, such as the cteliac axis, or may cause their obliteration by its pres- sure. Usually, it projects forward in the direction of least resistance ; but instances have been known of aneurysms originating on the posterior surface, and eating their way into the bodies of the vertebrae. Generally there is a distinct history of injury, or, if not, of some especially laborious occupation ; when there is not, when the dilatation is apparently spontaneous, it is probable that the vessel is seriously diseased. One or two instances of spontaneous recovery are recorded, the condition not having been even suspected during life. The svmptoms are very obscure until the sac has attained a considerable size. Pain is usually present, but it varies very much in character ; in some cases it is continuous, in others paroxysmal ; sometimes it radiates along the course of the nerves, at others it is fixed and localized; and the character is equally vague. Pulsation of the typical expansive description with a distinct systolic bruit, audible behind as well as in front, is nearly always present from the first, but often it is not noticed until it compels attention. Dyspnoea may occur from pressure upward toward the diaphragm ; dyspepsia, colic, constipation, and other troubles from interference with the stomach and intestines. Jaundice has been known from compression of the bile-duct. The liver may be displaced, or the left kidney ; but uriemia, anasarca, ascites, and other troubles that arise from pressure upon veins are seldom met with. The tumor is generally fixed, not moving with the diaphragm ; and the pulsation is usually most marked a little to the left of the middle line ; but especially when the upper part of the vessel is concerned it may require very deep pressure to feel it at all. Diagnosis. — The chief difficulty occurs in connection with a form of dila- tation which, especially in thin subjects, may be so striking and so distinctly ex- pansive as to simulate aneurysm very closely. Lumbar and psoas abscess, solid tumors resting on the front of the aorta, and pulsating growths in connection with the vertebrae mav be mistaken for it. Aneurysm of the coiliac axis usually pro- jects forward toward the right side under the liver ; when the sui)erior mesenteric is involved the tumor is more movable, but this does not hold good when the origin is affected. The character of the pulse-wave in the lower extremities should always be carefully investigated, although it does not give very clear indications, owing to the difficulty of comparison. As a rule, the course of the disease is very rapid ; the structures round yield readily and there is nothing to restrain the growth of the tumor. Death is usually sudden from rupture into the peritoneal cavity, but occasionally leakage is more slow and an ill-defined swelling forms in the iliac or lumbar region, and delays the end for a few days. A very marked degree of emaciation is not uncommon ; and the loss of strength and exhaustion, partly from the interference with the circula- tion, partly from digestive troubles, want of sleep, and pain, may be so great as to prove fatal before the sac gives way. Treatment. — Although one or two instances of spontaneous cure are known to have occurred, the treatment by rest and diet holds out a very slender chance. Probably this is due in great measure to the absence of support from the tissues around, and to the high degree of pressure in the sac. If there is no material im- provement within a fortnight or three weeks, there is not likely to be any afterward; and then it becomes a question whether something fiirther should be attempted. This depends upon the position of the aneurysm, whether it is above or below the renal arteries ; on its shape, whether it is sacculated or not; on its origin, whether it was spontaneous or distinctly traumatic ; and on the condition of the heart, the kidneys, and the other vessels. ANEURYSM. 257 If everything is fiivorable, the choice lies l)et\veen proximal or distal jiressure and opening the abdomen and introducing foreign substances into the sac, as in Loreta's case already mentioned. Proximal pressure is undoubtedly the best of these; but, without opening the abdomen, it cannot be effected above the renal arteries ; the aorta lies too deeply and is covered with structures, especially the pancreas, which may not be bruised. If the abdomen is opened, as has recently been done by Keetley, pressure can be applied almost directly to the vessel, but of course in such a case this itself is a serious matter. The bowels must be thoroughly cleared out with aperients and enemata, the l)ladder emj)tied, and care taken that the stomach contains no solid food. Then the patient must be placed under an anaesthetic, and Lister's or Carte's tourniquet carefully adjusted above the swelling, and slowly screwed down until the pulsation of the aneurysm is checked. It need not be said that this is only possible in a very limited number of cases. Once fixed, no current should be allowed to flow through until it is determined to bring the procedure to an end ; any rush of blood, such as would ensue from relaxing the pressure too soon, would at once sweep the coagulum away. How long com- pression can be maintained depends upon the condition of the patient. If there is no sign of shock, it may be kept up for three or perha])s four hours ; and possibly at the end of that time pulsation may be so much diminished that consolidation will follow of itself. In several cases, however, peritonitis has occurred, and proved fatal from the amount of l)ruising. Afterward, and for some time, the patient must be kept as quiet as possible in the hope that the coagulum will remain firm. Where this cannot be carried out, distal compression may be tried. In a few instances the two have been used together so as to ensure complete cessation of the circulation through the sac. By itself it is certainly not so effectual. Cessation of pulsation is attended by great loss of power with coldness and deficient sensibility in the parts below. After a time, if they are kept warm and protected from injury, this passes off and pulsation can be detected in the larger trunks again ; but naturally the collateral circulation, in man at least, can scarcely become sufficiently developed to replace the aorta. Iliac Aneurysm. Aneurysm of the common, external, or internal iliac artery forms a soft, cir- cumscribed swelling in the line of the vessel, with characteristic expansive pulsa- tion and bruit continued along its course. The pain is rarely severe unless the obturator or genito-crural nerve is involved ; and owing to the space around, other signs are often wanting until the tumor has reached a large size. If left it usually ends in rupture ; but in one or two instances oedema and gangrene have occured from venous obstruction. Diagnosis. — Aortic aneurysm, springing from just above the bifurcation, has been known to spread down as low as Poupart's ligament. Enlarged glands round the artery may cause a momentary doubt. Tumors growing from the bones, especially pulsating sarcomata, are much more difficult ; but in most cases they may- be distinguished by their extent, position, attachment to the bone, feeble, ill-defined bruit, and different pulsation. Moreover, they cannot be emptied by pressure ; they do not alter the pulse-tracing in the same way ; and the bruit (when there is one) is not carried along the artery. Abscesses in the same region require careful examination, as aneurysms not unfrequently send outlying pouches, which scarcely pulsate, under Poupart's ligament. In every case the rectum should be thoroughly explored. Treatment. — This depends upon the position, whether the common trunk is affected, or merely that part of the external branch which lies near Poupart's liga- ment. In the former case, if rest and diet do not soon effect a decided improve- ment, the same treatment must be adopted as for aneurysm at the bifurcation, proximal pressure with or without distal. If low down, either the same plan may be tried, or the common or external iliac may be ligatured according to the height 258 DISEASES AND INJURIES OF SPECIAL STRUCTURES. to which the sac ascends. Where neither of these methods is practicable, galvano- piincture affords the best hope ; distal ligature has never proved successful, and the injection of coagulants (although perchloride of iron once very nearly succeeded) is almost certain to give rise either to gangrene of the limb or suppuration of the sac. Aneurysm of the Branches of the Internal Iliac. The gluteal, and less frequently the sciatic and pudic arteries, are occasionally the seat of aneurysms, the majority being traumatic in origin. In some cases, especially when the sciatic is concerned, the sac lies partly inside the pelvis, partly outside ; in most it is altogether extra-pelvic. The mode of origin gives no clue to this, as either of the arteries may be wounded in the sacro-sciatic foramen and then retract ; the only way in which it can be ascertained is by rectal or, in the female, vaginal examination. Symptoms. — When the aneurysm is small, these are very vague, owing to the dejjth at which it is situated. There is jiain along the course of the sciatic nerve ; the movements of the hip are limited, especially in the direction of flexion ; and usually there is a hard, deep, ill-defined swelling. Pulsation and a bruit are rarely absent when it has reached any size, but so long as the sac is small it is very difficult to make certain. If left, spontaneous cure is possible, but very rare ; much more often the sac continues to enlarge ; the muscle and the tissues over it waste ; and at length rupture takes place. There is no means of telling sciatic from gluteal aneurysm, although the former is more })robable if the sac can be felt inside the pelvis. Diagnosis. — Pulsating Sarcoma. — In its early stages this is very difficult ; later, rectal examination or puncture with a fine trocar and cannula will give sufficient evidence. A bruit is greatly in favor of the tumor being aneurysmal, as it is rarely present in a sarcoma until this has attained a consideral)le size, and even then it is much softer in tone. Abscess. — The absence of pulsation and bruit is usually sufficient in chronic abscesses, the signs of suppuration in acute ones, but it must be remembered that gluteal aneurysms not unfrequently suppurate. Enlarged Bursa. — The subgluteal bursa may become distended with blood or serous fluid, but there is no bruit or pulsation, in spite of the thinness of the walls, and there is no tension ujjon the contents. Arterial Hcematoma. — Unless there is a distinct history of injury, or a cicatrix or some other evidence, a definite diagnosis may be impossible. The rapidity of formation and extension, the absence of pulsation and bruit, the tension and inflam- mation of the parts around are equally sugge.stive of abscess, arterial haematoma, and ruptured aneurysm. Of these the first can be excluded by means of an ex- ploratory puncture ; the other two are identical and require the same treatment. Treatment. — Constitutional treatment should be tried in these as in all other kinds of aneurysm first ; if they fail, resort must be had to operation. Pressure cannot be carried out, unless applied to the l)ifiir(;ation of the ab- dominal aorta. Perhaps this might be worth a trial first, under an anaesthetic. In the intrapelvic form ligature of the internal or common iliac is very serious, as an- eurysm rarely involves this part of the vessel without extensive atheroma. In the extra-pelvic one, the old operation, laying the whole sac open, necessitated an in- cision in Syme's case nearly two feet long, and this was followed by extensive ne- crosis and suppuration. Probably, therefore, unless the sac has already given way these aneurysms are best treated by galvano-puncture, or even the injection of co- agulants such as perchloride of iron. If supi)uration occurs and bleeding follows the opening of the abscess, the cavity must be packed from the bottom. Embo- lism would not be so serious a matter as in most other parts of the body. ANEURYSM. Fkmokai, ANr:uRvsM. 259 Aneurysm may occur in the course of the common, the superficial, or the deep femoral artery. Usually it is sacculated, hut occasionally fusiform ; sometimes in Hunter's canal it is rather flattened. As a rule there is no difficulty in the diagnosis, all the characteristic signs be- ing present, but not unfrequently it is almost impossible to distinguish whether the dilatation is on the superficial or the deep branch ; the former of the two is much the more common, and affects the pulse below to a greater extent, but this cannot always be relied ujjon. Of course if the pulsation of the superficial trunk can be distinctly made out overlying the deep one, there is no difficulty. The treatment consists in proximal pressure, instrumental or preferably digi- tal, and if this fails, ligature. If the aneurysm is in Hunter's canal, the same artery may be tied higher up ; if in Scarpa's triangle, or if the profunda is involved, the choice lies between ligation of the external iliac or of the common femoral. The former is usually preferred, owing to its freedom from branches at the seat of ligature, the better development of the collateral circulation, and the fact that it is less frequently atheromatous ; but the latter has been shown to be very successful in actual practice. PoPLiTE.AL Aneurysm, The popliteal artery is the most common seat of aneurysm, except the aorta itself. It is peculiarly liable to atheroma ; it is not supported by the structures around ; it is compressed more or less in flexion of the knee, stretched out in over- extension, sometimes even ruptured ; and immediately below it breaks up into a number of branches, so that an embolus, if it comes down the vessel, is almost certain to lodge there. That constitutional causes are of very great importance is shown by the fact that it sometimes occurs on both sides, and that it may even develop upon the second while the patient is lying in bed being treated for the first. Fusiform dilatation is occasionally met with, but sacculated aneurysm is much more common. In some cases it springs from the anterior surface of the artery and grows forward against the bone or the posterior ligament of the knee joint, and then it is usually slow in its course, rarely attaining a large size. In others it extends backward, and, meeting with little to oppose it, becomes immense, form- ing a thin-walled sac within comparatively a short space of time. Symptoms. — Occasionally the onset is sudden, dating from some exertion ; more frequently, the patient suffers from obscure rheumatic pain down the leg with stiffness of the joint and a sense of weakness, and then suddenly discovers, or has discovered for him, the presence of a pulsating swelling. Usually the expansive pulsation, the bruit conducted down the leg, and the way in which the sac empties upon compression and fills again on relaxation of the vessel are distinctive. Oc- casionally the tumor is harder and cannot be emptied, the pulsation is that of an artery only, and the bruit is indistinct and faint ; and in some very rare instances there is no pulsation at all. Probably, in the former case, the sac is already partly filled with fibrin, and possibly in the latter it is completely solid ; but as pulsation sometimes makes its appearance later, this explanation is hardly satisfactory. If the sac grows forward, synovitis of the knee joint sets in, the pain is very severe, and movement greatly restricted. If it takes a direction backward, the popliteal vein may be compressed and congestion and oedema follow ; or the in- ternal popliteal nerve may be stretched so that there is severe neuralgia extending down the side of the limb into the sole of the foot. Sometimes a distinct differ- ence can be made out in the two tibial pulses. Left to itself it occasionally undergoes spontaneous cure. Much more fre- quently it grows larger and larger, leaks, and ruptures either into the knee joint, or more usually into the cellular tissue of the leg. In either case the patient is con- 2 6o DISEASES AND INJURIES OF SPECIAL STRUCTURES. scions of something having given way, and becomes sick and faint with the pain and loss of blood. If the rupture takes place through the posterior ligament the knee becomes immensely distended at once, but the bruit and pulsation do not altogether cease, and the pulse can still be felt, though feebly, in the posterior tibial. If it is into the cellular tissue, a tense swelling forms rapidly in the popli- teal space, filling it completely and causing the most severe pain ; the limb below becomes cold and livid, the tibials cannot be felt, and in a very short time gan- grene sets in. Occasionally inflammation breaks out round the sac, the skin becomes red, oedematous, and exceedingly painful, and sometimes this is followed by suppuration. The diagnosis must be made from sarcoma growing either from the bones, the posterior ligament of the knee joint, or the lymphatic glands ; abscess ; bursal cyst, or diverticulum from the knee joint ; and solid tumors resting upon the artery. Arterial haematoma from perforation of the popliteal artery gives rise to the same symptoms as a leaking or a ruptured aneurysm, according to the size of the opening. In one case under my care there was a distinct bruit with faint pul- sation along the course of the vessel. Treatment. — Rest and diet are employed here only as adjuncts, but they should never be neglected, and unless the sac is enlarging rapidly, so that there is fear of rupture, it is always advisable to submit the patient to a few days' prepara- tion before employing any active treatment. If the aneurysm is of moderate size only, and there is no fear of immediate rupture, Reid's method with Esmarch's bandage, or digital compression, is the best, preference being given to the latter if there is much evidence of atheroma or of heart-disease ; to the former if, other things being suitable, there are enlarged glands in the groin. Flexion succeeds well with those that are small or already partially solidified. If these measures fail, or if the sac is enlarging rapidly and perhaps leaking, or if inflammation has set in, or if there is any oedema of the foot from pressure upon the popliteal vein, the artery should be tied at once at the apex of Scarpa's triangle, and the limb well wrapped in cotton-wool and raised. Moist gangrene after ligature, rupture of the sac into the cellular tissue or into the knee joint, disease of the knee joint, caries of the lower end of the femur, and suppuration round the sac, require amputation. If dry gangrene occurs, the parts may be covered with some antiseptic powder, raised, and wrapped in cotton-wool, in the hope that a line of demarcation will form. Recurrent pulsation after ligature must be treated by compression, Esmarch's bandage, or flexion ; if these fail and the patient is a young man with the rest of his arteries healthy, the external iliac may be tied ; if old, it would probably be better to amputate at once. If secondary hemorrhage occurs from the seat of ligature, the wound must be opened and both ends tied ; if this does not succeed, or the wound is in such a condition that success is improbable, amputation should be performed. OPERATIONS ON ARTERIES. 261 SECTION IV.— OPERATIONS ON ARTERIES. Arteries may require to be compressed so as to check the flow of blood for a time, or Hgatured. In either case it is usual to select certain points, owing to their being more accessible, or i'urther removed from important structures, or because of the condition of the collateral circulation. Wounds of arteries have been already- dealt with. Gener.\l Rules for Lkjatuke. The position of the patient must be such as to bring the artery as near the surface as possible, and at the same time make the various anatomical features of the limb stand out distinctly. The e.xact course of the vessel must be made out by feeling for its pulsation where this is possible, and by making use of the ordinary anatomical guides. In many cases it is advisable to mark it out upon the skin with an aniline pencil. Careful examination must be made for any abnormality either of the trunk itself or of its branches. Other things being equal, the sjjot selected should always be far away from any large branch. If this is impossible, or if when the artery is exposed it is found that one is near, it should be tied as well. As a rule, the incision should be in the course of the vessel, over it (excep- tions will be mentioned later on), the middle corresponding to the spot at which the artery is to be tied, and the length depending upon the amount of fat that is present and the depth of the.vessel. The first incision should divide the skin and the superficial fascia, taking care to avoid any large subcutaneous veins, such as the internal saphena or the external jugular. The deep fascia should be divided on a director to the same extent, and this holds good for every other incision ; the bottom of the wound, that is to say, should be kept throughout in the same plane, not deeper in one part than in another. Each anatomical structure should be recognized as it is exposed, the operator carefully making out the various landmarks in turn. Muscles, when identified, should be drawn to one side, the fascia which binds them down being divided if necessary, and the position of the limb being changed if they are too tense. The sheath of the vessel is recognized by its position, by the pulsation of the artery, and by the sensation the finger receives. When an artery is compressed it feels like a flattened band with thick and rounded edges, and it empties beyond the finger ; a vein can hardly be felt at all, while a nerve is round and solid. The sheath is formed of dense fibrous tissue, and in the larger arteries is separated from the outer wall of the vessel by more or less of a space traversed by minute blood-vessels and delicate connefctive tissue. In many cases the vein is enclosed with it, in a separate compartment, and sometimes a nerve as well. The nutrition of the coats of the artery depends almost entirely upon the vessels it receives in this way, and consequently the opening must be as small as is con- veniently possible, the sheath must be separated as little as can be, and care must be taken to open the right compartment. The loose areolar tissue that covers the sheath is lifted up with a pair of forceps at one spot, so as to form a small cone ; the side of this is cut with a scalpel held upon the flat, so that the edge does not at any time face the artery, and an opening made sufficiently wide to see thebluish- Avhite external coat of the vessel beneath. One edge of this opening is held up 262 DISEASES AND INJURIES OF SEE CIA I STRUCTURES. with a ])air of fine forceps, to make it tense, and the vessel gently separated from its sheath with an aneurysm-needle or a director. The other edge is then laid hold of and tlie process repeated on that side, until the whole circumference is detached for a very short distance. The aneurysm-needle is then passed round (unthreaded), keeping as close to the wall of the vessel as possible, and begin- ning on the side that faces the most important structure, whether it is vein or nerve. As the needle passes round, the opposite edge of the opening in the sheath should be seized with forceps and drawn outward in order to straighten out the route. Sometimes a few strands of tissue covering the point of the needle require division with the finger-nail, or even with the scalpel, but great care should be taken to keep the edge and the point away from the vessel as far as pos- sible (Fig. 55). When the needle has been passed, Fig. 55.— This diagram represents three distinct opera- the VeSSel is COmpreSSCd agaiust it with tions. A. Opening the Sheath. B. Drawing Ligature .^ r- ^ ^ ^^ ^ • ^ • ,-\ round the Artery, c Tying Artery. the finger, to make surc that it IS the artery (pulsation ceasing beyond) and that nothing else is included with it. Then the needle is threaded and with- drawn. A reef-knot should always be used. A few attempts have been made to sub- stitute a loop or hitch to avoid the pro- jection, but the same reliance cannot be placed upon it. The amount of pressure should be sufficient to draw the inner coat well together. AVhether this will divide it in the middle depends upon the shape and material of the ligature. With a flat band (such as Barwell's ox aorta) it certainly will not ; with stout catgut it is very doubtful ; with fine gut, kangaroo tendon, or silk, there is no question. In any case, the greatest care should be taken, in tying the knot, not to lift the vessel unnecessarily from its bed ; the fingers must be brought down to it. When a double ligature is used and the artery divided in between, it must be separated from its sheath for some little distance ; how far depends upon its size. The object is to enable the two ends to retract thoroughly. The portions that lie beyond the ligatures are practically cut off from the circulation, in the same way as the end of an artery that is tied or twisted on the face of a stum]), and like it either slough or become infiltrated with organizing lymph, according to the behavior of the wound and the addition or not of suppuration. This plan should be adopted in every case in which a sufficient length of artery can be exposed without inter- fering with the part too much. Fig. 56. — Aneurysm-needle. Ligature of the Innominate. The line of the artery runs from the middle of the manubrium to the right sterno-clavicular articulation ; the point of bifiircation is usually just below the upper border of the joint. The patient lies on his back with the shoulders slightly raised and the head turned toward the left. The operator stands upon the right side. The incision is triangular ; one side extends for three inches along the inner border of the right sterno-mastoid [in Smyth's case the incision was made along OPERATIONS ON ARTERIES. 263 the A// sterno-cleido mastoid], entling on the .sternum, the other outward from the lower end of this along the ui)per border of the clavicle ; the flap so formed is reflected outward on its base. The sternal head of the sterno-mastoid and the greater portion of the clavicular one are divided upon a director, close to their origin, and reflected in the same direction as the skin. The anterior jugular vein is drawn on one side or tied, as the case requires. The sterno-hyoid and the sterno-thyroid muscles are divided as far as they are exposed. The third layer of the cervical fascia is now laid bare. An incision is made in this over the common carotid ; the artery is followed down- ward with the finger until the origin of the subclavian can be felt and seen ; the internal jugular vein and the pneumogastric nerve are drawn to the other side, and the anterior surface of the sheath cleared by gently separating the loose fat and the numerous thyroid and other veins lying in it. The pleura is pushed to the right, the veins to the left, the sheath opened in between, and the needle pas.sed from right to left. A very great deal depends upon the length of the vessel. If possible there should be at least half an inch between the bifurcation and the ligature, and, to obtain this, part of the sternum and clavicle may be cut away if necessary. If there is not so much the base of the carotid should be tied as well, but there is never sufficient of the subclavian. The operation has succeeded only once in eighteen times, secondary hemorrhage having nearly always occurred from the distal end ; but possibly with more suitable animal ligatures of sufficient size and strength better results may be obtained. Several patients lived for long periods, notably Thomson's, of Dublin. Sedillot recommends a single longitudinal incision between the two heads of the sterno-mastoid, as enabling a better examination to be made of the bifurcation and the branches. Ligature of the Common Carotid. The line of the artery, whatever the position of the head, runs from the sterno- clavicular articulation to the lobule of the ear. It extends from the joint as high as the upper border of the thyroid cartilage, and is crossed opposite the cricoid cartilage by the omo-hyoid. It may be tied at the root of the neck, below the omo-hyoid or above it. If a choice is allowed the point selected is at the upper border of the muscle. I. At the Root of the Neck. — The position of the patient at first is the same as for ligature of the innominate. Afterward the head is slightly raised and rotated to relax the sterno-mastoid muscle. Either the angular incision may be used or Sedillot's longitudinal one between the two heads of the muscle. The preliminary steps are the same as tho.se described already, the sternal head of the sterno-mastoid being divided on a direc- tor if sufficient room cannot be obtained without. The sterno-hyoid and sterno- thyroid muscles are drawn inward with a retractor or notched, the cervical fascia divided, great care being taken not to wound the numerous thyroid and other veins that lie beneath, and the sheath of the vessel exposed. This must be opened well to the inner side and the needle passed from without inward. On the right side the pneumogastric and the jugular recede somewhat from the artery, and they may be drawn still further away by applying a retractor to the clavicular part of the sterno-mastoid ; on the left the vein may overlap it, and the thoracic duct lies immediately behind. The ligature should always be placed on the artery as far as possible from its origin, and this operation should not be selected unless, from the presence of aneurysm or from other cause, no choice is left. If it is attempted the artery will be found to lie much deeper than is generally expected. 2 and 3. Ligature Imtnediately Above or Below the Omo-hyoid Muscle. — The position of the patient is the same, the head being turned to the opposite side. An incision two inches and a half in length is made along the inner border of the 264 niSEASES AND INJURIES OF SPECIAL STRUCTURES. sterno-mastoid ; usually its centre lies opposite the cricoid cartilage, but it may be higher or lower as the case requires. The skin, superficial fascia, and platysma are divided first; the deep fascia is slit up on a director, exposing the inner border of the sterno-mastoid, and avoiding, if possible, the sterno-mastoid artery, thyroid veins, and a communicating vein that often runs down along the inner l)order of the muscle from the facial to the anterior jugular. If this cannot be done the ves- sels must be tied. The head is now slightly raised, the sterno-mastoid drawn out- ward, the sterno-hyoid and sterno-thyroid inward, the deep fascia divided, and the omo-hyoid exposed lying upon the sheath, with usually some filaments of the descendens noni nerve. The sheath is opened on the inner side, avoiding the veins which often cross the upper part, and the needle introduced from without inward. This operation may be required for wound of tlie artery, for liemorrhage from —-\j>tsccndc7is ^cni neri'e -—Omc-Jiycid ■X inusric Mastoid Muscle Fig. 57. — Ligature of the Common Carotid and Facial Arteries. or aneurysm of either the trunk or any of the branches of the internal or external carotid, or as part of the distal operation for aneurysm of the innominate of the aorta. Owing to the effect upon the circulation through the brain the two carotids should never be tied simultaneously, and if one is blocked the effect of temporary pressure should be tried upon the other before a permanent ligature is a])plied. Life has been maintained after both carotids and one vertebral have been ob.structed ; but, on the other hand, symptoms of cerebral an?emia have occasionally followed ligature of one, and not unfrequenlly that of both, even when the operations were performed with a considerable interval. The common carotid can be com])ressed against the tuljercle on the transverse process of the sixth cervical vertebra (the cricoid is opposite the fifth) by pre.ssure backward, or a little above this by grasping the artery between the finger and thumb, behind the sterno-mastoid when it is relaxed. Both are very painful and liable to cause syncope if kept up for more than a minute or two. OPERATIONS ON ARTERIES. 26 q LKiATl'KK OK THE Ex'I F.KNAl. C'aKOTID. The line of the artery runs from the back of the thyroid cartilage almost directly upward to the posterior part of the condyle of the lower jaw. The posi- tion of the jiatient is the same, with the face turned rather more to the opposite side. An incision is maile from behind the angle of the lower jaw to a short distance below the upi)er border of the thyroid cartilage, dividing the skin, superficial fascia and platysma, and watching carefully for the anterior division of the temporo-max- 'illary vein. This emerges from the lower border of the parotid and runs to join the facial, piercing the fa.scia either just below the gland or some little distance down. The anterior margin of the sterno-mastoid is then defined, its sheath laid open, and the deep fascia beneath carefully divided upon a director. The artery is usually tied opposite the cornu of the hyoid bone, the sheath being opened a little below and the needle passed from without inward. Any veins that come in the way — thyroid, lingual, or facial — are either pulled on one side or tied with a double ligature and divided. If the temporal i)ulse is watched there is no fear of mistaking the trunk of the internal for that of the external, although it often lies more superficially at its origin. The usual seat of ligature, at the level of the cornu of the hyoid bone, lies be- tween the superior thyroid and lingual arteries. When, however, the object is to cut off the blood -supply from the middle meningeal or some other branch of the internal maxillary, the vessel may be secured immediately under the margin of the parotid. Ligature of the external carotid is a very much more favorable operation than that of the common, partly because it avoids one of the great sources of collateral circulation and secondary hemorrhage, partly because it does not interfere with the blood-supply of the brain. It should always be adopted in preference where it can be shown that one of its branches — the middle meningeal, for example — has been injured, or where this is exceedingly probable, as in stabs and other injuries in the region of the parotid. On the other hand, in punctured wounds of the tonsil, in cases of sloughing diphtheritic and scarlatinal ulcers, and when the seat of the injury is in the region of the greater cornu of the hyoid bone, where the internal carotid is more superficial than the external, ligature of the common trunk affords the better prospect, always provided that the bleeding point cannot be secured in situ. It must be remembered, with regard to injuries of the tonsil, that wounds of the ascending pharyngeal are no less fatal than those of the carotid ; when a small branch arises from a main trunk the pressure in it near its point of origin is scarcely less than that in the trunk itself. Ligature of the Internal Carotid. This can be done through the same incision, the external carotid being drawn forward and the internal jugular vein backward. The needle is passed from without inward. The operation has been performed in a fair number of cases with success. Ligature of the Lingual Artery. The chief landmark is the greater cornu of the hyoid bone. The artery arises from the external carotid opposite this (when the body is in the position for ligature), and runs some little distance along its upper border. It may be tied either before or after it passes beneath the posterior belly of the digastric. [It should be remembered that occasionally this artery is given off from the superior thyroid instead of the external carotid.] The head of the patient is thrown well back and turned toward the opposite side. I. Behind the Digastric. — The incision, two inches in length, starts from the 18 ' * 266 i:>/SEAS£S AND J.Y/ CRIES OF SPECIAL STRC/CIXIiES. margin of the sterno-mastoid. and runs slightly curving upward immediately above the greater cornu. The skin, superficial fascia, and i)latysma are divided, watch being kept for the facial vein toward the posterior angle of the wound. If it is seen it must be pulled on one side. The projection of the submaxillary gland fills the upper portion of the incision and overlaps the other structures ; the deep fascia is divided on a director along its lower border, the gland pushed up, out of the way, the tip of the greater cornu drawn down with a hook, and the posterior margin of the digastric defined. The angle between this and the upper margin of the hyoid is then carefully cleaned, the hypoglossal nerve pushed upward, the ranine vein avoided, and the posterior fibres of the hyoglossus exposed. These" are either divided on a director, pushing it between them and the middle con- strictor ; or by picking them up with a pair of forceps and cutting through them layer by layer. The artery lies with one, and sometimes two veins, close above the bone. 2. After it Juts Passt-i1 tiic Dii^^astric. — The position is the .same, but the inci- sion starts half an inch below and external to the symphysis, runs downward to the junction of the greater cornu and the body, and then turns upward to a little below the angle of the jaw. The structures are divided in the same way, the submaxillary gland pushed up, and a triangle exposed formed by the two bellies of the digastric and the hypoglossal nerve, dipping under the mylohyoid in front. The fat and loose cellular tissue which fill this space are removed, care being taken not to in- jure the ranine vein ; the fibres of the hyoglossus, which form the floor, divided layer by layer : and the lingual artery, with its one or two veins, exposed, lying parallel to the upper border of the bone. T.IGATURE OF THE F.-VCIAL ArTERV. This may be tied at the anterior border of the masseter, where it is oijly covered by skin, platysma, and fascia. A short transverse incision along the lower margin of the jaw is all that is required. The vein lies behind. It can easily be compressed in the same situation. LlG.JiTURE OF THE TeMPOR.AL ArTERV. A short vertical incision immediately in front of the ear over the root of the zygoma is all that is required. The artery lies in some rather dense cellular tissue at this spot, with, as a rule, a single vein. The occipital artery may require to be ligatured in the scalp, midway between the mastoid process and the external occipital protuberance ; but in most cases, like the branches of the temporal, it can readily be controlled by pressure. In its deeper part, where it lies under the mastoid, it is almost inaccessible and is i>ractically out of the reach of injury. Ligature of the Subclavian Artery. The first part of the right subclavian has been tied fourteen times with a uni- formly unsuccessful result, and, except in the case of some abnormality among its branches, it is difiicidt to see how it could be otherwise. The first part of the left is quite out of the question. On the other hand, ligature of the third part, on either side, is a very succcssfitl operation. I. Ligature of the First Part of the Fight S///>e/a7'ia;/. — The artery extends forward, upward, and outward from the bifurcation of the innominate behind the sterno-clavicular articulation . The position of the patient and the line of the incision are the same as for ligature of the innominate ; the inner border of the clavicular origin of the sterno-mastoid is divided as far as required, and the outer of the sterno-hyoid and sterno-thyroid, exposing the anterior jugular vein and the deep layer of the cervical fascia. The OPERATIONS ON ARTERIES. ■67 f(jriner is tied or pulled on one side, the latter divided very cautiously ; the internal jugular vein, with the vertebral, running down to join the innominate, drawn out- ward ; the innominate, if it rises too high, jjressed downward, and the connective tissue gently separated until the bifurcation of the innominate artery is exposed on one side and the origin of the vertebral on the other. The vagus should be recognized and pressed inward toward the carotid, so as to avoid any injury to the recurrent laryngeal. If there is sufficient space between the origin of the vertebral anil the point of bifurcation, the sheath is opened midway and the needle i)assed from below upward and inward, remembering that the artery rests upon the ])leura behind as well as below : if the length is too short, the vertebral should be tied as well. 2. Ligature of the Third Part of the Subclavian. — The patient lies on the back with the shoulders slightly raised, the head turned to the opposite side, and the arm drawn downward to depress the clavicle as much as possible. The height to O-Jiyoid la. Fig. 5S. — Ligature of Subclavian and Lingual Arteries. which the artery ascends above the clavicle is very variable, particularly on the right side ; it may be almost concealed behind the bone, especially when the neck is short and the curves well marked ; or it may rise an inch and a half above it. The pulsation can always be felt upon the first rib between the trapezius and the sterno-mastoid. The course of the external jugular vein should be ascertained first. Usually it pierces the deep fascia an inch above the clavicle, just po.sterior to the sterno- mastoid. The incision, two inches and a half or three inches in length, is parallel to the clavicle, immediately above it, with its centre corresponding to the interval between the sterno-mastoid and trapezius ; the skin, superficial fascia, platysma, and descending branches of the cervical plexus are divided; there is no need to draw the skin down on to the bone. If the external jugular vein is exposed it should be drawn to one side. The deep fascia is cut through upon a director, and if the interval between the muscles is very small, the edge of one or other or both 268 DISEASES AND IXJUKJES OE SPECL4L STRUCTURES. may be notched. The space thus exposed is filled with loose cellular tissue con- taining a venous plexus formed by the terminations of the external jugular, su])ra- scapular. and transverse cervical veins, a branch from the cephalic, and sometimes the anterior jugular as well. To avoid wounding these, the tissues must be care- fully separated with a director behind the margin of the sterno-mastoid, until the edge of the scalenus anticus is felt with the finger. If this is traced down to the tubercle on the rib, the artery is made out at once, unless there is the rare abnor- mality in which it follows the course of the vein. As a rule, the sensation of the flattened band with rounded edges is characteristic, even if the pulsation cannot be felt. The chief difficulty arises with the lowest cord of the brachial plexus, but if care is taken to include only that structure which lies next to the scalene tubercle, and to feel the radial pulse before the ligature is tightened, it is scarcely likely to be mistaken. The artery in this situation is surrounded by a d.ense funnel-shaped sheath prolonged from the cervical fa.scia ; this is opened by a small incision, and the needle passed from above, downward, behind the artery, so as to avoid taking the lowest cord of the plexus. The posterior belly of the omo-hyoid, the subclavian vein, and the transverse cervical artery are rarely seen. The supra-scapular branch maybe in the way, running parallel to the clavicle, but it can always be drawn on one side. The third part of the artery is just free from the pleura. In many cases the posterior scapular or some other large branch arises almost from the spot at which the artery is usually tied ; if there is sufficient room the ligature is placed as far as possible on the dis- tal side ; if there is not, the branch is tied as well. In some few ca-ses, chiefly where the operation is done for aneurysm of the axillary, extending upward under the clavicle, the outer margin of the scalenus anticus must be divided, and the second part ligatured. In doing this, care must be taken to avoid the pleura, which lies behind and below it ; the transverse cervical and supra-scapular arteries, which not unfrequently cross it ; and the phrenic nerve, which runs down upon the scalenus anticus, but usually leaves it just before it reaches the level of the artery. In any case it is advisable to keep the line of division low down, but the position of the subclavian vein must be recollected. The third part of the subclavian artery is easily compressed against the first rib, unless the neck is exceedingly short and thick. The operator stands behind the patient's shoulder and uses the thumb of the same hand (right, that is to say, for the right subclavian) pressing downward, inward, and backward. If there is any difficulty, it is probably because the artery makes rather a higher curve than is expected. Sometimes a compressor is used, but the brachial plexus cannot then be so well avoided. Ligature of the Vertebral Artery. This has been performed for secondary hemorrhage after ligature of some of the larger trunks, and for epilepsy. The operation, however, so far as this last- mentioned affection is concerned, has been practically abandoned, although some of the cases derived considerable temporary benefit. The position is on the back, with the head slightly turned to the opposite side. There is no line for the artery ; the guide to it is either the transverse process of the sixth cervical vertebra, or the interspace between the scalenus anticus and the longus colli. The incision is three inches in length, down the posterior margin of the sterno- mastoid ; the external jugular vein must be avoided and drawn inward with the muscle. The fa.scia beneath is carefiiUy divided until the scalenus anticus, with the phrenic nerve and the transverse cervical artery, are recognized. Avoiding these, the inner border of the scalenus anticus is to be made out, and next to this, lying between it and the longus colli, is the artery. The transverse process of the sixth cervical is a further guide to the division if it is required. The vein lies almost OPERATJOXS ON ARTJ-IR/ES. 269 always in front of the artery. Alexander, who has had the chief experience in this operation, recommends that it should be drawn inward or outward, whichever is most convenient, with an aneurysm-needle. Another needle is then passed from without inward, behind the artery, threatled, and withdrawn. The pleura lies on the inner side of the wound, the subclavian artery below. If the vertebral enters the fifth foramen instead of the sixth it generally runs slightly more to the inner side. LiG.ArURE OF THE INTERNAL Ma.MM.\RV ArTKKV. The internal mammary runs downward behind the costal cartilages to the margin of the sternum in the sixth interspace, where it divides. At its origin it is crossed by the phrenic nerve and by the junction of the internal jugular and sub- clavian veins ; in the first three interspaces ligature is fairly easy ; after that, it becomes more and more difficult. The incision is oblique, with its centre corre- sponding to the middle of the intercostal space concerned ; the skin, superficial fascia, aponeurosis of the pectoralis major, and the intercostal fa.scia are successively divided and the artery exposed, with a vein on either side. If there is not suffi- cient room, part of the costal cartilages or of the sternum should l)e removed as well. Ligature of the Axillary Artery. The axillary artery is tied either on the front of the thorax in the first part of its course, or from the axilla in the third. The line of the ve.ssel, when the arm is abducted from the side, is from the middle of the clavicle outward to the inner side of the prominence caused by the coraco-brachialis. 1. I?i the First Part of its Course. — The patient is placed on the back with the shoulder unsupported, hanging over the edge of a pillow, and the arm by the side. Later, after the muscle is divided, a greater amount of space can be obtained by pushing the elbow somewhat upward. Various incisions have been used, but the most simple is one running parallel to the clavicle, half an inch below it, from just inside the coracoid process to within an inch of the sternal end. The skin, superficial fascia, and some fibres of the platysma are divided ; the clavicular portion of the pectoralis major is cut through in successive layers, any vessel that bleeds being clamped at once ; and the costo-coracoid membrane exposed, with the cephalic vein crossing inward and the acromio-thoracic artery (some branches of which have already been divided) coming forward through it. The layer of fascia is cut through on a director, parallel to the clavicle, above the perforation of the cephalic vein, and the axillary sheath exposed, covered with a little loose fat. The sheath is opened above ; the vein lies almost in front of the artery, but it can usually be pressed down with the finger out of harm's way. The needle should be passed from below upward, avoiding the long thoracic nerve which lies behind the artery on the serratus magnus, and the lowest cord of the brachial plexus, which lies immediately above. This operation can readily be performed upon the dead subject, but it is very doubtful if, in the living, it has any advantage over ligature of the third part of the subclavian ; and certainly it has several grave disadvantages. Its branches are numerous, the vein is seriously in the way, very large abnormal branches not unfrequently arise from it, and the operation is much more difficult. 2. In the Third Part of its Course. — The arm is abducted from the side and rotated outward to bring the folds of the axilla and the head of the bone into prominence. The line of the artery is parallel to the margins of the axilla, but nearer the anterior than the posterior. When operating on the left side, the sur- geon stands between the arm and the thorax ; on the right, it is more convenient for him to place himself on the outer side (Fig. 59). The incision, three inches in length, runs down the inner border ot the coraco-brachialis from the highest point of the axilla. The skin and superficial 270 DISEASES AND INJURIES OE SPECIAL STRUCTURES. fascia only are divided. The deep fascia is slit u]) on a director, the inner border of the muscle defined, the median nerve which lies next to it (excei)t the musculo- cutaneous which perforates it) pulled slightly to the outer side, and the artery exposed behind it. The sheath is opened in front and the needle passed from within outward. r' "tyz-ri linrZinl/s m/isclf- 2;it '. /^u/an£ous nerfe . Fig. 59. — Ligature of Axillary Artery. If the axillary vein is single and occupies the normal relation to the artery, it may not be seen at all or only indistinctly through the sheath ; but often there are two, and sometimes they lie on opposite sides and are united by transverse branches across it. Abnormal branches are not at all uncommon, the radial, for example, arising high up. Ligature oy the Brachial Artery. The brachial artery may be tied in any part of its course. The line is from the inner margin of the coraco-brachialis in the axilla, down the inner margin of the biceps to the middle of the bend of the elbow. BSce/is muscle Median, nerve Fk;. 60. — Ligature of Brachial Artery. The arm is abducted, extended, and rotated outward. In the later steps of the operation, if the biceps overlaps the artery, the elbow may be flexed to relax it (Fig. 60). I. In the Upper and Middle Part of its Course an incision two inches long is made over the inner margin of the muscle, dividing the skin and the superficial OPE RAJ JONS OX AJ ,, JEjctensor i/rr-pis cligUoruiin nmscle (yfensor /iro/irius /lollicis Fig. 73. — Ligature of Dorsalis Pedis Artery. DISEASES OE LYMPHATICS. CHAPTER III. IXJLRIES AND DISEASES OE THE LYMPI/ATJCS. INJURIES OF LYMPHATICS. The lymphatics are so widely distributed that they must i)e severed or torn in every cut or bruise to a greater or less extent ; but as a rule they collapse at once and give no trouble. Persistent escape or collection of lymph, unless there is some obstruction higher up, causing (edema of the ])art, is very rare ; but probably a great deal of the early discharge from wounds conies from the divided lymphatics, and certainly the poisons that cause the various kinds of wound fever (sei>tic and traumatic), are chiefly absorbed through them. The thoracic duct has occasionally been wounded, leading to the di.scharge through a fistulous opening of a spontaneously coagulating liquid, milky during digestion ; and in one case its opening is stated to have healed under a plug. In another instance the duct was ruptured opposite a fracture of the spine, and the contents were poured out into the pleural cavity, compressing the lung and ulti- mately causing death. DISEASES OF LYMPHATICS. Lymphangitis. Acute inflammation of the lymphatic vessels is always secondary, and is usually caused by the entrance of an irritant poison through the connective-tissue rootlets. Exceptionally it follows sprains, or the inflammation spreads from surrounding structures and involves the wall directly. In most cases the immediate source is a poisoned wound, often a mere pin-prick or scratch, sometimes so small that it is overlooked altogether ; and consequently it is of frequent occurrence among butchers, cooks, and those engaged in post-mortem work. In the case of the throat it may perhaps originate without an abrasion, the poison entering through the spaces between the epithelial cell ; but naturally this is incapable of proof. Recent wounds are much more likely to be attacked than granulating ones, and those which are not kept at rest or in which there is any discharge confined under high tension, and above all, pustules, are the most likely of all. Whatever the irritant may be, it probably does not cause inflammation of the w^all of the vessel unless it is arrested by clotting. If this does not take i)lace, it is hurried on to the neighboring lymphatic glands, and sets up inflammation there. Pathology. — The changes are best seen in larger trunks. The delicate cellular tissue that surrounds the vessel and forms its outer wall is swollen, softened, and congested ; the intima becomes cloudy, the endothelial plates lose their dis- tinctness of outline, and the lymph that fills the vessel and the plasma that circu- lates through and around its walls coagulate. They are no longer in contact with healthy structures. Outside the vessel altogether, some distance away from the irritant, the blood-vessels dilate, and the blood and the plasma circulate more rapidly and in greater quantity ; immediately around the exciting cause, the stream either ceases or is carried on very slowly, and the lumen of the vessel, the interstices in its wall, and the cellular sheath become filled with a coagulating exudation. The future course, whether resolution, organization, or suppuration sets in, depends upon the cause. Resolution begins at once, if the irritant is slight and transient ; the fibrin disappears, the walls of the vessel recover, the endothelium is regenerated, and the circulation is re-established. Organization is probable if its 19 282 DISEASES AND INJURIES OF SPECIAL STRUCTURES. action is persistent, as in syphilis ; and the coats of the vessels, and the celhilar tissue in Avhich they lie, become hard, dense, and sclerosed. Suppuration only takes place when pyogenic micro-organisms are the exciting cause, coagulation-necrosis setting in, and the solid tissues becoming liquefied and melting away. As a rule, it is circumscribed, but if the tissues are badly nourished from intemperance or starvation, or if there is septic decomposition as well to assist, it may be diffuse and boundless. Symptoms. — These are plainest when the superficial vessels are involved. Red lines mark out their course upon the skin — wavy, irregular, very tender to the touch, slightly raised above the surface, and hardened from thrombosis. Some- times they are quite narrow ; sometimes, when the poison is very active, an inch or more in breadth. At the same time the glands are swollen and tender, and if the affection is extensive the limb below may be oedematous. With the deeper trunks most of these signs naturally are wanting ; but usually, even in the deepest, faintly outlined patches of redness are visible here and there upon the skin, where the superficial plexuses communicate with the deep ones. A rigor is not uncommon at the beginning, and if the inflammation is widely spread there may be a very considerable degree of fever and prostration. Simple lymphangitis is rarely serious ; if, however, suppuration sets in it may be attended by very grave illness, and if the vessels (which run in groups) are extensively de- stroyed, a condition of solid cedema is very likely to persist, leaving the limb more or less crippled. When it occurs as part of a diffuse inflammation of the cellular tissue its significance is, of course, altogether different ; it is part then of a general suppurative infection, not unlikely to end in pyaemia, the chief safeguard against the constitutional affection spreading through the lymphatics being the arrest of the pyogenic micrococci in the neighboring glands. Treatment. — The cause should be removed at once or rendered innocuous by the free use of antiseptics ; tension immediately relieved by incision, drainage, warmth, or other measures, as the case requires ; absolute rest enforced ; and the limb raised to diminish the amount of blood entering it as well as to facilitate the return of the lymph. Cold evaporating lead lotion is the best local application. Quinine may be given internally if the temperature is high ; and the bowels usually require to be opened. If suppuration occurs the abscess should be incised at once. Afterward, when the inflammation has subsided and the wound healed, if there is any oedema left it may be relieved, if not cured, by the proper application of massage and band- aging. Lymphadenitis. Inflammation of lymphatic glands always accompanies inflammation of the vessels ; but in a very much larger number of instances it occurs independently of them, the irritant having been carried along by the lymph stream without causing any symptoms until arrested in the gland. It may be simple {acute, ending in resolution or suppuration, and chronic) or specific, as in tubercle, syphilis, glanders, and perhaps some chancroids. I. Simple Adenitis or Bubo. The pathological changes are similar to those that occur in inflammation else- where. The cortex is the part first involved ; it becomes more vascular, soft, and swollen ; the lymph-paths are filled ; the corpuscles are packed in the follicles as tightly as they can be ; the reticulum loses its distinctness ; and here and there, where stasis occurs and the capillaries give way, masses of red blood-corpuscles can be seen. In recent acute cases the gland is a deep purple throughout, and the connective tissue around is swollen and infiltrated with lymph almost to the same extent. This may terminate in resolution; or the inflammation may become chronic ; or suppuration may occur. DISEASES OF LYMPJf.l TICS. 2S3 (I. Resolution. — The process is exceedingly simple; the hyperemia diininishes ; the excess of lym])h-corpuscles is gradually removed ; the lymph-paths are opened up again ; old extravasations are (piietly absorbed ; and the whole gland resumes, or nearly so, its normal condition. A certain degree of enlargement is very com- monly left, especially if the attack is repeated. /'. Chronic Inflanunation. — This termination is almost as common. The cellular exudation, insteatl of being absorbed or undergoing fatty degeneration, becomes organized ; the cai)sule is thickened, hard, and adherent to the structures round ; the adenoid tissue of the follicles is indurated ; and occa- sionally, when the glands are extensively involved, the circulation is seriously impeded, leading to dilatation of the lym]ihatics and even solid cedema in the parts below. c. Suppuration. — This may begin either in the gland itself, yellow foci of coagulation- necrosis occurring in the various parts of the cortex and enlarging until they fuse ; or more generally as periadenitis. In the latter case, when the abscess is opened, the gland is found lying in a more or less sloughing condition, attached to one side of the cavity. Residual abscesses are of common occurrence in connection with lymphatic glands ; inflammation subsiding and remaining quiet perhaps for years, and then, from some slight additional irritant, suddenly break- ing out again and running on to suppuration. Causes. — x\ moderately acute form of inflammation not unfrequently follows over-exertion or exposure to cold, esjjecially if there has been at any time a pre- vious attack. The glands become swollen and painful ; the skin over them is tender on pressure ; the neighboring muscles are stiff, and movement is much restricted. As a rule, this subsides without any serious result as soon as the cause ceases to act ; its importance is due to the fact that the tissues, enfeebled by inflammation, form the most suitable soil for the development of any germs that may reach them. Suppuration may occur, especially in those whose health is broken down ; tubercular disease may follow ; I have known it to develop rapidly in the femoral glands after a strain in jumping ; and in children it is probable this often happens. The eruption of the teeth, for example, is attended with a considerable degree of enlargement and some inflammation of the submaxillary glands. In most cases this subsides of itself as soon as the parts become quiet again, but occasionally it forms the starting point for suppuration or tubercular disease, the micrococci or bacilli, as the case may be, gaining access to the damaged tissue through the mucous membrane of the mouth. When the glands are healthy these germs are practically inert. Acute inflammation of the glands arises from the same causes as acute lymph- angitis, especially poisoned w^ounds in which there is friction or tension to facili- tate absorption. In rare cases it is said that there is no breach of surface, but it is proverbially impossible to prove a negative. Specific forms of inflammation can only arise from specific causes, and these are rarely limited to the gland first involved ; tubercle, syphilis, glanders, etc., all tend to spread from one to another, although there may be at first a temporary arrest. This is not so with the micro- cocci of suppuration. Against these the adenoid tissue seems to possess an unusual power of resistance ; not only does the mischief rarely extend beyond the glands first attacked, but these themselves appear capable of holding out for an excep- tionally long period. Inflamed glands are exceedingly common as the result of gonorrhoea, soft sores, pustules, poisoned wounds, and many other injuries ; but although, of course, many instances do occur, suppuration is by no means invariable. The pyogenic micrococci must be carried to the glands in abundance by the lymph corpuscles and the lymph stream ; but if the adejioid tissue is fairly well nourished, and protected from injury, in many cases they are only able to excite a certain degree of inflammation. Chronic adenitis, if not of specific origin, usually results from the frequent repetition of acute attacks. The glands are left slightly enlarged, hardened, and infiltrated with fibrous tissue ; and they may persist in this condition without 284 DISEASES AND INJURIES OF SPECIAL STRUCTURES. change and without causing any symjjtoms for years. \\\ many instances it is impossible to say how tar this is due to syphilis. Symptoms. — When the attack is acute, and the gland is tightly bound down by fascia, the symptoms are severe. On the other hand, if there is a large amount of loose cellular tissue around, so that there is but little tension, they may be very slight ; in the axilla even suppuration may occur without the patient com- plaining of it. Pain, heat, and swelling are the most i)rominent ; the first esj)e- cially, when the deeper glands are involved ; the last when the structures round are soft and yielding. Tenderness on pressure is always present ; and if the gland can be felt, it is fixed in its bed, partly from its size, partly from the cellular exuda- tion around binding it down. The constitutional disturbance, like the pain, depends largely upon the tension ; in the slighter cases it is scarcely noticeable ; in the more acute ones, especially when the deep glands are inflamed, it is often very marked. Suppuration may begin very quietly when the tissues around are loose and yielding, or there may be high fever and even a rigor. The part begins to throb, the skin is red, glazed, and cedematous, the swelling rapidly increases in size, and the outline becomes ill-defined. If the pus forms in the interior fluctuation is often very indistinct ; if around the gland it may be apparent almost at once. There is rarely any difticulty in the diagnosis of acute inflammation ; the locality, the nodular character of the swelling, and the evidence of an exciting cause (which may, however, have already disa])peared) indicate at once the struc- ture concerned. Chronic enlargement is more difficult, especially in the groin, where it is easily mistaken for epii)locele and vice versa. The shape of the swell- ing, the direction it takes, and the fact that it is rarely single, but nearly always involves the neighboring glands, are the most important distinctions. The ques- tion of suppuration is very difficult ; in a large proportion of cases it is practically impossible to say, without exploration, whether it has commenced or not. Treatment. — The exciting cause should, if possible, be removed at once. Absolute rest, cold, uniform compression, and elevation are the most effectual measures for preventing suppuration ; heat and counter-irritants only encourage it. When pus forms the shortest way is to open up the abscess freely, allow the con- tents to escape of themselves, and apply boracic fomentations, with a considerable degree of pressure, in order to keep the surfaces at rest. If the gland has been destroyed and remains adherent to the inner surface of the abscess it should be removed at the time of the operation. In the groin, if the redness and oedema are very well defined, showing that there is not much infiltration of the cellular tissue round, two punctures with a drainage-tube or a bundle of horse-hair passed across may succeed, and in very slight cases even a single one ; but unless the patient is kept in bed with such an amount of dressing on that the limb is practi- cally fixed it is very likely to end in the formation of a chronic sinus. 1 1 . Tubercular A denitis . The lymphatic glands are one of the most common seats of tubercular dis- ease. The bacilli enter through the mucous membrane of the respiratory or alimentary canal, or through the skin (after wounds, abrasions, attacks of eczema, and the like), and at once, if there is the least predisposition, or if the resistance of the tissues is lowered by inflammation, lead to the deposit of miliary tubercle. In a few cases infection may take ])lace through the blood. No glands in the body are exempt ; but naturally those in certain localities — the neck, the mes- entery, and the mediastina — are more often affected than others, and it may occur at any age, although it is by far the most common in children and during young adult life. Pathology. — The changes are characteristic ; gray miliary nodules develop, usually in the centre of the adenoid masses, with typical giant and epithelioid cells, and outside these an infiltration of smaller ones, lying in a zone of hyper- D/SEASJ'.S OF f.YMPHATJCS. 285 femia, and caseation soon begins in the middle. Several of these small nodules form near each other and fuse, so that when the gland is cut across there is a dead white caseous spot surrounded by a soft, pinkish gray areola. (Gradually, as these increase and multiply, fresh tubercles forming round their margin, the whole gland becomes enlarged, the capsule grows thicker, partly from the irritation and ten- sion to which it is subjected, partly from the condensation on it of the loose cellular tissue around, and at length, if it is cut across when the disease is advanced, the only trace of normal adenoid tissue left is a thin layer immediately under the capsule; the whole of the rest is converted into a dense white caseous mass, many times the size of the original gland, but still showing its origin by its shape and by the relation it bears to the trabecular. The subseijuent changes are the same as those that occur elsewhere. If the tubercle-bacilli spread and the whole gland becomes involved, the central portion breaks (jown into a greenish-yellow puriform fluid, the surrounding cellular tissue is invaded through the hiluni, and sujiiHiration follows, forming an irregularly- shaped abscess (often extending long distances under the fascia) with the remains of a lymphatic gland, consisting chiefly of the capsule lined with caseating tuber- cle, still adherent to one ])art of the wall. If, on the other hand, they perish, either calcification or fibroid induration, or both together, follow. Symptoms, — The characteristic feature is a chronic, painless enlargement, affecting usually several glands in the same locality, although often one more than the rest. At first they are freely movable, but, after a time, they become matted together and adherent to the surrounding structures. Later, after a very variable period, softening may occur, the swelling enlarges in size and becomes more ill- defined, the skin becomes reddened at one point, grows thinner and thinner, and finally gives way, leading to the discharge of a thin oily pus, mixed with caseous debris, and leaving a sinus which nearly always pursues a most irregular and devious course. Healing, if these cases are left to themselves, is always very protracted ; the growth of the tubercle must cease, the whole of the caseous material come away, and the sinus close from the bottom, and as the skin is usually undermined in all directions, and it is exceedingly difficult to keep the parts at rest, it may be many years before it is complete. General infection from superficial caseating glands is rare, although it may take place from mediastinal ones. Local recurrence again and again is not uncommon ; but at length, in the vast majority of cases, the patient lives down the bacillus and recovers, bearing the traces of his illness in the deep seams and cicatrices left. Treatment. — The constitutional treatment of tubercular adenitis is of the greatest importance : sea air, tonics, cod-liver oil, good feeding, and careful pro- tection against cold, exposure, and irritants of all kinds. In many instances the balance between caseation and liquefaction on the one hand, and absorption and organization on the other, turns entirely upon this. The local treatment depends largely upon the amount of inflammation present and the number of glands involved. If there are only two or three and they are perfectly quiet and painless, without any evidence of adhesion to the tissues round them, they should be left altogether alone, or the skin may be thickly covered over with ung. plumbi iodidi and oiled silk at night. Rubbing and counter-irritants, such as tincture of iodine, are only too likely to precipitate an acute attack. If in spite of this the enlargement continues to increase, or signs of softening or of inflammatory adhe.sion begin to appear, excision may be performed, provided there is a reasonable hope of removing the whole ; either caseation has taken place already in spite of all that has been done to check it, or it will very shortly, and undoubtedly the best and. most effectual method, when the disease is limited and superficial, is free removal. It leaves a linear cicatrix in a situation chosen because it is concealed, and the wound is sound within a week, in place of a sinus that may continue to discharge for years, and invariably causes a depressed, seamed, and irregular scar. Even when the skin is involved the same plan may be tried -86 DISEASES AND INJURIES OE SPECIAI STRUCTURES. with success. It must always l)e remembered, however, that the real number of the glands concerned is probably far in excess of the apimrent, and that removing the more superficial ones is very likely to expose many more that lie deeper. The operator, therefore, must always be prepared, as unle.ss the whole affected area is cleared little good is likely to result. Even such extreme measures as division of the sterno-mastoid and dissecting out the great vessels and nerves of the neck have been recommended. If softening and suppuration have already taken place the actual cautery may be used to perforate the inflamed structures and destroy the interior of the gland ; or it may be freely incised, the interior thoroughly scraped out with Volkmann's spoon, and packed with iodoform. Unhappily, in most cases the number of glands involved precludes anything like radical treatment of this kind ; and all that can be done is to open any abscesses that are pointing ; slit up or enlarge and drain any devious sinuses running beneath the fascia ; scra])e out all the caseous debris that is accessible ; and try by means of constitutional treat- ment to improve the general health, so that cicatrization may take place. It not uncommonly ha])- pens in the neck that chronic sinuses with purple overhang- ing edges are left for years, similar to those met with in the groin. In many cases these can only be cured by cutting away all the overhanging tissue, scraping out the interior, thor- oughly stimulating the base, and making the route direct. Hilton, however, has shown what it is possible to do to these by the judicious appli- cation of trusses in the groin ; that the chief reason of failure of union is the perpetual motion to which the part is subjected ; and that repair can take place, even in advanced cases, if alisolute rest is enforced ; and Treves has strongly advocated the same thing in the neck. There is no doubt that, although the pre- sence of caseous gland tissue and the indirect burrowing under the fascia have much to do with the delayed union and unsightly cicatrices so common after tubercular adenitis, want of rest is almost if not quite as important ; and in every case in which this cannot be ensured in other ways some appliance, such as Treves' s])lint or a gutta-percha stock, should be used after operations. Aiohne d '^•rbi inann. Fig. 74. — Treves' Cervical Splint. LvMPHAiic Glandular Ti:iM()ks. All forms of carcinoma and many of sarcoma involve the lymphatic glands sooner or later ; these, however, are secondary growths, and derive their signifi- cance entirely from the primary one elsewhere. In addition there are others which originate in the glands themselves. Primary lymphatic glandular tumors form an exceedingly difficult group ; it is impossible to classify them satisfactorily either by their pathological structure or their clinical history. Microscopical examination fails to show any definite distinction between normal gland tissue, inflammatory hypertrophy, simple tumors, or malignant ones ; and clinical symptoms are no more successful, at any rate in DISEASES OF LYMPHATICS. 287 the earlier stages when the diagnosis is of importance. Certain varieties that are fairly well characterized can be described ; the rest must be grouped round them, nearer or further away, according to the sum of the features they present. I. Lymphoma. ;iven to a perfectly simple form of overgrowth affecting one or, As such, it is decidedly ouL ^^ This name is at the most, two or three glands in one part of the body rare (Fig. 75). No cause is known ; the gland steadily but persistently increases in size with- out undergoing the least change in structure. It is not inflamed or ])ainful ; it does not contract adhesions to the parts around ; it does not degenerate or decay in any way ; and it is not attended with any form of cachexia. On section it is ai)solutely normal, or at the most slightly lighter in color than the other glands. It may attain a fair size and cause considerable annoyance, but it is seldom very large. Lymphatic glandular tumors answering this description are certainly exceptional. In the vast majority of instances, if they are excised (the only treatment suitable for them) and divided in two, it is found either that they contain a caseous focus in the middle, or that, without aiiy change visible to the naked eye, they are full of miliary tubercles ; in other words, that they are really examples of tuber- cular adenitis, which from some unknown cause, pos- sibly an unusual power of resistance on the part of the patient, have followed an unusual course ; the tubercles have continued to increase, but the lym- phatic tissue has increased at a faster rate, without sufficient inflammation to make the capsule contract adhesions. In other cases it is probable that they are really the beginning of lymphadenoma, for sometimes, if they are left, they suddenly change their character and begin to grow rapidly. II. Lymphadenoma. Two forms of this are described by some, according to whether leukaemia is present or not ; but, as it is impossible to say upon what this depends, why it should occur in one case and not in another, it does not seem a sufficient reason for separating them. It is sometimes known as Hodgkin's disease or malignant lymphoma. The pathological changes that occur in the glands in the earlier stages are identical with those met with in lymphoma or in chronic inflammation. In some instances the adenoid tissue is in excess and the glands are soft and juicy ; in others there is a large amount of fibrous tissue, the size is smaller, and the consistence firmer. The difference, however, does not appear to be anything more than a physical one ; clinically the two forms are precisely alike. Lymphadenoma, at its commencement, may be confined to the lymphatic glands ; or it may occur in the spleen before the glands are involved ; and deposits of adenoid tissue, w^hich, however, may be secondary, are not uncommonly found in the alimentary canal, the liver, kidneys, the medulla of bone, and elsewhere. It is evidently, therefore, a di-sease of an entirely different character from true lymphoma ; but when it is primarily glandular, it may be impossible to distinguish one from the other, until, by the appearance of secondary growths, it is too late. Nothing is known with regard to its etiology ; it is most common in )Oung adult Fig. 75. Lymphoma, from the Cervical Glands. 288 DISEASES AND INJURIES OF SPECIAL STRUCTURES. life, and in the cervical region ; but it may begin in the inguinal, or axillary, or even, though rarely, in some of the internal glands. The growth is more rapid than that of lymphoma, sometimes so rapid as to cause a certain degree of tenderness from the stretching of the fascia round. Gland after gland is involved, and instead of remaining isolated from each other, they become matted together into smooth, bossy, prominent tumors, which, how- ever, remain for some time encapsuled. In this condition they may last unchanged for several years, or they may even diminish in size, although they very rarely disappear ; but at any moment they may suddenly begin to grow again, spread into the cellular tissue that surrounds them, forming enormous masses from which all trace of the original glands is lost, and start in other parts of the body as well. When this takes place the end, as a rule, is not far off. The patient's health begins to fail, emaciation is rapid, sometimes hectic and profuse night-sweats occur, the appetite is lost, diarrhoea or epistaxis sets in, dropsy makes its appearance, and the sufferer usually dies of exhaustion. In other cases the trachea or oesophagus is compressed, even the action of the heart may be interfered with ; masses in the abdomen may cause jaundice, and toward the end more or less leukaemia, though not sufficient in every case to give a distinct white tinge to the blood, is a very usual feature. Instances are sometimes met with in which the whole of the tissues of the neck seem to be involved. The skin is red, as if inflamed, soft, and almost fluctuating, and from the head to the thorax is simply a gigantic, shapeless mass of adenoid tissue, growing rapidly, exceedingly vascular, and enclosing the blood-vessels, nerves, and all the important structures of the part. III. Sarcoma. Lymphatic glands are occasionally the seat of an intensely malignant form of sarcoma, round-celled, spindle-celled, or lymphoid. It differs from lymphadenoma in the extreme rapidity of its growth, in the fact that (until quite late in the course of the disease) only one tumor is formed, that it remains limited for a much longer time to one .set of glands, that it tends to invade the skin and all the structures round, and that it is not accompanied by leuksemia. Sometimes it is so soft and attended with such a degree of pyrexia that it may be mistaken for an abscess, and I have known it, springing from the mediastinal glands, displace the heart and lungs, cause pressure upon the recurrent laryngeal and other nerves, and from its extreme va.scularity pulsate so forcibly as to raise the .suspicion of an aneurysm. Treatment. — The treatment of lymphatic glandular tumors is very unsatis- factory, chiefly on account of the great difficulty of diagnosis in the earlier stages. Simple lymphoma, if it does not rajjidly subside under tonics and cod-liver oil, should be excised, whether it is true lymphoma or a caseous gland (as it u.sually is) or the beginning of lymphadenoma ; only, as already mentioned in tubercular adenitis, the operator must be prepared to remove the whole, and often it is much more extensive than it appears to be. Lymphadenoma, if it has once passed this stage, is better left alone ; comj)lete removal is practically hopeless ; no sooner is one ma.ss taken away than another appears beneath, more difficult of access still ; and the presence of leukemia is an absolute bar to any surgical operation not of imperative necessity — such, for instance, as tracheotomy : the hemorrhage is uncontrollable. Arsenic, with iron and cod-liver oil, is of undoubted value in many cases, although, unfortunately, the improvement is rarely permanent. It is usually given in the form of Fowler's solution after meals, and the dose must be increased by about a minim a week until the patient can take no more ; other drugs do not seem to have any effect, and no local application of any kind is of any use. DISEASES OF LYMPJIATICS. 289 Lymph ANciEiF.CTAsis and Ly.mphangkioma. 'I'hc lymi)hatics are liable to dilatation and distention in the same way as the capillaries and veins. Sometimes this is congenital, like naivus, sometimes it is caused by obstruction. Ihe minor form, affecting especially the smaller vessels, is known as lymphangeiectasis, the more pronounced as lymphangeioma. I. Coih^ciiital Dilatation. This niav appear under various shapes. In the simplest there is merely an irregular expansion of the lymphatic vessels, generally in the skin, forming am- pullar and cavities of various sizes, lined with the characteristic endothelium. In those that are more severe the dilatation is greater, the partition walls between the cavities are thinner, so that they break down, and enormous, irregularly branching spaces are formed, sometimes spreading among the deeper structures to a distance of which the outside appearance gives no conception. The most exaggerated form of the cavernous lymphangeioma is known as hydrocele of the neck, congenital cystic tumor, or sim])ly hygroma. It may be pres- ent at birth, or it may be so small that at that time it does not attract attention, and then later, when it begins to enlarge, it may be mistaken for an acquired growth. The most common situation for it is the neck, but it may occur in the axilla or the back, or even in the region of the kidney. Sometimes it is apparently a single cyst, extending an enormous distance under the fascia ; more frequently it is polycystic with cavities of all sizes, in some of which the fluid is clear and watery, in others greenish, and in others again distinctly and perhaps deeply blood-stained. The favorite locality is the posterior triangle of the neck, or just behind the angle of the ja\v, whence they may extend into the mouth, over to the opposite side ot the body in front or behind the trachea, down into the thorax, or, in short, almost everywhere. The w'alls vary in strength, though never very thick. Occasionally they contain here and there portions of njevoid tissue, which can be detected when superficial by the bluish tint they give. Much more rarely there is a considerable amount of solid growth, so as even to give rise to the suggestion of sarcoma (Fig. 76). A similar pathological condition prob- ably underlies macroglossia, macrocheilia, and some at least of the varieties of con- genital overgrowth of the limbs. Whether the enlargement of the breast, which, though not congenital, sometimes develops at puberty, is to be attributed to the same cause is uncertain. It appears at least to affect only the cellular-tissue elements of the gland, not the secreting structure. The treatment of any of these con- genital affections recjuires to be carried out very circumspectly. Single cysts may be tapped, and, if they refill, injected with iodine or with Morton's fluid. Larger ones may be drained, or a seton passed through them, but it must be remembered that very often they have very deep connections, and that if suppuration occurs the fever that follows is likely to prove exceedingly serious or even fatal. Polycystic growths may be drained seriatim, a deeper part being opened only when the super- ficial has contracted to a sinus. Excision is rarely practicable. In cases of congenital giant growth, if the size is excessive, or if sarcomata develop from the imperfectly organized tissues, as sometimes occurs later in life, amputation is the only resource. Macroglossia and macrocheilia, when they are Fig. 76. — Serous Cyst of the Neck. (Birkett's case.) 290 DISEASES AND INJURIES OE SPECIAL STRUCTURES. small, can sometimes be kept in check by astringents, but usually inOannnatory hypertrophy is added to the congenital form, antl the only hojje is partial excision. II. Obstructive Dilatation. Long-continued obstruction to the lymphatics causes a certain degree of varicosity similar to that which occurs in the veins, only much more rarely, because of the greater freedom of anastomosis. Sometimes the smaller vessels are affected most, so that the superficial parts, skin, or mucous membrane, as the case may be, are channeled in all directions by a reticular network, which may even raise up the epidermis in the form of minute vesicles ; sometimes the larger ones, tubular . lymphangeiectasis. The same thing occurs in connection with the veins, but in neither is the reason for the difference obvious. After a time the condition known as solid oedema follows : the part becomes hard and brawny ; the skin and the sub- cutaneous tissue are thickened and indurated ; an enormous growth of lowly organized connective tissue takes place throughout the limb ; the muscles waste ; the veins are compressed, making matters worse ; the part becomes so heavy and stiff that the patient can hardly use it ; and at length it develops into a state prac- tically identical with elephantiasis. At first the outline is smooth, uniform, and rounded ; but after a time local inflammation occurs from some trivial cause, owing to the poor nutrition of the part ; and then it becomes irregular and nodu- lated all over. Finally, in some cases, rupture of the lymphatics takes place ; a thin clear fluid, coagulating more or less perfectly, continues to drain away {lyniphorrhoea') ; the patient's health fails ; and the continued moisture of the part leads to an eczematous condition of the skin, which again in its turn makes the inflammation worse. Causes. — Obstruction may be due to various causes, and, according to the part of the l)ody affected, leads to very various results. The simplest variety is that which follows repeated attacks of erysipelas (in- fective capillary lymphangitis). If this recurs often, partly from the obstruction to the lymphatic vessels, partly perhaps from the chronic induration of the glands, the skin remains permanently thickened, and when the face is concerned a very serious degree of disfigurement is left. In phlegmasia alba dolens, the form of white leg that occurs so commonly after pregnancy, it is probable that the veins are involved as well as the lymphatics, sometimes one, sometimes the other being the worst. It is rarely serious, although it often assists in the production of chronic ulcers of the leg ; but I have known it, when frequently repeated, end in the most enormous nodular enlargement of the whole limb (except the foot) and lead to very serious lymi)horrhoea from an open- ing in Scarpa's triangle. Cancerous enlargement of the lymphatic glands in the axilla leads to the same condition in a very short space of time. The axillary vein may be ligatured and cut away with impunity ; there will scarcely be even transient oedema ; but when the cancerous growth involves the glands, the hand and arm enlarge to such an extent that the patient is unable to lift the limb from the bed. The presence of parasites, especially the filaria sanguinis hominis, produces even a more striking series of symptoms. The, parent worm usually resides in one of the larger central lymphatics, and from this locality discharges into the stream myriads of ova or embryos. Some of the main channels become obstructed by the inflammation that takes place around them ; dilatation sets in, and in many cases rupture follows, most frequently into the bladder (probably because of the very variable degree of support the mucous membrane receives), causing chyluria, but occasionally into the cavity of the tunica vaginalis (chylous hydrocele), and sometimes even externally. The same thing has been known to occur from the pressure of tumors, and from other causes leading to obstruction of the thoracic duct. It is ])robal)le that the disease known as Elephantiasis Arabian really origi- DISEASES OF LYAfPI/ATICS. 291 nates in the same way. Essentially it is a chronic h)'i)crtn)])hy of the skin and the subcutaneous tissue, usually of the leg or the scrotum, causing enormous enlargement and deformity, and resulting from rejieated attacks of inilammation ; but though thus far it resembles the worst cases of solid cjedema, it differs consid- erably in other respects, especially in the peculiar form of fever and the acute inflammatory attacks that accompany it. The fever is of a remittent type and is known locally as elephantoid. Some- times it is exceedingly severe, and attended with great pain ; more often it is only moderate in degree and as the diseases advances tends to die out. The intervals between the attacks may be as long as a month ; with each there is an outbreak of acute inflammation, the limb becoming tense and hot, the skin red- dened, and even covered over with vesicles as in erysipelas. In a few days the symptoms subside, but the limb never regains its former size ; and one attack follows another until the condition becomes hopeless. In the early stages the skin is but little affected ; later it becomes pigmented, covered with eczema, ulcerated, scarred, roughened, and nodulated in proportion to the severity of the local inflammation. The legs and the external genitals are the parts most often affected ; the scrotum in particular, from the looseness of its natural texture and the ease with which it borrows skin from the abdomen, may be enlarged, so that it sweeps upon the ground. Very often enormous hydroceles, or dilatations of the lymphatics (varix) and lymphorrhtca are associated with it. Treatment. — Much can be done to relieve the symptoms in the milder cases of lymphatic obstruction, even when the cause is beyond control ; rest in an elevated position, massage, bandaging, support when the limb hangs down, and, according to some, the constant current (the positive pole always nearest the sound parts) often effect material improvement in a very short space of time. Cancerous obstruction, however, of the axilla, and obstructions to the abdominal lymphatics and lacteals rarely admit even of relief. Elephantiasis in its milder forms should be treated in t\it same way. Rest, pressure, and elevation succeed best during the acute stage, combined with suitable constitutional measures. Afterward either support and pressure must be used, Martin's elastic bandage being of especial service, or, if the mass is such as to disable the patient, it must be removed, by amputation in the case of the leg (it rarely extends far up the thigh) or incision if it is the scrotum. In either case, the part should be well bandaged and elevated first, in order to reduce the amount of blood it contains as much as possible, and careful examination made so that no hernia is overlooked. An attempt should always be made to dissect out the penis from the enor- mously hypertrophied prepuce ; and sometimes at least the testes can be preserved, their position being easily ascertained by the amount of the hydrocele fluid that surrounds them. Ligature of the main artery of the limb has been practiced with temporary alleviation ; possibly compression deserves a further trial. 292 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER IV. INJURIES AXD DISEASES OF NERVES. INJURIES. Xerves may be divided, wholly or in part; torn across, or torn out of the spinal cord ; bruised from external violence ; or compressed against some resisting structure. The immediate effect is an interference with the conducting power of greater or less extent and duration, according to the kind of injury sustained. I. Wounds of Nerves. Pathological Changes Folloioing Division. — A nerve that is cut across begins to degenerate at once. The whole of the peripheral part is involved simultan- eously ; the myelin runs into cylindrical masses which become granular and fatty, and at last disappear. The axis-cylinders split up into fibrils and disintegrate, so that they can scarcely be recognized at the end of a week ; and the nuclei of the sheath increase in size and begin to multiply. In two or three weeks the whole of the peripheral segment is atrophied. The central end changes in a similar manner, but only for the distance of one or two nodes ; above this it remains practically unaltered, it may be for years. The subsequent course depends upon the proximity of the two ends, and upon the possibility of union taking place between them. {(i) WHien they are in Apposition and the Wound Heals by the First Inten- tion. — Union takes place by what is known as nerve-callus, vascular granulation- tissue developed from the nuclei of the sheath and perineurium as well as from the ordinary sources. In animals newly-formed axis-cylinders grow from these nuclei, connecting one end with the other, within three or four days. In man this has not been proved ; but in all probability the same mode of union does occur, though rather more slowly, as occasionally, when placed under very favorable conditions, the conducting power of a divided nerve returns within a few days. Such a result, however, is exceptional ; immediate suture, even when apposition is accurate, usually requires weeks. (Ji) When the Ends are Not in Apposition. — The changes that follow are more complex and depend largely upon the distance between. Bowlby has described a process of spontaneous regeneration as taking place in the distal segment six or seven months after section. The nuclei of the sheath increase in number, become spindle-shaped, range themselves in rows in the spaces of the perineurium, and gradually transform themselves into fibrils, round which a myelin sheath develops. How far this takes place in all cases, even whether it occurs in all, is uncertain. That it must materially assist the restora- tion of function in the case of secondary union there can be no question. Repair may occur when there is an inch between the ends ; and a few cases are recorded in which even greater distances than this have been bridged ; but they are few and far between ; and the restoration of function in most of them is very imperfect, even after a long period of time has elapsed. As a rule only a fibrous band is found, sometimes not that. If union fails, the regeneration of the distal segment dies away again, per- manent degeneration sets in, and the nerve is reduced to a small fibrous cord, the structure of which can still be recognized on cross section, owing to the peculiar nature of the perineurium. The central end may remain almost unchanged, or grow out into a rounded expansion of variable size — a nerve bulb. These are met INJURIES OF NERVES. 293 with chielly in ainpiitation-stiinips. hut they may occur anywlierc ; they consist for the most part of fibrous tissue ; but in the end nearest the nerve-trunk a consider- alile production of new nerve-fibres takes place, although their size is small and there is only a limited amount of myelin round them. In very old cases atrophic changes are met with in the spinal cord as well, affecting especially the intermedio-lateral coluniii on that side, the posterior very little. Symptoms. — The immediate symi)toms are due to interruption in the func- tion of the nerve , the remote ones are the pathological lesions that follow. 1. Immediate. — Loss of sensation over the region supplied by the nerve is definite, provided it is complete. On the other hand, persistence of sensation does not in any way negative division. Very little, scarcely anything, indeed, is known about nerve-anastomosis, either the coarse blending that can be shown by dis.section, or the finer union that probably takes place in the nerve plexuses; and there are many instances in which nerves have been divided, and have even had pieces excised from them, without leaving the expected area of anaesthesia. A considerable length of the musculo-spiral, for example, has been excised without any loss of sensation corresponding to the radial. Further, in many cases the area of anaesthesia, if time is allowed to elapse, very often becomes smaller, as if collateral branches grew in all round the margin. The sen.sation that persists after nerve-section is sometimes almost perfect : more frequently localization is inexact, especially at first ; anci occasionally analgesia occurs without anc'esthesia. In any case of suspected injury the examination must be made with the greatest care. The patient should be blindfolded ; the part well supported, so that there is no communicated vibration ; and various kinds of stimuli u.sed, ther- mic, for instance, as well as tactile. In no case may a conclusion be drawn either as to the non-division of a nerve, or its union after suture, without taking into consideration other effects as well as loss of sensation. Loss of muscular power is equally definite, provided it continues and is fol- lowed by other signs, such as rapid wasting and disappearance of faradic excita- bility. Temporary paralysis may occur from shock, contusion, or compression, and be indistinguishable for two or three days. The atrophy is of the most extreme kind ; the fibres lose their striation, degenerate and shrink ; the nuclei multiply ; the interstitial connective tissue increases, until in a very short time the whole muscular substance disappears, and nothing is left but a rigid, inextensible mass of fibrous tissue. Faradic excitability disappears very soon ; there is often a distinct diminution by the third day ; galvanic, on the other hand, continues longer, but rarely or never, according to Bowlby, shows the increase that usually occurs after nerve-section in animals ; and the anodal closure contraction precedes or occurs as soon as the cathodal. 2. Later Changes. — In addition to the muscular wasting, the joints, the skin, and the connective tissues exhibit after a time very distinct alterations. The car- tilages undergo fibroid degeneration, the capsule and the connective tissue round shrink and grow hard and rigid, the joints becoine stiiT, fibrous ankylosis sets in, and osseous union has been known to follow. The skin becomes smooth and glossy. If the hand is involved the fingers assume a peculiar tapering shape, the hairs fall off, the natural wrinkles and folds disappear, and the color becomes a pinkish red. Sometimes, especially when the weather is cold, there is a constant burning pain — causalgia. Vesicular and bullous eruptions, herpes, subcuticular whitlow, and ulceration are not uncommon. In rarer cases the end of the finger is slowly eaten away, or dry gangrene sets in and involves the w^hole anaesthetic area. The nails are often affected ; they may be short, stunted, and fibrous, or curved either across or longitudinally, so that their edges and angles bite deeply into the flesh. The connective tissue disappears, the secretion of sweat ceases, and generally (after the first few days at least) the temperature of the part falls one or two degrees. In exceptional instances it has been known to continue higher than that of the corresponding part on the opposite side of the body. 294 DISEASES AND INJURIES OE SPECIAL STRUCTURES. These changes are noted more or less regularly after section of any nerve, though, owing to the frequency with which the ulnar and median are divided at the wrist and the musculo-spiral damaged in the arm, they are more commonly seen in connection with the hand than in all the other parts of the body put together. Other affections, however, are occasionally met with of a more special character. Perforating Ulcer of the Eoot is the most common and in some respects the most striking. It occurs chiefly in connection with locomotor ataxy and the chronic form of nerve-degeneration that is associated with it ; but it is also met with in the anaesthetic form of lei)rosy, after fracture of the spine with partial paralysis, and after degeneration of the nerves without the spinal cord being affected at all. In most cases it is situated on the ball of the great toe, but it may occur on the outer side of the tread or in any part. A corn forms first ; after a time the epidermis in the centre softens and breaks down, and an opening is left in the middle, which at first sight appears altogether insignificant, but if a probe is passed into it, it is usually found to extend far into the substance of the foot, and not unfrequently to involve the bone or the metatarso-phalangeal articulation. There is little or no pain, the edges of the sore are usually whitened and callous, and in many cases the skin around it is entirely anaesthetic. Not unfrequently it is present on both feet at the same time. In the majority of cases perforating ulcer heals readily as soon as the foot is raised, protected from injury, and kept warm. Very often it breaks out again if the part is used. The nutrition of the tissues is so enfeebled that, though they can repair the effects of an injury when very favorably placed, they are unable to withstand the slightest pressure or irritation. How far these changes are due to lesions of trophic nerves, and how far they are simply the result of malnutrition from disuse, is undetermined. In any case injury plays an important part in causing them. Sensation is lost, the immediate effect of any violence is unperceived, and fresh injury inflicted before the first has a chance of getting well. Ulceration and gangrene of the fingers, for example, which attain their climax in anaesthetic leprosy, and perforating ulcer of the foot are directly excited by injury, although they would not occur without the nutrition of the part being defective ; the point at issue is whether this arises simply from disuse and anaesthesia, from the interruption of trophic nerves, or from their irri- tation. There is no evidence that partial division of a nerve is followed by trophic or inflammatory disturbances more frequently than complete section. On the other hand, when it does occur, the consequences are limited to the distribution of the divided fibres, and they follow regardless of the manner in which the interruption is effected, whether by section, rupture, compression, or chronic inflammation, provided only it lasts a sufficient length of time. II. Subcutaneous Injuries of Nerves. Contusion. — Section of a nerve is followed by the most characteristic conse- quences, other injuries differ according to their severity. If, for example, the force of the blow is only slight the conductive power of the nerve is suspended for the moment, there is a certain amount of dull aching at the injured spot, tingling is felt at the periphery, and often there is a subjective sense of heat, with at times actual flushing. When the injury is more severe and the nerves are badly crushed, loss of sensation and of muscular power may be complete and followed by wasting and disappearance of the faradic excitability over the whole area sup- plied. As a rule, the prognosis in these cases is good, or at least better than in section, because the physical continuity is not destroyed, and although trophic lesions may follow they usually disappear again of themselves, but occasionally they persist. Some of the worst cases occur in connection with the upper cords of the brachial plexus, one or all of them being crushed in falls upon the shoul- INJURIES OF NERVES. 295 ders, and leaving paralysis, perhaps permanent, of a corresponding portion of the arm. When, on the other hand, the jjlexus is torn out from the cord (as when a man in foiling from a height catches hold of something in the hope of saving himself) the lower cords suffer most and with them the symj^athetic of the eye, leading to narrowing of the palpebral fissure and permanent contraction of the pupil. The diagnosis of the extent of the damage sustained in subcutaneous injuries is very difficult. If the faradic excitability of the muscles persist, the hurt is probably slight. If it rapidly disappears and this is followed by wasting and the reaction of degeneration, there is no doubt that the physiological continuity of some of the nerve-fibres is interrupted, and if the whole of the muscles supplied by the trunk are affected in this way it is highly probable that the nerve itself is torn across. Compression. — The same s}'mptoms are caused b}' gradual compression, whether this is due to the growth of a tumor (a cervical exostosis, for instance, })ressing on the brachial plexus), the enlargement of an aneurysm, the growth of callus, the contraction of a cicatrix, or some external agent. Paralysis of the musculo-spiral is not uncommonly caused by a person going to sleep with the arm hanging over the back of a chair, the nerve in this particular position being caught, almost unprotected, between the wood and the bone. When the cause is slight and only temporary, there is merely tingling or pricking, followed by numbness and a sense of warmth, with some loss of power over the movements of the part ; in more severe cases, the anc^sthesia and paralysis are complete, but the prognosis, if the cause can be removed, is usually favorable. Crutch paralysis is perhaps the most common form, sensation being less affected than movement, but both varying very greatly in distribution. Whether the curious instances of paralysis of one or more of the nerves of the arm (sometimes of the whole brachial plexus) occurring during sleep are to be accounted for in this way, or, as Duchenne tried to prove, by cold draughts at night, is doubtful. The absence of any evidence of neuritis renders the latter explanation very difficult to under- stand. Stretching. — The effect of violent strain upon a healthy nerve is closely simi- lar, the pathological lesion probably being of the same character — interruption of the medullary sheaths, with extensive disturbance of the axis-cylinders (rupture only in very severe cases), minute hemorrhages, and, subsequently, congestion. The worst instances occur in connection with dislocations, the injury being caused sometimes by the pressure of the displaced bone, sometimes by the tension to which the nerves are subjected at the time of the accident or in subsequent attempts at reduction. Treatment, — {a) When a nerve is divided in an open wound, the two ends should be found, brought together as accurately as possible, and sutured with chromic gut or fine kangaroo tendon. There is no objection to passing the suture through the nerve itself; indeed, in the case of small ones, it is the only way in which it can be effected ; but the needle used should be flattened from side to side, so as to inflict the minimum of injury. In the case of large ones the sheath should be sutured as well. The rest of the wound is treated according to the condition it presents ; the limb placed upon a splint to prevent tension upon the sutures, and every endeavor made to procure union by the first intention. As already mentioned, perfect recovery may take place within a fortnight, so that no difference is perceptible to the patient or to others. This, however, is exceptional. In the majority, trophic lesions begin to show themselves, and then, slowly, after some months, disappear again, sensation returning before movement and voluntary power before electric excitability. No case should be considered a failure until at least a year has elapsed ; sometimes no improvement can be de- tected for months, then it sets in and progresses rapidly ; sometimes it is steady and gradual from day to day. Bowlby explains the differences, in part at least, by the independent regeneration of the distal segment, which is no doubt has- 296 DISEASES AND INJURIES OE SPECIAL STRUCTURES. tened very considerably as soon as connecting axis-cylinders develop in the inter- vening splice. The ultimate prognosis is fairly good, but complete failure occurs in a certain number of cases, partial failure in many more, delicacy of touch and accuracy of movement being impaired ; and in all, or nearly all, the sense of localization re- quires re-educating. The presence of suppuration distinctly diminishes the chance ; in one or two instances, indications of commencing recovery have suddenly disappeared again, probably owing to the onset of inflammation checking repair. {b') When the injury is a subcutaneous one from the commencement, or the wound (if there was one) has healed, every endeavor must be made to assist the natural process of repair. Rest, pressure, bandages, splints, cold, position, and elevation may all, or some of them, be required, according to the nature of the injury. Everything else must wait until time has been given for the parts to be restored to their natural condition. The only exception is in those cases in which the compression is progressive, due to some internal cause; for these, naturally, something further is required; callus, for example, if it does not soon become absorbed, must be cut away and the nerve dissected out ; a cicatrix in the soft tissues must be treated according to circumstances; an exostosis removed, or perhaps the nerve displaced a little to one side to avoid the offending body. If the faradic excitability of the muscles persists, recovery takes place rapidly; if it disappears and is succeeded by wasting and the reaction of degeneration (as always occurs after section) the prognosis should be more guarded, and means must be taken to maintain the nutrition of the part as soon as the fear of inflam- mation is past. Warmth, friction, massage, stimulating liniments, galvanism, everything, in short, that can improve circulation and nutrition is beneficial ; and, especially if there is any anaesthesia, great care must be taken to protect it from injury. The galvanic excitability increases in animals for some time after the faradic is lost : but by the end of four months the muscles refuse to react to either. In man it is doubtful whether the increase takes place, but the galvanic excitability, at any rate, lasts very much longer than the faradic, and for this reason galvanism is preferred, as treatment, to faradism. The sittings should not be too long or too frequently repeated ; every other day for a quarter of an hour is usually enough, the time, of course, being chiefly determined by the extent of the paralysis and the number of muscles concerned. Massage should be applied afterward, and a weak ascending current used at the end to diminish the sense of fatigue. The skin is thoroughly well soaked with salt and water first ; and care must be taken not to irritate an insensitive part by using a current that is too strong. An occasional interruption now and then, reversing the direction, is said to be very beneficial. Increased sensitiveness of skin is the first sign of recovery. If this is noted, the treatment is continued in the same way ; in some cases improvement is very rapid : the muscles soon regain their shape, although their strength and size and the accuracy of their movements may be defective for a long period ; in others it is much more slow. After section, voluntary power returns before electric excita- bility, but this is not invariable in subcutaneous injuries. How long this should be continued, supposing there is no improvement, varies with each case. In a child, for example, repair, if it is going to take place, begins earlier than in an adult ; probably six months may be taken as the limit. If, at the end of this time, there is no sign of improvement, it does not follow that there never will be any ; but it is almost certain that it never will be very perfect, and that while secondary suture does not add any material risk, it offers the possibility of considerable benefit. If a neuroma has developed upon the central end, repair is hardly possible. Secondary Suture. — This may be performed at any time after failure of primary union. If an attempt was made to secure this at the time of the injury, it is advisable to wait for some months ; conductivity does not return equally soon INJURIES OF NERVES. 297 in all cases. If no attempt was made, the sooner secondar)- suture is jjcrformed the better. According to IJowlby, so long as the case is of less than a year's duration, the amount of time does not influence materially either the rapidity with which union takes i)lace or its perfection. After two years, however, perfect recovery is very doubtful, although a certain degree of improvement has been noted even at the end of twelve. As in primary suture, the period at which sen- sation and motion return is exceedingly variable. The former has been known to appear again within twenty-four hours, or two or three days (and sometimes in these cases, probably owing to changes taking place in the wound, it fails later) ; while in other instances it has been months and even a year before there was decided improvement. The latter, as might be expected from the change the muscles have undergone, and the necessity for them almost to grow again, is longer still, months and even years not being uncommon. No case, therefore, should be given up as a failure until at least two years have elapsed. The method of performing the operation is very simple, although in carrying it out great difficulties may be encountered. Esmarch's bandage should be applied, so that everything may be seen without confusion. An inci.sion is made over the seat of division, frequently traversing a scar, and the ends of the nerves sought. The upper one, especially if it is bulbous, usually presents but little diffi- culty ; the lower, on the other hand, may be so shrunken, fibrous, and matted to the structures around that it can scarcely be recognized. The bulb on the upper one should be cut away and no more ; the less of the lower one that is sacrificed the better ; it may appear hopelessly atrophied, but it is not in a more favorable condition further away. If, after they are freed from adhesions, the ends can be brought together without much traction, they should be sutured wdth chromic gut, as already men- tioned. In many instances, however, there is a great gap between, and sometimes this is the case in primary operations when a considerable portion of the nerve has been lost or is too much bruised to live. An additional inch or more may be obtained by stretching the ends, having first removed the bandage. If this fails there are various methods which have been recommended and some of which have been tried successfully. 1. Nerve-splicing is said to have succeeded (Despres), the distal end of the divided median having been implanted between the separated fibres of the un- injured ulnar. 2. Flaps have been used. An incision partly through the trunk of the nerve is made some little distance from the end, and a flap of nerve-tissue reflected downward from it, leaving it attached at its base, so as to bridge across the gap. This, too, is said to have been of use, sensation returning in four weeks and com- plete recovery in one year. 3. In a dog, the sciatic nerve was resected, the two ends sutured at some dis- tance, and inclosed in one of Neuber's decalcified drainage-tubes. Union fol- lowed, but such a proceeding would be hardly likely to succeed in man. 4. The humerus has been resected in order to bring the ends together. 5. Grafts from animals have been used, portions of freshly excised nerves being imbedded in the gap and fixed. In one case in which a rabbit's nerve was employed to replace part of the ulnar and median, sensation returned in four weeks and movement in nine, although the gap was more than two and. a half inches in width (Tilleman's). In another case, in which the sciatic nerve of a dog was used, the result was doubtful. 6. Finally, Mayo Robson, in a girl fourteen years of age, removed two inches and a quarter of the median nerve for a neuroma, and two days later transplanted into the gap a portion of the posterior tibial from a recently amputated leg. Sensation began to return within thirty-six hours, and within four months was almost complete, although some of the muscles were still much wasted. There is no doubt that any of these measures would be much more likely to succeed in a case of primary suture than where the distal end has been already 20 • 29S DISEASES AND INJURIES OE SPECIAL STRUCTURES. long separatetl from the proximal one. It is possible, of course, that they show nothing more than that the nuclei of the sheath multiply more rapidly, and arrange themselves more readily in rows when mechanical assistance is given them, and they are, as it were, directed into one particular line, instead of being allowed to coil up indiscriminately into a ball. Complications . Injuries of nerves as a rule heal readily, whether the nerve fibres unite or not. Occasionally they are followed by sequelae, some of which are very perplex- ing. 1. Reflex Paralysis. — By this is meant paralysis of one part of the body consequent on injury to another with which the paralyzed one has no direct con- nection. It may occur immediately after the accident, or some time may elapse. a. Imviediate. — Most of the instances recorded are the result of gunshot wounds ; a very severe injury is suddenly inflicted and a distant part of the body is paralyzed almost at once. In all probabilities these cases are due to shock, although it is an open question how this produces such a result. b. Secondarx. — These are of a total different character. A slight injury is inflicted upon one of the peripheral nerves, the muscles supplied by it gradually lose their power, anaesthesia, muscular cramp, and trophic lesions follow ; other nerves become involved, first those distributed to the same limb, then the corresponding ones on the opposite side, and subsequently similar changes in nutrition make their appearance there. In short, the symptoms are those of progressing chronic neuritis. 2. Reflex Spasms. — Trivial wounds of cutaneous nerves are occasionally fol- lowed by a peculiar series of symptoms of which tonic muscular spasm alternating with violent contraction is the most prominent feature. In many cases it is distinctly traceable to neuritis ; shortly after the injury the track of the nerve becomes exceedingly painful, the wound is exquisitely tender, and the least touch throws all the muscles around into a state of rigid spasm. In course of time as the wound heals this subsides ; but the scar often remains painful and tender, and the least touch at one particular spot may bring all the symptoms back. In other cases, however, there is no evidence of any inflamma- tory affection at any time ; the whole trouble appears to arise from a nerve-fila- ment being entangled in the cicatricial tissue and irritated when the part is moved. This was apparently not infrequent in days gone by after the operation for venesection ; some of the cutaneous filaments at the bend of the elbow were caught in the cicatrix, and the biceps and the other flexor muscles were thrown into a state of spasmodic cramp if the scar was touched or an attempt made to use the arm. Reflex spasmodic contraction of an apparently similar description is common in children after slight injuries, especially those affecting joints. In them it is doubtful how far the disorder is due to the as yet imperfect development of volun- tary control, and when there is no evidence or past history of neuritis spreading along the nerve, this should not be lost sight of in older patients, especially if there is a suggestion of hysteria. The treatment, if this factor can be eliminated, consists simply in excision of the cicatrix, or of the painful spot in it, as soon as the acute symptoms have subsided. 3. Epilepsy. — A few cases of epilepsy have been definitely traced to a peripheral lesion as the exciting cause ; the aura originates in the scar-tissue and the least pressure is immediately followed by an attack. In any such case, or where there is the least possibility of such a thing, the scar should be thoroughly excised, or the nerves coming from it freely divided. The sooner this is done the better, for there is evidence to show that the constant repetition of an irritation of this kind may at length lead to a condition in which an exciting cause is no longer required. DISEASES OF NERVES. 299 4. Tetanus. — Whether this disease is ever produced by i^eripheral irritation is open to question. It certainly is one of the rarest of all rare complications, if the number of accidents and operations in which nerves are injured is taken into consideration. On the other hand, its distinctly epidemic occurrence, the period of incubation, and the general course of its symptoms strongly favor its microbic origin, even if no weight is attached to the somewhat contradictory results of experiment. Probably the only valid reason for including it here is the occasional occurrence of tetanic contractions after subcutaneous injuries (simple fracture, for examijle) in which nerves had been strained or stretched. It must be remembered that tetanus, the disease, is a very different thing from spasmodic muscular contraction, even though this is tetanic in character. DISEASES OF NERVP:S. Neuritis. Inflammation of the peripheral nerves may be acute or chronic ; in either case the active changes are limited to the connective tissue ; the medulla and the axis-cylinders are only involved secondarily. Acute Neuritis. — The whole nerve is swollen, softened, and intensely con- gested. The sheath and the septa of cellular tissue are thickened and infiltrated with lymph, and in severe cases the section is strained with minute extravasations ; but suppuration is rare. The myelin breaks up and disap[)ears, the axis-cylinders become indistinct, the nuclei of the sheath are said to increase in number, and in the worst cases the whole appearance of a nerve is lost. Such extensive changes as this, however, are very rarely met with. Chronic Neuritis. — In this there is an increase of all the connective-tissue elements of the part. The sheath is thickened and adherent to the structures around ; the nerve itself becomes hard and dense, shrinking after a time to less than its normal diameter, and the fibres are atrophied and in great measure dis- appear. The term chronic neuritis is, however, applied in a very general way either to a true chronic inflammation, with increased cellular exudation and organization, or to a simple process of degeneration, in which the nerve fibres atrophy in much the same manner as after section. In many of the forms of so-called neuritis there is no evidence, past or present, of inflammation of any kind. Causes. — Inflammation occasionally follows injury, even when the skin is unbroken : why, it is difficult to understand. Acute or chronic inflammation of the cellular tissue in or round a nerve can, of course, be caused by the presence of foreign bodies or of micro-organisms ; but the result is very rarely proportionate to the cause, either as regards severity or persistence of the symptoms, and the worst cases not uncommonly follow such accidents as sprains. There must be some other factor as well, very likely a personal one. The influence of cold is variously estimated. The sciatic and facial nerves are the most often affected, the latter, it is said, being compressed by eff"usion in the bony canal, so that facial paralysis results ; but, according to Duchenne. neuritis is much more common than is usually believed ; certainly many cases of paralysis, especially of the musculo-spiral, commence during sleep, whether they are caused by cold or pressure. Neuritis is not uncommon in gouty and rheumatic subjects as a result of exposure to cold and wet, especially after great fatigue. The fibrous sheath is filled with inflammatory exudation which compresses the nerve filaments and in all probability the nervi nervorum as well, judging from the intense local pain and tenderness. In syphilis degeneration of peripheral nerves is not uncommon, and, of course, gummata occasionally develop in connection with them. In anaesthetic leprosy a chronic form of inflammation is the essential lesion. The abuse ot 300 DISEASES AND INJURIES OF SPECIAL STRUCTURES. alcohol is stated to be the main element in the production of what is known as progressive multiple neuritis. Degeneration akin to inflammation, if not depend- ent upon it, occurs sometimes in locomotor ataxy, Pott's disease, chronic myelitis, etc. But even when full allowance is made for all of these there is a very large residue for which no explanation is forthcoming. Some of the cases are distinctly inflammatory ; others (those, for instance, associated with herpes zoster and sloughing bed-sores) only exhibit degenerative changes ; there is no evidence of true neuritis ; but the changes are so much more marked and so much more rapid than those that follow simple section that it does not appear advisable to separate them. Symptoms. — i. Constitutional. — These depend upon the severity, and extent of the inflammation ; rigors, high fever, and delirium are present in the worst cases, but these are very rare. In chronic ones constitutional signs may be altogether wanting. 2. Local. — These vary with the character and connections of the nerve, whether it is motor or sensory. In acute inflammation the trunk is enlarged, excessively tender, and the skin over it is reddened and hyper^esthetic. There is the most intense pain, radiating over the whole area of distribution, sometimes of a burning character (causalgia), sometimes dull and aching, with numbing, prick- ing, and tingling sensations. Muscular twitching and fibrillar contraction may be present in the earlier stages, but tonic spasm is more common, and in a little while this gives way to loss of power, with rapid wasting and diminished faradic excitability. Paralysis, more or less complete, trophic changes of the most varied character, and anaesthesia are the final stages, the pain frequently con- tinuing the whole time ; but naturally the extent to which these occur differs in every case. Traumatic neuritis is always local at first, but in many instances it spreads upward along the nerve trunks until it meets other branches, involves these as well, and may finally implicate the whole of a limb. Then at length it subsides or becomes chronic, leaving the muscles wasted, the joints stiffened, the nerves thickened and tender on pressure, and the general health, both of mind and body, impaired from prolonged suffering. Other forms of neuritis are seldom very acute, although many of them, espe- cially the rheumatic, are often severe ; pain, tenderness, swelling along the course of the nerves, wasting of the muscles, and diminished faradic excitability are rarely absent ; sometimes they are marked as in the traumatic variety ; sometimes, on the other hand, as when the facial nerve is paralyzed from cold, the effect is compara- tively slight, consisting merely of temjjorary loss of power without any very perceptible alteration in the electric reaction. A peculiar form of multiple neuritis is described as occurring in connection with alcohol and syphilis, although it is doubtful whether these are to be regarded as the sole cause. In some cases it is stated to have originated from cold. The hands and feet are first involved, the extensor muscles on the front of the leg suf- fering so often that, according to Buzzard, this of itself is diagnostic. The pain is intense ; numbness with formication and a sen.se of fearful burning are nearly always present. The nerves are swollen and tender ; the skin red and glazed ; other trophic lesions follow and rapidly spread up the limb. Muscular power is lost almost from the beginning ; reflex phenomena disa])pear ; the reaction of de- generation sets in ; wasting is extreme, the muscles remaining flaccid, without be- coming fibroid ; and the movements resemble those of locomotor ataxy. In some cases there is a considerable degree of fever as well, and the general health usually fails rapidly. The course of the disease is very variable ; in a few cases it has con- tinued to spread, commencing at the extremities and rapidly advancing until the spinal cord became involved ; in some it has remained stationary for a long period, often at the level of the hands or feet, and then di.sappeared again, recovery taking place often imder anti-syphilitic treatment ; while in others again it has steadily progressed from bad to worse, until the patient died from exhaustion or was carried DISEASES OF NERVES. 301 off by some intercurrent disorder. Some of these cases are difficult to distini^aiish from tal)es dorsalis ; the gait is ataxic ; there are girdle pains, and not unfre(iuently lightning ones as well ; but as a rule in spinal ataxy the electric reaction of the muscles continues normal. Treatment. — Constitutional measures are most imjjortant. In the vast majority of instances, even if the inflammation is excited by cold or injury, its ])er- sistence and severity are due to some other cause, whether gout, rheumatism, syphilis, malaria, chronic alcoholism, or debility, and by itself local treatment is not likely to succeed. \w acute neuritis the first thing is to relieve the almost intolerable pain ; warmth, belladonna, fomentations, injections of morphia, Indian hemp, and other anodynes are the most useful. Afterward, when the first severity of the attack is past, narcotics, and opium in particular, should be employed as little as possible. Counter-irritants, leeches, blisters, iodine, and even acupuncture are of decided benefit ; warm and Turkish baths frequently give great relief, particularly before going to bed ; the constant current interrupted occasionally and preferably weak, but long continued, is often most successful, and in the later stages, when the ex- treme tenderness has subsided in some measure, massage does more good than any- thing else, in all probability by causing absorption of the inflammatory exudation and preventing the formation of adhesions and dense cicatricial tissues. Quinine and salicylic acid are sometimes very useful. Stretching the nerve itself, paralyzing the nervi nervorum and freeing the sheath all round, has proved of great benefit, even in such diseases as multiple neuritis and anesthetic leprosy, and in the worst cases is almost certain to give temporary relief. Neuralgia. By neuralgia in the general sense of the term is meant an acute paroxysmal pain in the course of a nerve. In many cases it is really a symptom of neuritis, or of disease of the brain or spinal cord, and the treatment must be guided by the cause. Sometimes, however, it does occur with great severity without there being any perceptible change in the nerv^e or the centre from which it springs. Neuralgia of this type is nearly always due to some constitutional disorder, although it may be started by a local cause. Neuralgia of the testes, for example, arising from irritation of the kidney, or of the face from the presence of a carious tooth, is seldom severe except in those who are predisposed to it by a constitu- tional affection, whether it is mental or physical, hereditary or acquired. It is especially common among members of what may be called, for want of a better term, neurotic families. Anaemia, dyspepsia, over-lactation, mental worry or over- work, malaria, gout, debilitating influences of all kinds, may induce it ; but the worst form of all, that which is known as epileptiform neuralgia, or when it involves the fifth nerve, as tic, has so far eluded every attempt at finding a reason. It may occur in both sexes, in the young as well as the old, the robust as w-ell as the weakly, and it may so completely destroy strength and health, both of mind and body, as to drive the patient to commit suicide. This peculiar variety of neuralgia is usually met with in the face, affecting one of the branches of the fifth pair, or in severe cases all of them. The pain is parox- ysmal, of the most intense description, coming on instantaneously from the slight- est cause — a touch, a breath of cold air, an attempt at mastication, or even from no cause at all ; it may last a few seconds or some minutes ; and it may come on at frequent intervals, or not for days and even weeks. Whenever it occurs the suf- ferer describes it as the most intolerable agony, usually comparing it to something burning. There may be convulsive spasm with it {tic convulsif) or not ; in many cases there is profuse lachrymation, in others the mucous membrane of the nose and mouth is hot and dry, occasionally the whole side of the face flushes, and in many instances the hair is affected too. Usually in its earlier stages it is traceable to some tooth as its starting-point, but in the true epileptiform variety it is not 302 DISEASES AND INJURIES OF SPECIAL STRUCTURES. uncommon to find that the patient has had every tooth on that side of the head removed without experiencing even a temporary cessation. Closely akin to this is a variety of neuralgia that is occasionally met with after amputations, different altogether from that which is due to the nerve-ends having become bulbous or entangled in the scar. It does not begin until the wound is sound. The whole of the stump is the seat of a fearful burning pain, though to the touch it is intensely cold. The skin is red, glazed, and congested, the color returning very slowly after pressure. The muscles of the joint above, and some- times of the whole limb, are in a state of constant spasmodic twitching, and the pain radiates not only through the amputated part but over the whole of the limb. This (though, like tic, it may have commenced as a local affection from a local source of irritation) when once established is only too liable to become permanent, in the same way that local epilepsy sometimes does, either from constant repetition only, or from a peculiar unstable condition of the central nervous system ; and I have known it return after four successive amputations, and even after the nerves had been stretched on the face of the stump as far as they could be without being torn out. No single one appeared to be involved, the disease, whether central or not, was general. Treatment. — The ordinary form of neuralgia is only a symptom of an affec- tion either of the nerve itself (neuritis) or of another part of the body, and the treatment essentially consists in finding the cause, whether local or constitutional. If nothing is discovered, all that can be done is to relieve the symptoms by large doses of quinine, salicylic acid, croton-chloral hydrate, or tincture of gelseminum internally, and anodynes — belladonna, veratria, aconite or menthol — locally. Naturally, as the constitutional condition that underlies the case may be of the most different description, the line of treatment required for one patient is often diametrically opposed to that advisable for another. Purgatives, colchicum, iodide of potash, and alkalies may suit one ; while complete change of air, often to the seaside, rest, tonics, iron, quinine, arsenic, strychnia, or phosphorus may be required for another. Very great care is essential in advising stimulants or morphia. Epileptiform neuralgia is rarely benefited except by operation, and even then in too many instances only temporarily. As a rule, by the time the neuralgia has assumed this type all the teeth on that side of the head have been extracted in the hope of obtaining relief. Sometimes this is successful, but in the worst form either the patient is entirely unable to state from what particular spot the neuralgia starts, or else, if there clearly is one offending tooth, no sooner is it removed than the pain transfers itself to another. Careful examination, however, should never be omitted ; there is more than one case on record in which excision of part of the gum or of the alveolar border succeeded after all. Quinine seems to have no control over it ; anodynes soon lose their effect ; morphia, if persisted in, only makes the condition of the patient worse. Gal- vanism is sometimes beneficial. If this fails, nerve-stretching may be tried, and as a final effort the whole nerve may be removed with its branches as far as possi- ble, up to its exit from the cranium. The trunk most commonly affected is the superior maxillary, and there is a sufficient number of cases in which excision of Meckel's ganglion has succeeded, to justify the operation. It is true, relief has not been permanent in all or nearly all, but in most it has lasted some months, in many one or two years, and that alone would be sufficient. OPERATIONS ON NERVES. Nerve-stretching. The great sciatic may be stretched subcutaneously without a wound, and with almost as great success ; in the case of other nerves an incision is required. If the cord is a large one, one or more fingers may be placed beneath it and steady OPERATIONS ON NERVES. 303 traction exercised upon it, first in one direction, then in the other ; as it yields a sensation as of crackling or snapping is transmitted to the finger, and the length and flexibility of the part exposed are distinctly increased. Small nerves should be lifted upon a rounded hook, sharp edges being avoided as much as possible. The immediate effect is to loosen the sheath, separating it from all the struc- tures around, and tear across the smaller vessels, so that its section is stained with minute ccchymoses. The myelin of the more superficial fibres is broken up into segments, many of the tubules are ruptured, and, unless the force is very extreme, the excitability is increased for a time. In a little while the part becomes more vascular, some of the fibres degenerate and disappear, the nuclei of the sheath multiply, all the interstices are filled with lymph, and the fibrous tissue becomes swollen and softened. At this stage, after its temporary increase, the excitability of the nerve diminishes, anaesthesia and loss of power follow, corresponding to the fibres affected, and the faradic excitability of the muscles is greatly depressed. Gradually this gives way in turn to regeneration ; new nerve tubules are formed, the hyperemia subsides, and at length all the functions of the part are restored. It is especially noteworthy that the effect of nerve-stretching is not limited to the spot at which the traction is applied. It extends for long distances up and down the trunk, involves the branches that come off from it, and occasionally produces a considerable effect upon the spinal cord. It is probable that no degree of traction that can be safely exercised upon a nerve during life moves the cord to any appreciable extent ; but whether this is the case or not there is no doubt that hyperaimia of the colunms of Goll may follow, and that sometimes, in animals at least, sclerosis of the posterior columns makes its appearance afterward. The effect varies with the force, and this, of course, is regulated by the size and the condition of the nerve. In some people the cords naturally stand a much higher strain than in others. The greater the length exposed the less the risk, as the force is more distributed. There is not so much fear of the nerve giving way as of its being pulled out from its spinal attachment, and great care, therefore, must be used when the part exposed is situated near the intervertebral foramina and the traction is from the centre. In any case the pull must increase uniformly without the least jerk. To stretch the sciatic nerve subcutaneously the patient is placed under an anaesthetic, and the hip flexed while the knee is kept in rigid extension, until a sufficient effect is produced. The hamstring muscles suffer to a certain extent at the same time, the ischial tuberosity being very tender for days afterward. I have done this with temporary benefit on more than one occasion, but it does not free the sheath of the nerve from surrounding adhesions in anything like the same degree. Neither operation is devoid of risk, especially in the case of the sciatic. Paralysis of other nerves coming up from the same region of the cord has been known to follow, and even the corresponding one on the opposite side of the body may suffer. Meningeal hemorrhage, meningitis, and myelitis have all occurred and have proved fatal, and in other cases sloughing bed-sores, cystitis, suppurative nephritis, and other trophic lesions have followed. Whether the frequency with which these occur after operations upon the sciatic is simply due to the fact that this nerve is more often affected than others, or to the exceptional amount of force that is sometimes used, as there is so little danger of tearing the trunk, is not known. The good effect that follows the operation in so many different diseases has been accounted for in many ways. There is no doubt that old adhesions are broken across and the cord freed from constricting bands. In other cases, when the neuralgic pain is local, not referred to the periphery of the nerve, the benefit may be due to the effect upon the nervi nervorum. Something, perhaps, may be said for the increased vascularity that follows ; the fibres are better supplied with blood and better nourished. But in all probability the chief good is due to the actual interruption of the fibres, both of the trunk and its branches, securing physiological rest for the centre until its normal nutrition is restored. 304 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The effect (except where there is some local reason, such as chronic inflam- mation or the presence of adhesions) is usually temporary. When the nerves are regenerated the old symptoms return again ; either the original cause still remains at work, or the effect upon the centre has been repeated so frequently and for such a length of time that habit has become second nature. Sometimes, however, the interval is sufficiently long, the vicious circle is broken, and the patient remains free. Nerve-stretching has almost superseded nerve-section : it produces the same effect without interrupting the physical continuity of the cord ; it acts upon the branches as well as the trunk ; a longer section of the nerve is examined, and adhesions, if there are any, are broken across. The wound is a larger one, it is true, but that is scarce4y a serious objection. Its chief use is in connection with all forms of neuralgia and chronic neuritis, even that which occurs in anaesthetic leprosy. In many of these cases it is extra- ordinarily successful. Epileptiform neuralgia, however, is usually only relieved ; it is almost certain to return. In addition, it has been used with varying success in tabes, both to relieve the pain and for the ataxic .symptoms, and in facial tic. In spastic spinal paralysis, tetanus, paralysis agitans, and spasmodic wry-neck its value is very doubtful ; sometimes it is said to have procured temporary relief, but it is not probable that the whole number, or even a large proportion, of the cases in which it has failed, has been published. Neurecto.mv and Nerve- EVULSION'. The former of these signifies merely the removal of a portion of a nerve-tnink ; the latter, etc., complete separation from the highest point that can be reached, as a rule, the orifice of a bony canal. Neurectomy is practiced upon the spinal accessory for uncontrollable spasmodic wry-neck, and occasionally upon the nerves of the head and face for neuralgia. Nerve-evulsion is rarely tried except in the case of the second and third branches of the fifth for epileptiform neuralgia. Meckel's ganglion may be excised, either from the side or in front. In the former operation the zygoma with the attachment of the masseter is separated and reflected ; in the latter the anterior wall of the antrum is trephined. If the light is good (an electric light or at least a reflector attached to the forehead of the operator is essential; the anterior operation is quite feasible, and, though permanent cure is rare, may be relied upon to give relief for at least one or two years. A crucial incision is made down to the bone over the infra-orbital foramen ; a half-inch circle is removed with a trephine from immediately below it, and the nerve traced back, cutting away the floor of the infra-orbital canal and groove until the posterior wall is reached. A second trephine opening is made in this, taking care not to wound the soft tissues beyond, and, as a rule, Meckel's ganglion is exposed at once, and can be removed with its posterior dental branches and the whole length of the infra-orbital, thus securing complete anaesthesia of that side of the palate. The inferior dental nerve may be exposed through the vertical ramus of the jaw, a circle of bone being excised with the trephine ; but in most cases it can be reached as satisfactorily through the mouth, and a disfiguring scar avoided. A gag should be placed between the teeth on the opposite side, and the mouth opened as widely as possible ; the incision runs along the projecting fold of mucous membrane, fjassing from one jaw to the other behind the last molar teeth, and the finger is pushed between the internal pterygoid muscle and the ramus until the sharp spine of bone that marks the orifice of the dental canal is reached. The nerve may then be hooked forward with an aneurysm needle, and separated from its connections for some little distance by the finger. Care must be taken not to mistake the long internal lateral ligament of the lower jaw for it. OPERATIONS ON NERVES. 305 Nkuromata. True neuromata — that is to say, tumors composed of nerve-tissue — are very rare. A few cases are recorded in which nerve-fibres (usually small and without much myelin) have been found, and, in one or two, nerve-ganglion cells as well ; but the total number is very small, and there is no means l5y which they can be distinguished from false ones during life. The nerve-fibres are not arranged in any definite order, and do not conminnicate with those of the trunk ui)on which they grow. False neuromata are fibromata, sarco- mata, or cysts developed in connection with the fibrous tissue of the nerve. They may attain any size and grow either on the side of the nerve or in among the fibres, dis- placing them. Sometimes they are multi- ple, as many as two thousand having been counted in one individual, and these are not unfrequently associated with moUuscimi fibrosum. Occasionally their section pre- sents a plexiform appearance: The symp- toms naturally vary with the kind of nerve from which they grow and the extent to which they interfere with its functions. Shooting pains, especially when the growth is handled in a particular way, neuralgia, paralysis, spasm, trophic lesion, and even paraplegia (when the tumor is situated in the spinal canal) have been described in connection with them. Neuromata must not be confused with the bulbous enlargements which make their appearance upon the ends of nerves after section, although the microscopic appear- ance is closely similar. Excision is the only treatment. If the growth proceeds from one side of the trunk there is no difficulty ; if, however, it is interstitial this may be impossible. Under these conditions the only course open is to excise a portion of the nerve and brin sible, by means of sutures. Fig. 77, — False Neuroma. A large oval tumor, six inches long by four wide, implicating the sciatic nerve and its posterior tibial branch. The tumor is hollow, presenting a large central cavity with sofi, shreddy walls. The trunk of the nerve, a, is seen passing into the tumor above and emerging below at a point below the popliteal space. Vari- ous filaments are represented spread out on the walls of the tumor, bb, and many other nerves can be detected by examination in the central cavity. For about one and one-half inches above the tumor the nerve is much thickened and indurated. All that is known of the history is that the limb was . amputated. The chief mass of the tumor was found, on microscopical e.xamination, to consist of fibrous tissue of various consistence, granular amorphous material, round and oval cells of the size of pus-globules for the most part, elongating fibre-cells, and remnants cf nerve tubes. (Holmes.) the two ends together, if pos- p6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER V. INJURIES AND DISEASES OF MUSCLES, TENDONS, ETC. Sprains and Contusions. Contusions of muscles are rarely serious, although they may cause consider- able effusion of blood, with pain and loss of power. In a itw instances, however (especially in the case of the quadriceps femoris), permanent atrophy has followed. I have known the same thing occur after a violent sprain, and that, too, without the fibres being torn to any extent. Tendons themselves seldom suffer ; the soft delicate sheath that surrounds them receives the brunt of the violence. Repeated strains, however, are not unfrequently followed by chronic inflammation, which may end in ossification. a. Hyaline cartilage. i. Proliferat- ing cartilage. c. Remains of old matrix of cartilage, with enclosed medullary spaces. d. New bone developed from the car- tilage and arranged in irregular tra- becular w a. Lacunae and canaliculi. 6. Lamellae. C c. Haversian artery. Fig. 78. — Rider's Bone seen in Section, with its Microscopical Appearance. The best known e.xample is what is called rider's bone, developing in the tendon of the adductor longus in those who are accustomed to rough riding, but I have met with similar ones in the tendons of the psoas, (piadriceps, and biceps. In chronic rheumatic myositis the tendinous expansions attached to the bones often become ossified, so that the intermuscular ridges stand out, covered with irregular osteo- phytes. This condition, however, is rarely diagnosed during life. RUPTURE OF TENDONS. 307 Rri'l LIKE. Muscles are torn by external violence, by sudden spasm, as in tetanus, or by splinters of bone being driven into them in fracture, and the injury may be either simple, with the skin unbroken, or comijound. In cases of external violence the rupture may of course involve any part ; the sheath only may be torn, or the whole thickness of the muscle. When it is due to sudden contraction the fibres SUorl cAc„,,r — ^-^r aW ft ^,! ^"^'^-—^^"^ Fig. 79. — Thumb, with 'rendons, etc., Torn out by Machinery. are usually wrenched out from the tendons, the line of junction being the weakest part. If, for example, the last phalanx of one of the fingers or the thumb is pulled off, it brings with it the whole length of the flexor tendons (Fig. 79). The signs of such an accident are very conspicuous. There is a sudden sharp pain followed by a dull sense of aching and of helplessness, and a feeling as if fluid were trickling down the skin. The ends retract immediately as far as they can ; an immense amount of- blood is poured out ; and the separation grows more distinct with every attempt to use the part. By degrees the blood is absorbed ; the swelling becomes less prominent, the lymph that is thrown out becomes organized, and, if the interval is not too wide, a slice of cicatricial ti.ssue is developed. Later it appears that this is in some measure replaced by muscular elements again. If only the investing fascia gives way the muscle substance is squeezed out through the rent, and forms a mushroom-shaped swelling known as muscle hernia. The adductor longus often suffers in this way in the almost involuntary grip upon the saddle when a horse swerves ; and full power is seldom regained. The biceps in the arm ; the quadriceps in the leg ; and the rectus abdominis, among the flat muscles, are ruptured almost as frequently. Others are seldom injured ; but the lower part of the pectoralis major may be torn (when, for instance, a person tries to save himself from falling by clutching at something) ; the sterno- mastoid may give way from vomiting, or (probably from excessive traction) during birth ; and the biceps femoris, the semi-membranosus, and many others occasion- ally suffer. Whether the plantaris ever does is, I think, open to question. There is a well-known form of accident, the symptoms of which are always strikingly alike, known as lawn-tennis leg, or as the "coup de fouet." It is rare among women and hospital patients, but exceedingly common in men past middle life and of a somewhat gouty tendency. There is a sudden violent pain in the calf of the leg, like a whip-stroke, and the patient stops involuntarily, whatever he may be doing, with his leg perfectly helpless. In a few minutes a little extravasation makes its appearance behind the inner malleolus ; a certain amount of puffiness and oedema may occur as well ; and then the pain subsides. The toe is placed upon the ground, but not the heel ; all the resolution the patient is capable of cannot bring it down ; the weight cannot be borne upon the leg ; and walking is out of Fig. 80.^ — Ruptured Tendon of Biceps. 3oS DISEASES AND INJURIES OF SPECIAL STRUCTURES. the i]uestion. In some cases a sHl^^Iu degree of eversion of the foot has been noticed. This peculiar accident is always attributed to rupture of the plantaris tendon, but I am not aware of any instance in which this lesion has been demon- strated. On the other hand, I know of at least one case in which the same accident occurred twice in the same leg at a different spot within the month. From the symptoms, the class of person in whom it occurs, and the rapidity with which recovery takes place, if proper measures are taken (not without), I am inclined to think that it is rather a rupture of some one of the deep-seated veins, which are so often varicose, than of that exceedingly long tendon. Treatment. — 'i"he limb must be placed in the position tliat secures the maximum degree of relaxation, and the extravasation checked as far as possible by cold and pressure. Firm bandaging assists in keei)ing the muscle from con- tracting and helps to press the broken surfaces somewhat nearer. Afterward the ])art must be kept absolutely at rest until organization is complete. If union takes place the nutrition will soon recover under the influence of massage and gal- vanism. When the tendo-.A.chillis is ruptured a high-heeled shoe must be worn for two or three months afterward. If the ends cannot be brought into fair apposition, union, of course, is impos- sible. The gap grows wider and more distinct as the blood that fills it is absorbed ; the ends of the muscle atrophy ; and its use is entirely lost. In many cases some appliance is needed afterward — an abdominal .support, for example, to prevent ventral hernia, or a thigh-belt if the adductor is ruptured. In open wounds an attem])t may be made to draw the surfaces together by deei)ly-buried catgut sutures passed through the whole thickness of the muscle, or through its investing layer only, but it rarely succeeds. With tendons, on the other hand, primary suture is very successful and should always be practiced. Chromic gut is the best material, the sutures being passed through the thickness of the tendon, and the wound, if necessary, enlarged for the purpose. At the wrist, where deep transverse cuts are of common occurrence, this is specially important ; but the tendo-Achillis and many others have been joined again in this way. Even secondary suture, freeing the ends from the cicatricial tissue around, freshening them, and fastening them together, is very often successful ; but the greatest care must be taken to secure union by the first intention, and the limb must be held rigidly fixed for some little time upon a splint, to avoid the smallest accidental movement. Where the interval is too great the tendon may be split and the two ends spliced, as described in speaking of nerve-suture. In one or two instances resec- tion of the shaft of the bone has been performed to reduce the size of the gap ; and transplantation of a muscle from a dog into the biceps is said to have succeeded. Rupture of the plantaris tendon recpiires an entirely different method. The limb must be raised for a few minutes in order that the oedema may subside ; and then carefully strapped and bandaged from the foot upward. As soon as this is accomplished -the patient is to walk with his heel well down upon the ground ; the sooner it is done, the more speedy is recovery ; prolonged rest always leaves a most serious degree of stiffness, probably from the organization of the extravasated blood tying together all the planes of cellular tissue between the muscles. The bandage should be renewed as soon as it becomes loo.se, and should be kept on for eight or ten days. Any stiffness that is left disapi)ears rapidly under massage and hot douching. Reunion of the tendon, if it is really ruptured, does not appear to be material. Dislocations. The peronei tendons are occasionally displaced from behind the external malleolus in severe sprains of the ankle, in spite of the tough fibrous sheath that binds them down. Reduction is easy, but often it is almost impossible to retain MUSCULAR ATROPHY. 309 them in position. Tlie foot should be carefully bandaged, with firm pressure behind the bony projection, and passive motion commenced at the end of the first week at the latest. It often happens, however, in spite of every care, that repair is not perfected, antl that some trivial slip, even months later, tears the old wound open again. The extensor tendons on the back of the wrist suffer in the same way, but rarely give rise to more than temporary inconvenience. There is a moment's pain ; the tendon slips back, and, beyond a certain feeling of soreness and weakness, the use of the hand does not suffer. The long tendon of the biceps may be displaced from its groove, although no doubt many of the cases in which this accident has been diagnosed are really the result of rheumatoid arthritis. There is a sudden twist with a sensation of sicken- ing pain, and the use of the arm is restricted in certain directions ; it cannot be raised above the level of the shoulder, and the head of the bone is too prominent in front ; then, suddenly, after a little manipulation, a snap is felt, and full power is regained almost immediately. In one case under my care this occurred on several occasions, the patient being able to throw the head of the bone out of gear. as it were, almost at will ; and although the diagnosis was not verified, it is difficult to understand what other kind of lesion could have given rise to so peculiar and constant a train of symptoms. Similar accidents have been recorded in connection with other tendons. Thus the tibialis posticus may be displaced from behind the internal malleolus in the same way as the peronei on the outer side of the foot ; and the sartorius may be forcibly wrenchecl from its 'surroundings at the knee-joint (especially when the knee is flexed) ; but these are all rare. Displacement of the tendon of the quad- riceps in cases of genu valgum is regarded rather as a dislocation of the patella. The slender muscular slips that lie packed side by side in the neck and in the loins are sometimes displaced ; but it is doubtful whether this should be called a dislocation. It usually occurs in some sudden awkward action, when, for example, the head is twisted round to look upward. There is a sensation of something giving way, or of a snap, with acute pain ; and the head is either fixed, or is very slowly and painfully brought into a straight position again. In some instances this is caused by the momentary locking of the articular processes, or strain of the capsular ligaments ; but occasionally a distinct, elongated, and very tender swelling has been noted, and complete relief has followed rapid manipulation, the muscle being pressed back into position while the patient endeavors by some sudden action to make it contract. Many of these cases, however, are probably due to tearing of the membranous fascia enclosing the muscle and partial hernia, or to rupture and extravasation in its substance. Either of these hypotheses would explain the facts equally well. Atrophy. Muscular atrophy may be due to the supply of blood being insufficient ; to affections of the nerves or nerve centres ; or to both together. Deficient supply of blood, such as arises from disuse, the pressure of an elastic stocking, or the ligature of the main artery of a limb, causes simple wasting, with or without fatty degeneration. The electric reaction is not affected ; the size and strength of the muscles diminish ; they lose tone and feel soft and flabby to the touch, but it requires nothing more than increased vigor of circulation to restore them. As soon as the cause is removed, they begin to improve at once with massage and galvanism. Atrophy due to affections of the nervous system is more serious. If the nerves are divided, faradic excitability diminishes from the first, and may disappear altogether in the course of a few days. The same thing occurs with the slowly interrupted current ; but, for a little while (at any rate in animals), the irritability 3IO DISEASES AND INJURIES OF SPECIAL STRUCTURES. appears to l)e increased, and a peculiarly slow and continuous contraction is caused by stimulation that is not strong enough to make any im])ression upon a healthy structure. This may last for a week or two, but rarely for much longer ; and at the end of three or four months, if the separation is complete, the muscles are insensitive to stimuli of all kinds. The atrophy that occurs in connection with neuritis is almost as rapid; but the worst examples of all are .seen in infantile paralysis, and progressive muscular atrophy, when the centres in the anterior cornua of the spinal cord are destroyed. In these disea.ses the corresponding muscular fibres may waste so completely that no trace of them can be found. Muscular atrojjhy following lesions of the motor area of the brain is not accompanied by the reaction of degeneration ; the fibres simply waste away from want of use. Rigidity, tremors, and contraction, however, follow if secondary descending sclerosis sets in and involves the motor tracts in the sjjinal cord. Functional Disorders. Loss of power, with or without spasmodic contraction, is sometimes met with in muscles that are constantly overworked ; and, as no definite lesion is known to exist, it is usually described as functional impotence and functional spasm. It may affect a single muscle by itself (the peroneus longus for example), so that it cither remains powerless or in a state of rigid contraction, instead of shortening and relaxing in harmony with the rest ; or more frequently it involves a group associated together for some particular action, and only when that action is being carried out ; for all other purposes they are as strong as they were before. The most common example is known as writer'' s cramp, the muscles of the hand being affected only when an attempt is made' to grasp and direct a pen ; but it is frequently met with in other occupations (so that it is sometimes known as a professional neurosis), especially those in which finely adjusted movements are kept up without intermission for a great length of time. At first there is little more than a sense of fatigue ; the pen is grasped more tightly, or is held in some unusual way; then involuntary contractions set in; at the beginning they are only of momentary duration ; soon they become more persistent and exaggerated ; the more attention that is paid to them, and the greater the effort, the worse they grow ; the muscles of the forearm become involved as well as those of the hand ; even those of the head and neck may suffer ; then they spread to the opposite side of the body ; and finally, the least attempt at placing the hand in position is sufficient to throw it into a state of the most violent and painful agitation. The electric excitability of the muscles is usually slightly depressed ; the nerves, especially the median, are tender on pressure; neuralgic pains are very frequent, at first only when the one ])articular action is attempted, but later more constantly ; and partly from this, partly from the mental distress, the general health fails and the nutrition of the muscles becomes still more impaired ; but there is no evidence of neuritis or of any gross pathological lesion. It may occur even in those who are strong and healthy ; but it is distinctly more frequent in members of neurotic families ; and in a few cases it can be traced, in part at least, to slight hemiplegic attacks occurring at an earlier period of life ; recovery is perfect for all ordinary actions, only unusually delicate combinations such as these are carried out at a disadvantage, and foil in jierfection sooner than they otherwise would. The style of writing is probably of some importance. Those who rely upon their fingers only, who do not use the wrist or forearm, appear especially subject to it. Short-hand writers, Avhose style is necessarily very free, are seldom affected. It is probable, as Vivian Poore suggests, that these disorders (or at least writer's cramp, which may be taken as the type of the rest) are due to neuro-muscular fatigue, the tenderness along the course of the nerves, the tremors, and the dimin- ished excitability all being susceptible of the same explanation. Certainly the MYOSITIS. 3t. most successful remedies are those which tend to improve muscular nutrition. Massage, combined with passive motion and suitably arranged exercises, has met with the most conspicuous success, cases of many years' duration having begun to improve almost at once, and having been at length completely cured, so that full power of writing was regained. At the same time tonics, galvanism, and local injection of strychnia are of very great assist- ance. Rest alone effects but slight alleviation, and that only of a temporary character. II .1 1- ■ t 1 u tic. 8i. — Nussbaiim's Instnimer.t for n early cases the appliance invented by Writer's Cramp. Nussbaum may be used with benefit. It is framed to exercise the extensors and abductors of the fingers, so that they may be better able to resist and overcome the spastic contraction of the flexors and adductors (Fig. 8i). Contracture or Permanent Shortening. This is distinguished from ordinary muscular rigidity (such as occurs in the early stages of inflammation of a joint and in hysteria), by its not relaxing under an ancesthetic. The change is in the sheath and the connective tissue of the muscle ; the fibres atrophy, the cross section is very much diminished in size, and in some of the more extreme cases scarcelv anv trace of true muscle substance is left. It is produced in various ways. A mild form of it may be caused by pro- longed rest in one position, as in the case of the gastrocnemius, when the patient is confined to bed ; the worst cases are usually the result of chronic inflammation of the muscle itself, descending neuritis, or persistent irritation along some portion of the motor tract. Hence its frequency in descending sclerosis following lesions of the cortex. Slight cases, provided the cause is not a persistent one, can be cured by mas- sage and passive motion ; tenotomy, however, is often necessary in old joint dis- ease, before the parts can be restored to their natural position. Section should always be subcutaneous, and performed at the spot at which the muscle (or prefer- ably its tendon) is most superficial and farthest away from important structures. Myositis. Subacute inflammation of muscles usually occurs in connection with gout, rheumatism, and exposure to cold and wet, or it follows prolonged overwork, or a sudden strain rupturing some of the fibres. The pain is often severe, especially at night, and when an attempt is made to move the part ; and this, combined with stiffness, is the most conspicuous feature. Fever, swelling, and local pyrexia are seldom present. Inflammation due to other causes is more rare, although it sometimes extends into the muscles from the surrounding structures, and occasion- ally arises from direct infection through a wound or through the blood. In chronic inflammation the exudation becomes organized and contracts while the muscular substance itself wastes and degenerates. In many cases this ends in a condition of rigid contracture, requiring prolonged massage and even tenotomy before use of the part is regained ; and ossification is not uncommon, spreading from the insertions of the muscles into the tendons and along the fibrous septa, until the bones are covered with irregular osteophytes. Suppirative myositis may either occur as a local affection (an abscess forming in the substance of the muscle, from injury, or the impaction of a foreign body), iiSiVi, 312 DISEASES AXD INJURIES OF SPECIAL STRUCTURES. or as part of a general infective disorder. Diffuse suppurative myositis, for exam- ple, sometimes breaks out under the same conditions as diffuse inflamma- /'^ y '■ , tion of the cellular tissue, or diffuse / " ' _ ' . suppurative periostitis, although it is' y C ■, ' much more rare; the pyogenic or- ,^ > ' ,' ganisms gain access to the i)art 1%^ A, . '/I through a wound, or when the skin y*^, ■• ]k/ is unbroken through one of the mu- Mj ^"^ r,l cous surfaces, and owing to their "^^ being accidentally favored in some /V.-rioir-^""- - • ^ ,■ -' way (by extreme fatigue, for instance") \:^ /^^o^X' ^-f^^ give rise to wide-spreading suppura- ( ' v'^;^;' ■ '-^^ tion. v^ In addition to this, a few cases ' V' "."•» V^'^ii/ji' i'iV'P'V' are recorded of an a(7//(f //■<7^/r.y.f/?'(f ' fUr-' I I ffiyositis, involving all the voluntary T- „ c-L • 1. TT 1 r- „ -., , r-.. muscles of the bodv, and generally FiG. 82. — Showing the Early Fig. 83 — 1 he Late or Fibrous . ^ , ^ - , . ° ■' or Cellular Stage. Stage. proving fatal from asphvxia or pneu- From a case of sterno-mastoid induration in an infant. mOnia. It appears tO reseillblc trich- inosis in many of its features, and in all probability is parasitic, although as yet no actual evidence is at hand. Inflam- matory swelling of the muscles, with the most intense pain, so that the patient can barely move ; an urticarial or papular eruption upon the skin, followed by cedema, and rapidly increasing weakness, have been noted in all ; while in some there was cramp, or a tonic contraction of the muscles, with insomnia and profuse sweating. The diaphragm, heart, and bladder appear to escape. In all the cases examined evidence of acute inflammation has been found, sometimes parenchymatous, the fibres being pale, rigid, friable, and infiltrated with serum ; sometimes, on the other hand, interstitial, with hemorrhages scattered everywhere among the fibres. Gummata are not uncommon, especially in the tongue and the sterno- mastoid. In the latter muscle a peculiar firm and hard nodule, which is certainly not always due to syphilis (Figs. 82 and 83), is sometimes noted shortly after birth. In most instances it appears to be traumatic. Leprosy, tuberculosis, and other similar diseases give rise at times to specific deposits among muscular fibres, as in other tissues. A very peculiar form of inflammation is occasionally met with {jttyositis ossifi- cans), in which large plates of bone are developed, chiefly in the dorsal region, but also all over the body, in the substance of the muscles, so that the bones become united together by osseous sheets of the most fanciful shapes. Nothing is known as to its pathology. Teno-svxovitis. The synovial sheaths of tendons resemble the deeper bursas and the lining membranes of joints in structure and pathology. Inflammation may be caused by any continued irritant, organized or unorganized. The simplest form is that due to mechanical injury, such as tension or overwork ; others, more severe, are the result of specific ailments, gout and rheumatism, for example, or of infection, as in tubercle and syphilis ; suppuration never occurs without the presence of pyo- genic micro-organisms, whether they come through a wound, through the blood, as in pyaemia, or directly from surrounding structures. I. Acute. — Simple acute teno-synovitis is caused by strains or prolonged over- work. The course of the tendon is marked out by an ill-defined swelling, the skin over it is tender and sensitive, the temperature is slightly raised, the action of the muscle is painful, and whenever the part is used or moved in any way there is a TEN OS YNO VITIS. l^^l peculiar soft crepitus, as of two pieces of silk gently rubbed together. The endo- thelial lining is detached, the surface covered with lymph, and the least movement causes friction. In more severe cases the exudation involves the loose cellular tissue around as well as the tendon sheet itself; often it is mixed with blood, and the pain, heat, and tension are more severe. The whole of tiie dorsum of the hand and forearm, for exami)le, may be swollen and (edematous, and the bruising extend far above the elbow, after a fall ujn^n tlie back of the hand, doubling the wrist upon itself. The subsecjuent changes are the same as those that occur in other parts under .similar conditions. The whole of the exudation may be absorbed without leaving after-trouble of any kind. I'art of it may undergo organization (especially if there is .some constitutional ailment jjresent, keeping up a persistent though slight degree of irritation), so that the attack becomes chronic; or supjjuration may follow. 2. Chronic Tenosynovitis. — Chronic inflammation may begin as such, or follow an acute attack, kept up either by a constitutional cause, such as gout or rheuma- tism, or by the presence of adhesions. This is a frequent result of over-caution and the fear of passive motion in the treatment of sprains and other injuries. The tendon-sheath, after some slight accident, is filled with lymph, which becomes organized and forms bands extending between contiguous structures, tying them together. At first these are thin and delicate, and break down at once ; but if the parts are kept at rest too long, they grow firm and rigid, and then, unless they are torn right in two, or at least are stretched to such an extent that no more tension falls upon them, they become the cause of fresh attacks. Every contraction of the muscle strains them, and gives ri.se to pain ; fresh effusion follows, and this in its turn becomes organized, and makes them stronger still. The frequent repeti- tion only makes matters worse, while one sudden, and sufficiently vigorous, well- directed wrench would remove the cause, once for all. The pain in chronic tenosynovitis is very variable ; usually it is rather of a dull, aching character, with a sen.sation of soreness ; it is never intense and throb- bing, as in the acute form. The temperature is only .slightly raised, there is little or no redne.ss of skin, Ixit the swelling is generally conspicuous, involving the loose tissue around as well as the sheath it.self, and attended with great impairment of power. In many cases the effusion is simply serous, but it may be thickened, almost gelatinous, or mixed with myriads of melon-seed bodies, all practically the same size and shape, consisting of concentric laminae of fibrin, developed from the lymph poured out on the walls and septa. The inner surface may retain its normal smooth character, but not unfrequently, especially in rheumatism and in the neigh- borhood of joints affected with osteo-arthritis, it is rough, irregular, and covered over with ma.sses of dendritic outgrowths, which can be felt rnstling and crepitating with every movement. Tubercular inflammation is met with most frequently in the large sheaths which spread along the flexor tendons under the annular ligament of the wrist. The walls and mesotena are enormously thickened and converted into granulation- tissue, similar to that met with in tubercular synovitis of joints. The fluid in the interior may be gelatinous, like that found in ganglions, or turbid from the exuda- tion mixed with it ; but it is rarely much increased in quantity. The lining membrane is softened and rough, the movements of the tendons impaired, and the use of the part greatly limited. The most prominent symptom is a chronic, painless swelling, occurring, as in compound palmar ganglion, above and below the annular ligament of the wrist, .soft and elastic to the touch, but not fluctuating, and not admitting of its contents being driven from one compartment to another. 3. Suppuration. — This may be caused by direct infection, as after amputation of the toes when long open channels are left, placed vertically in the most con- venient position for receiving all the discharges of the wound ; or by pyaemia, or by extension from inflammation near. The most common situation is on the fingers {thecal abscess or tuhitlow), owing to the frequency with which poisoned 21 314 DISEASES AND INJURIES OE SPECIAL STRUCTURES. wounds occur, and the jjcculiar distribution of the lymphatics. Instead of the loose, horizontal arrangement which prevails in the subcutaneous tissue of other parts, the general direction of all the fibres and lymphatic spaces in the fingers is from the skin toward the periosteum or the tendon-sheath, and any poison that is inoculated on the surface is carried down to the deeper structures, causing inflammation, which is all the more severe because of the dense, unyielding char- acter of the tissues. This is the explanation of the frcr vears. l^mcture with a trocar and cannula is not more satisfac- tory. Subcutaneous section with a tenotomy-knife, dividing the .sac in two with a single horizontal sweep, answers better; but if the cyst causes any real trouble •or is unsightly, the most efficient plan is to cut down upon it and excise it. The cure is effectual, and a linear cicatrix only is left. I'he limb should be placed upon a splint afterward, until the wound is sound, as not unfrequently the tendon is exposed, and sometimes the cyst communicates indirectly with a neighboring joint. Comi)Ouncl ganglion is much more serious, and if the walls of the synovial sac and the septa are thickened and irregular, or if they are covered over with lymph, and the cavity is full of melon-seed bodies, a very guarded prognosis must be given. Pressure is of no use. A free incision may be made into it above and below the wrist, and the whole cavity emptied and drained as thoroughly as pos- sible ; but though the fluid is removed, and most of the melon-seed bodies, many are sure to be left, the condition of the lining membrane is untouched, and the drainage is very imperfect. Syme laid the whole sheath open, dividing the annu- lar ligament ; and it is a question whether this would not be the best proceeding now, at least for those cases in which melon-seed bodies are present and the walls are much altered in character. The greatest care must be taken to avoid suppuration. If this occurs, the tendons are almost sure to slough ; and if there is the least tension, or if the vitality of the tissues is lowered by the poisonous products of decomposition, it is almost certain to become diffuse and to spread to the wrist joint, or to the deep planes of cellular tissue in the forearm, and cause the most extensive destruction. Dupuytren's Contraction. The palmar fascia, and the prolongations of it which run by the side of the fingers and are attached to the periosteum of the first phalanx, not unfrequently become the seat of a peculiarly obstinate form of contraction, tying the fingers rigidly down into the palm of the hand. It rarely occurs under thirty years of age, and is much more common among men than women ; indeed, according to some, the latter are entirely exempt, but this is not the case. Usually its begin- ning can be traced to some slight injury, such as the pressure of a round-headed stick in the palm of the hand during convalescence from severe illness ; or a sudden strain, pulling the finger back; but there is no doubt that it is depend- ent, to a very large extent, upon gout, although I am not aware that deposits of urate of soda are ever found in it ; and it is much more common among the well-to-do than among hospital patients. Certain classes of the latter, however, engineers' fitters, for example, are often affected (Fig. 85). The ring finger is usually attacked the first, but in many cases all the three on the ulnar side are involved more or less ; the index only suffers in the worst. Fig. 85. — Dupuytren's Contraction. The first thing to attract attention is a small, hard nodule in the palm of the hand, at a point corresponding to the lowest of the transverse creases into which the skin is thrown and to the interval between the ring and the little fingers. It is not painful unless roughly handled, and does 3i8 DISEASES AND INJURIES OF SPECIAI STRUCTURES. not at first give rise to any inconvenience. Soon, however, the skin begins to waste and lose its flexibility ; the fat disappears, and the cutis becomes tied down so firmly to the fascia beneath that it is practically incorporated with it. Then prolongations make their appearance, running from this upward toward the wrist and downward to the fingers. The skin becomes adherent in other ]iarts ; the bands of fascia stand out more rigidly, and gradually the fingers are flexed and tied down into the palm of the hand in an altogether hopeless way. Extension has not the least influence over them. The flexor tendons take no share in the deformity, although at first sight it is easy to mistake the rigid bands that stand out in the hollow of the palm for them. The disease is entirely due to the contraction of the fascia, the deep as well as the superficial layer, and the vertical bands that pass between them and the skin. It affects the fingers on the inner side of the hand more than the rest, because in all probability they are weaker and less able to stand a strain than the others ; and if they are bent backward the prolongations of the fascia over the metacarpo- phalangeal articulations are stretched and hurt. It is the peculiarly obstinate and progressive character of the contraction that makes it so serious. When once it has commenced, it tends steadily to grow worse and worse, tying one finger down after another; and although in the earlier stages it may be relieved or even cured without great difficulty, in the later ones this is impossible without operation. Treatment. — Systematic massage, with the finger well extended, will often check the contraction, if not too far advanced, and cause absorption of the inflammatory exudation. If this does not succeed a splint may be worn at night, fitted on to the dorsum of the hand and firmly strapped to the wrist. Little caps of metal are adjusted to the phalanges and attached to the dorsal splint by means of elastic bands, the strength of which the patient can regulate for himself. In other cases a more complicated appliance is required. A broad, well- padded metal plate is fitted to the back of the hand and wrist, w-ith extension racks lying over the fingers bent at an angle to suit the degree of flexion. Improvement, however, in this way is very slow, and it rarely happens that patients can be induced to take the trouble before the deformity is too far advanced and the bands too rigid. If the angle of flexion approaches 90°, it is almost impossi- ble to straighten it without operation. Dupuytren himself merely made a transverse incision through the skin and fa.scia at the most resisting point, so that when the finger was straightened out a lozenge-shaped woimd was left, the sides of which might in successful cases grow together. Modern treatment, however, resolves itself either in subcutaneous section with a fine tenotomy-knife at many points (after Adams), or into a modi- fication of Goyrand's original plan, dissecting out the whole of the contracted portion. Whatever is done, it must be recollected that unless immediate union is obtained the result is likely to be very far worse afterward than it was before. When the bands extend far down the sides of the fingers, there is no doubt that Adams's method is jjreferable. The hand should first be thoroughly soaked in an antiseptic bath and well raised, so as to limit the amount of hemorrhage. The palm is dealt with first, selecting those points where the skin is still movable over the subjacent tissue ; then each side of the fingers by itself, as many punc- tures being made as are necessary to allow them to come out perfectly straight. The little wounds are then covered with iodoform-collodion and cotton-wool, a palmar si)lint adjusted to keep the hand at rest, a bandage j^laced over the whole, and everything left for three days. By that time all the punctures should be healed, and extension may be commenced with an appliance similar to that already described. The more rapidly this is carried out the better; to be successful the fingers should be perfectly straight within the fortnight. Excision is only practicable where the contraction is of limited extent, and such cases, of course, succeed the best with tenotomy as well. The incision is BURS.^. 319 made down the length of the band ; the skin, which is usually very much atrophied and closely adherent, detached from the fascia beneath without bruising; and then ^ the hard, contracted band isolated and removed. The advantage of this metliod is that the straightening is more perfect and the risk of recurrence is less ; but it is very questionable whether this is real. Certainly some of the cai>es which have apparently succeeded have relap.sed again in an altogether hoi)eless manner. AVhichever method is adopted the apparatus must be worn at night for some considerable time to prevent recurrence. During the day it may be disjjensed with as soon as the fingers are straight. Massage, warm bathing, deep friction, and everything that can encourage absorption should be thoroughly practiced from the moment that the wounds are sufficiently sound. Nodules and deep bands of the fascia are always left behind, even when the attempt at excision is fairly successful ; and every endeavor should be made to promote their absorjjtion, to limit the amount of inflammatory exudation, and to restore as soon as possible the suppleness of the skin. BURS/E. Bursae are spaces developed in the cellular tissue by friction. The deei)er ones, lying between tendons and bones, are present at birth, and are lined with a definite endothelium similar to that in tendon-sheaths and joints. Subcutaneous ones, on the other hand, do not, for the most part, make their appearance until later, and are less regular in shape and structure. Many are constant in occurrence, and are reckoned among the normal structures of the part ; but they may be devel- oped anywhere by friction, and throughout life they have a tendency to grow, until in many cases they form communications with neighboring synovial cavities. The fluid in the subcutaneous ones is more serous than joint synovia, but that in the deeper ones is identical with it. Bursas that communicate with joint-cavities naturally possess a special impor- tance. Very often the channel between the two is so narrow that no fluid can be made to traverse it ; but where there is the least ground for suspicion, the swelling should always be given the benefit of the doubt, and treated as if it were an out- lying part of the synovial sac. Injuries. — Incised and punctured wounds inflicted with a clean instrument heal readily. The latter are the more serious, owing to their tendency to become valvular. Lacerated ones may cause considerable trouble, owing to the fact that the part is the seat of constant friction. For the same reason contusions are frequently followed by slight inflammation. No special treatment, however, is required ; if there is a wound it must be thoroughly cleansed and drained ; a large extravasation of blood may be aspirated ; and in any case careful pressure must be used to prevent tension and to keej) the parts at rest. Inflammation of Biirsce. — Simple inflammation is very common. It may be acute or chronic, and subside or end in suppuration. Specific diseases are more rare, but superficial bursae in particular are liable to be affected in syphilis, gout, and tubercle, probably owing to the frequency with which they are injured. [a) Acute hiflammatioti. — This is nearly always due to injury. The symptoms, if the bursa is superficial, are plain at once. Swelling is very conspicuous ; and redness and local pyrexia are well marked ; but owing to the presence of a cavity in which the exudation can collect the tension at first is not very high, and the pain and constitutional disturbance not severe. In deeper ones, on the other hand, the diagnosis is more difficult ; swelling cannot be detected ; the pain is often very great, especially on movement ; and the fever may be such as to lead to the suspi- cion that other even more important neighboring structures are involved. In these cases the diagnosis often rests almost entirely upon a knowledge of the action of the muscles that surround the part. Thus, if the bursa under the deltoid is inflamed, rotation of the humerus is fairly free when the arm is moder- 320 DISEASES AND INJURIES OF SPECIAI STRUCTURES. ately abducted from the side; in adduction or great abduction it is very painful, owing to the tension upon the sac. So with that under the psoas ; if the thigh is flexed the head of the femur rotates without pain. On the other hand, th^limb is kept extended when either the bursa l^etween the quadriceps and the femur, or that l.)etween the ligamentum patella; and the tibia, is affected. In other cases the position of the swelling is the most significant sign. If, for instance, the bursa between the os calcis and the tendo-Achillis is enlarged there is a swelling on either side behind the limb, but none in front, as when the I)one or the ankle joint is inflamed ; and unless the bursa on the front of the pouur communicates with the knee joint there is no distention of the synovial fccmhes on either side of the patella, even if it suppurates. {b) Chronic Inflammation. — This may either be the re.sult of an acute attack, or be chronic from the first. Usually it is caused by some slight but frequently repeated injury, or by a more severe one (a contusion, for example, filling it with blood), the effects of which are perpetuated by constant friction. The pathological appearance varies very considerably. Sometimes the wall is thin and the cavity immensely distended with a fluid which at first is blood-stained, but which in course of time loses its color and becomes clear and serous. In other cases the wall is thickened (whether there is fluid present or not) either by the deposit of fibrin in laminae on the inner surface or by the formation of dense inflammatory tissue around, or by both together, until it is an inch or more in diameter, and the central cavity is reduced to a cleft (Fig. 86). It rarely disappears altogether. Not unfrequently the interior is rough and irregular, covered with warty nodules, or traversed by thickened bands, some of which, as in the case of the prai- patellar bursa, may be the remains of the septa between the different cavities, while others are new formations altogether. Occasionally melon-seed bodies are found in numbers, either white or stained with blood, as if they were formed from blood-clot. More rarely there are definite pedunculated outgrowths with floating cartilaginous ends, similar to those found in joints. This, however, is not common except in osteo-arthritis, when the bursre, even though they do not communicate with the neighboring joint, not unfrequently undergo a similar transformation. Finally, sometimes, in very old cases, calcification takes place. Tubercular inflammation is characterized chiefly by a slow, painless enlarge- ment, due to the accumulation of fluid mixed with flakes of caseous material. The interior is lined with pale, flabby granulation-tissue containing giant cells, but few bacilli. Sometimes, especially in the case of the sub-gluteal bursa, these cavities attain a very large size, and spread for considerable distances among surrounding structures before they break ; and then they are ])rone to leave behind them chronic sinuses covered by flaps of purplish skin. Usually they retpiire the free applica- tion of the cautery or of Volkmann's spoon before they get well. Syphilitic disease chiefly occurs round the knee and over the tuberosity of the ischium, owing in all probability to the great liability of these parts of the body to injury. The gummatous deposit breaks down, leaving round, punched-out oi:)enings with overhanging edges. In gout the bursa that forms over the metatarso- phalangeal joint of the great toe is the one that suffers most frequently, but occa- sionally deposits of urate of soda are found in the interior of those in other parts of the body. {c) Suppuration. — The onset of suppuration in a bursa is usually marked either by a rigor or by a sudden rise of temperature with severe throbbing pain. The swelling rapidly increases in size ; the skin becomes l)oggy and cedematous ; and if free exit is not given at once the walls of the bursa give way, the pus si)reads far and wide in the softened and hviicra^mic connective tissue around, and diffuse inflannnation of the cellular tissue follows. In part this is due to the difficulty BURS.-^. 321 the pus has in escaping through the dense layer of tissue that has been formed over the cavity by constant friction ; in part to the fact that, after all, a bursa, even when it is surrounded by a wall of its own, is only a space in the cellular tissue, and is in free communication with all the interstices around. Usually the neigh- boring lymphatic glands are involved as well, and sometimes, especially in the case of the bursce over the olecranon and the patella, the mischief s|jreads into the bones, and even by direct extension into the synovial cavity of the joints. Treatment. — Acute inflammation must be treated by rest, cold, and pressure. [Hot antiscplic fomentations are serviceal)le in these cases.] In most cases it is advisable to place the limb upon a splint, and when the lower one is concerned to confine the patient to bed. If this does not succeed and the swelling does not subside, it should be punctured and the fluid let out to prevent suppuration. Simple distention, if the wall is thin, may be treated very successfully by tapping with a trocar and cannula, and applying pressure afterward; or, if the case has not lasted long, and the part is conveniently situated, pressure alone may be tried first. Counter-irritation (the free application of l)listering fluid) some- times effects a cure. The injection of iodine is strongly recommended by some ; but the limb must be placed upon a splint, and careful watch kept that the reaction does not go too far. In such cases the walls are probably well-defined, but if the iodine should escape into the cellular tissue, it is not unlikely to cause a consider- able degree of inflammation. When the wall is much thickened, measures of this kind are of very little use. It is better, if the bursa is unsightly or causes any inconvenience, to excise it altogether ; and this is certainly adv;isable when foreign bodies are present, unless they can be thoroughly cleared out by free incision. Deep-seated bursse are so frequently in communication with neighboring joints, especially when they become enlarged, that very great care is required in dealing with them. The most treacherous of all, perhaps, is that which appears sometimes along the inner border of the popliteal space. When the knee is extended it forms a firm, elastic swelling, owing to the tension of the semi-mem- branosus and the inner head of the gastrocnemius between which it lies. In flexion, on the other hand, it is so soft and flaccid that it can scarcely be felt ; but neither in one condition nor the other is it possible to prove or disprove whether it has a communication with the joint. Fortunately, in these deep-seated bursae the more serious consequences, such as the formation of loose bodies and suppuration, are of rare occurrence ; but even chronic distention causes a very unpleasant sense of weakness and greatly impairs the utility of the limb. Sometimes, moreover, as they grow larger they approach nearer the surface (the pressure in their interior increases in proportion to their size), and then, like the synovial diverticula they so much resemble in structure, they may either point beneath the skin and be opened by mistake, or may actually cause it to rupture and give way. In cases such as these aspiration and pressure should be tried first ; but if these fail, and the cyst is accessible, it is better to cut down upon it, excise it, and stitch the neck up with catgut, than to resort to measures calculated to excite inflammation. In the case of suppuration, free incision as soon as possible is the only course. Very often more than one is necessary, and not unfrequently, especially in the case of the knee, they must be made some little distance from the actual bursa, down by the side of the limb, so as to tap the cavity at its lowest point. Recovery in such cases is always exceedingly slow. Sloughs of fibrous tissue often have to separate ; the skin is extensively undermined ; the part, even in the case of the knee joint, is very difficult to keep at rest ; matter will collect in outlying pockets, which have to be drained ; and even when recovery is apparently ensured, not unfrequently as soon as the joint is used, some of the old cicatrices break down again. If the suppuration has extended to other structures — if, for example, the bone beneath is exposed and carious — repeated operations may be required before it is sound enough to stand friction and pressure. 322 DISEASES AND INJURES OF SPECIAL STRUCTURES. CHAPTER VI. INJURIES A.\D DISEASES OF BOXES AXD JOINTS. SECTION I.— MALFORMATION AND DHFORMITIHS OF THH LIMBS. Disproportionate Growth. Overgrowth, involving either a limb or one part of it only, is not uncommon. The condition is present at birth, but naturally becomes more noticeable as age advances. One foot may be many times larger than the other, or one or two toes only ; one or two fingers in each hand may grow until they are three or four times the natural size, and occasionally this is almost symmetrical. On the other hand, there may be congenital absence of the whole or part of one of the bones ; the radius, for example, may be wanting, or the tibia or fibula, causing very severe distortion of the foot or hand as the case may be, and associated occasionally with defect of the corresponding digits ; or one end may be developed and not the other. Deformities of this nature are, as might be expected, gften associated with other defects, mental as well as bodil\', but they occur as well in people who are in all other respects well formed and well developed. Supernumerary fingers and toes are occasionally met with, particu- larly in connection with the thumb. If they are merely attached by a pedi- cle of skin, it maybe divided at once ; but in all other cases a careful examination should be made first, as not unfrecpiently the synovial membrane of the joint that belongs to the supernumerary finger communicates with that of the normal one (Fig. 87). CoNGENiT-AL Dislocations. This name has been given to a peculiar deformity, which is of common occur- rence at the hip joint, and is occasionally met with elsewhere. Instances of it have been recorded in connection with the shoulder, elbow, wrist, fingers, knee, patella, ankle, toes, and even the lower jaw ; l)ut in many of these other more grave defects were present as well. Like similar deformities which do not involve joints, it may exist in many grades ; it is rarely noticed at birth, and it becomes more and more marked so long as the period of growth lasts. ['' It is probable that congenital displacements may occur in all the articulations of the skeleton ; in most of them their existence has been established by dissections." — Frank Hastings Hamilton.] The chief interest is in connection with congenital dislocation of the hip joint. The limbs at birth appear well developed and in most cases there is no suspicion that anything is wrong until the child is a twelvemonth old ; possibly there is slightly greater difficulty in abduction than usual, but not sufficient to attract the nurse's attention. Walking, however, is unaccountably delayed, and even when the child begins to move about, its action is exceedingly awkward and insecure. On examination it is found that there is an unusual prominence in the gluteal region, that extension and abduction are unduly limited, and that the head of the femur can be made to slii< up and down upon the dorsum ilii. Fig. 87. — Supernumerary Thumb. CONGENITAL DISLOCATIONS. 323 When the child at length does walk, the deformity, provided the affection is bilateral, is exceedingly characteristic. The normal rounded shape of the gluteal region is lost, the trochanters are pushed up far beyond their proper level, and form a great i)rojection over the ilium ; the basis of support for the pelvis is shifted backward, the front part of the body projects, the shoulders are thrown back, and in other words there is extreme lordosis with an unusually jjrotuberant abdomen. In many instances this is associated with consideral)le inversion of the limb and flat-foot. If one side only is affected the deformity is even more conspicuous, owing to the difference in length of the legs, and consequent tilting of the pelvis and lateral curvature of the spine. When the child is lying on its back the malformation is much less distinct, and at first at least the head of the femur can be drawn down nearly to its natural situation (Figs. 88 and 89). Formerly this was attributed to traumatic dislocation occurring at birth, and Congenital Dislocations of Hip. Fig. 88.— Double. Fic. 89.— Single. it was pointed out in support of this view that it was much more common in breech presentations than in others ; and that the extreme shallowness of the acetabulum would undoubtedly favor it. Without, however, denying the possibility of such an occurrence (in one or two cases a distinct slip has been felt at the time), there can be no doubt that this is not the ordinary cause. It is very doubtful whether it is really more common in these presentations ; in the majority of cases the birth is described as having been particularly easy ; the affection is often bilateral, it may be hereditary, and it is seven or eight times more frequent in female children than in male. Opportunities of examining the interior of the joint are not common, and in all the cases hitherto the patients have either been adults or at least have walked for some time, so that secondary changes had developed. There is, however, a fair amount of agreement among them ; the iliac portion of the acetabulum is want- ing, either altogether or in part; the cavity itself is very small and triangular in shape ; it may be lined to some extent with cartilage, but it is much too shallow to 3-M DISEASES AND INJURIES OF SPECIAL STRUCTURES. accommodate the head of the bone. The ligamentum teres is usually present (its occasional disappearance is probably secondary) ; the capsule is strongly developed and contains the head of, the bone, although, of course, it is immensely stretched. The upper extremity of the femur is rather smaller than natural, somewhat flat- tened, and rests in an imperfect socket upon the dorsum. I'he lower part of the innominate bone is narrow and elongated, the ischial tuberosity everted, and its ramus twisted, and the glutei muscles (esi)ecially the maximus), are usually con- siderably wasted. It is po.ssible that this may be caused by extreme distention of the synovial sac in utcro ; there is no doubt that, even when the head of the femur fits much more securely in its cup than it does at that period of life, dislocation within the cai^sule can be produced in this way, the fluid penetrating between the articular surfaces until it separates them from each other ; and it is also true that reparative processes are carried to a much greater extent of perfection in intra-uterine life than after- ward : but certainly for the majority there is no more evidence in favor of this view than there is in favor of traumatic dislocation. Sometimes it is associated with what has been called genu recurvatum — hyper-extension of the knee, caused by fixed malposition /// utcro ; but there is no ])roof that this is present in ordinary cases. In comparison with this, congenital dislocation of other joints is exceedingly rare, that of the humerus being perhaps the most common. The diagnosis rarely presents any difficulty. After acute epiphysitis in infants the limb sometimes assumes the same position and direction, owing to the head of the bone having been destroyed ; but the history and the cicatrices are sufficient evidence. Treatment. — It rarely happens that this deformity is detected until some considerable time after birth, so that even if it were due to traumatic dislocation during parturition any attempt at reduction would be futile. In the vast majority of cases little or nothing can be done for it. Continued extension, however, kept up for a twelvemonth or even longer, has been followed by improvement more or less permanent. In other cases, pelvic bands and supports of various kinds have been worn to transfer some of the weight directly on to the trochanters either by vertical or circular pressure, but such accurate and at the same time constantly varying adjustment is required that it is very doubtful if any real benefit is conferred. In the worst cases (and they differ very much in severity) Ogston recommends the formation of a new cavity in the proper situation, and dovetailing the femur into it. If it is unilateral a high boot must, of course, be worn, to obviate twisting of the pelvis and lateral curvature of the spine. Club Hand. A distorted and deformed condition of the hand is occasionally met with at birth, consequent on defective development of one of the bones of the forearm. Very rarely it is due to mu.scular rigidity or contraction of the palmar fascia. In a few cases a certain amount of benefit is obtained by tenotomy and the use of splints; but in the majority it is beyond remedy. WKBnKD Fin(;f.rs and Toes. In this malformation the double fold of skin which should be limited to the angle between the digits is prolonged downward along the sides until in some cases it reaches the whole length (Fig. 90). Very often it is symmetrical, and some- times, in the worst cases, all the fingers are united. Division is apparently a simple matter, but unless proper precautions are taken CONGENITAL TA L I PES. 325 reunion from the angle onward is almost sure to occur. It has been recommended to make a hole through the web as far back as possible and insert a metal ring, in order that thorough cicatrization may take place first, and tlien r>- the rest can be divided without fear, but if there is sufficient thickness of tissue a plastic opera- tion is preferable. In one foshion (that of Di- dot) an incision is made along the dorsal surface of one finger and the palmar of the other, and the flaps of skin so marked out are reflected toward each other until they meet in the middle. The division is then completed, and the flaps carefully wrapped round and sutured in position, the dorsal one, for example, reaching round to the palmar surface of the same finger and vice versa. This, however, is rarely practicable unless there is a good thickness of tissue available, and the longitudinal cicatrix running down the middle of the palmar surface of one finger is not unlikely to lead to a very obstinate variety of contraction. In Agnew's method a dorsal flap, triangular in shape, is cut from the upper surface of the web. The apex corresponds to the free margin, the base to the interval between the proximal ends of the first phalanges. This is reflected back- ward on to the dorsum of the hand, the rest of the web divided as far back as necessary, and then it is folded over, in between the fingers, so as to fit into the gap. The edges, both of the reflected flap and of the wounds down the sides of the fingers, must be sutured accurately so as to ensure primary union. Fig. go -Weblied Fingers. Congenital Talipes. There are three primary varieties of this deformity. 1. Talipes Equino-varus. — The heel is raised, the inner edge is drawn upward, and the sole is twisted inward so that the patient stands upon the outer side of the foot, or in extreme cases upon the dorsum and the outer ankle (Fig. 91). 2. Talipes Calcaneus. — The toes are raised and the heel depressed, so that this part only of the foot is brought into contact with the ground. 3. Talipes Valgus. — This is the opposite to varus, the foot being so twisted that the outer side is raised and the patient walks upon the inner ankle. Occa- sionally it is associated with equinus or calcaneus (equino-valgus or calcaneo- valgus), but it is very much more rare than the others (Fig. 92). Congenital absence of the tibia or the fibula gives rise to a form of talipes, which must not be confused with the preceding, in which the bones are present. Causes. — Congenital talipes in the vast majority of instances is merely an arrest of development with persistence of growth, similar to cleft palate and other malformations. The parts retain the relative position that is natural to them at different periods of foetal life, slight modifications following as the size of each increases. The cause of the arrest is unknown. In exceptional instances it may be due to pressure, as suggested by Parker and Shattock, the foot being confined in some irregular position, so that the natural evolution of the limb cannot take place, just as genu recurvatum can be produced in the foetus by persistent extension of the knee ; but in the majority no evidence of such confinement exists, the parts are as well grown (in point of size) and the skin as natural as in ordinary feet. Like other malformations, it is not un frequently hereditary, and often 326 DISEASES AND INJURIES OE SPECIAL STRUCTURES. descends in the father's line. In a certain proportion of cases it is associated with spina bifida and other defects, and on this the argument has been based that, because they occur together, one is the cause of the other. The muscles and nerves going to the part have lx;en examined many times, but in nearly every instance their structure has been perfectly normal, and with the above-mentioned exceptions, the same maybe said of the spinal cord. Pathology. — In talipes equino-varus the foot retains the position it assumes about the sixth week, when the hip and knee are flexed and the feet meet over the lower pjart of the abdomen and cross each other. In talipes calcaneus the deformity is much later, dating from the time when the feet are bent upward with the dorsum resting against the front of the leg, and the normal unfolding of the part is not interfered with. The earlier the date at which the arrest takes place, the worse the deformity. The chief change is in the astragalus, and particularly in the obliquity of its neck, which retains the direction that is normal in anthropoid apes. This is measured ^Parker and Shattock) by means of two threads stretched over the bone when placed upon a horizontal surface. One passes from before backward over the middle of the trochlea, at right angles to its transverse diameter ; the other along the outer edge of the neck. The angle that the two make with each other in front is the measure of the deviation. In adult specimens the mean was found to be 12° ; in the foetus at full time 35° ; in varus 49° ; and in a young orang 45** (it is less in the adult). In other words, although the difference in the various Fig 91. — Congenital Varus. Three Grades of Severity. Fig 92. — Congenital Valgus. specimens was considerable, these observers found a regular gradation from the earlier periods of life to the later, and showed that the deformity in talipes varus was the worst, in talipes calcaneus much less. The position of the internal mal- leolar facet, which runs nearly as far forward as that for the scaphoid in the foetus at full term and the anthropoid apes, may also be taken as an indication of the obliquity ; in the former it recedes, in the latter it persists, though not in quite such a marked degree. Defective development of the lower limbs is exceedingly common in children at birth. The hips and knees in many infants cannot be straightened out for months ; and the feet, although they can readily be brought into the proper line, and by degrees come to it of themselves, in the vast majority assume naturally the position of varus. In others there is a certain degree of calcaneus, which, how- ever, unless it is associated with other troubles, nearly always disappears sponta- neously. With regard to this latter deformity, as it does not appear, like talipes varus, to have a persisting representative among the lower animals, it may possibly be due to the accidental retention of the foot in one position ; and perhaps this may account for the fact that it rarely requires much treatment. If this really is the case there is a very distinct difference in origin between the two. the one being due to retention of a normal developmental condition, the other to what maybe considered an accidental one, acquired late in the evolution of the race. The amount of distortion in the common forms varies very considerably, and is immensely exaggerated if the child is allowed to bear its weight upon the foot in the deformed position. The tuberosity of the os calcis is drawn upward until CONGENITAL TALIPES. 327 its direction is almost vertical ; and at the same time it is rotated on its longitu- dinal axis until the greater process rests upon the ground. The astragalus is tilted forward, almost out from its socket, and its neck twisted even more. The scaphoid is drawn up to its inner side, leaving the front articulation and forming another for itself between the astragalus and the internal malleolus, while the cuboid is so twisted round that its dorsal surface may even rest upon the ground. The outer border of the foot becomes convex downward from the heel to the toes, the inner border is much shortened. The head of the astragalus is divided into two parts, an outer subcutaneous and an inner, almost at right angles with it, for the scaphoid ; and the external malleolus is pushed far back, beyond the level of the internal. The inferior calcaneo-scaphoid, and the anterior and middle parts of the internal lateral ligament of the ankle joint are very much shortened ; the bands on the outer side, on the other hand, are stretched ; and the tendons of the anterior and posterior tibial muscles are brought close together. In the worst cases, those which have been neglected or have relapsed, the whole foot is shortened and stunted, the weight is borne upon the cuboid, the external malleolus, and the outer side of the anterior end of the os calcis ; an enormous bursa or callosity is developed, covering the whole surface ; and the metatarsal bones are so squeezed together that the transverse arch of the foot is narrowed, and a deep longitudinal furrow formed in the sole. Analogous changes, but, as a rule, much less marked, are present in talipes calcaneus and in the rare form of congenital valgus. Treatment. — Slight cases are treated by manipulation. If the foot comes easily into the proper position, and the muscles are well nourished, it will assume the normal position in course of time with very little assistance. The joints should be thoroughly worked and rubbed every night and morning, taking care that the foot is in plantar flexion w^hen eversion is being practiced ; and all that is needed is perseverance [during these measures, in the interval between the movements a fan-shaped adhesive plaster is applied to retain the foot in position, as suggested by Mr. R. Barwell.] In every case it is essential to make sure that the varus is real. In many in- stances of apparent equino-varus, one- half of the deformity disappears as soon as the gastrocnemius is thoroughly re- laxed ; the traction of the tendo-Achillis has caused equinus, and the natural ten- dency to inversion, when there is nothing to prevent it, has led to the semblance of varus. If both are present, the equinus should be left to the last. A combination of these two plans is very successful ; a strip of metal being placed next the flannel, running up the side of the leg and under the sole of the foot, with a few turns of plaster bandage over it. Just before the plaster sets the foot is twisted outward a little and left. Careful watch must, of course, be kept upon the circulation in the toes. When manipulation does not succeed, and yet there is no degree of rigidity, the foot may be twisted into the proper position by the hand, and fixed by means of a splint or plaster bandage, until the bones have grown into the normal shape. A flannel bandage is applied first, from the foot to above the knee. An outside metal splint (either of tin or zinc) is then fixed along the limb and the foot drawn out to it (still in the equinus position) ; or a plaster bandage placed over it, and Fig. 9J — Barwell's Adhesive Straps, with "Rubber Muscle." {After Sayre.) 32S DISEASES AND INJURIES OE SPECIAL STRiCTURES. the limb held as near the normal as possible, without using too much force, until it is firmly set. A splint must be removed and reapjdied at least every second day, the skin being thoroughly well rubbed and sponged with spirit and water each time, so that there may be no redness ; a plaster bandage may be left for a week, but it is not advisable to leave it longer. As soon as the varus is thoroughly corrected (or, better still, a little over-corrected, for it is sure to relapse somewhat) the etiuinus may be attended to ; the object of leaving it is to give a better ]jur- chase for the bandage, and to allow the anterior part of the tarsus and the os calcis to move freely upon the astragalus. Nearly the whole of the inversion and ever- sion of the foot takes place at the calcaneo-astragaloid articulation, very little at the mid-tarsal, at least on the outer side. In a large proportion of cases this treatment, if persevered in, .succeeds admirably ; but in the worst, in which the sole of the foot is inverted and deeply furrowed, and the muscles and tendons stand out rigidly, something further is required. \^Briscmcnt Eorce. — This consists in forcibly breaking all the resisting struct- ures, either by the hand or by some one of the traction apparatus. The patient, being fully anaesthetized, is placed on a table and the foot upon a triangular, cloth-covered Fic. 94. — Morton's Club-foot Stretcher. {After Brad/ord.) Fig. 9;. — Bradford's Club foot Stretcher. wood-block. The operator gra.sps the foot, and by main force pres.ses it against the block until all resistance ceases. Then the deformity should be over-corrected, on account of the constant tendency to recontraction. The foot is then firmly held in its corrected position and bandaged. Over this a plaster-of- Paris bandage is applied and allowed to remain for a period of ten to twenty days, according to the severity of the case. Morton's club-foot stretcher may be used instead of the hand in obstinate cases. A certain number of clul>-foot cases may be well cured by brisement force, but so many relapses occur that tenotomy is certain to continue to be employed in the largest proportion of cases.] The plantar fascia, the anterior and posterior tibial tendons, and sometimes the tendon of the flexor longus digitorum may require division ; but the only rule is to divide all soft tissues that stand out tensely and prevent rectification. Tenotomy. — Tendons and ligaments should be divided subcutaneously. A small puncture is made in the skin with a tenotome opposite the i)roposed seat of section (which, other things being equal, is the spot at which the tendon is thin- nest and stands out most prominently), and either the same instrument or a simi- lar one with a blunt point is passed with its blade on the flat behind the tendon CONGENITAL TALIPES. 329 (as a rule), while the assistant holds tlie linib in such a way as to relax the struc- tures to be divided. As soon as it has i)assed a sufficient de])th, the blade is rotated through a (luarter of a circle and the cutting edge Ijrought against the tough, fibrous tissue, the assistant meanwhile changing the position. Hexing or extentling as the case may be, so as to make everything tense. Then, with a gentle back- ward and forward movement, the fibres are cut through in succe.ssive layers, giving a kind of crisp sensation to the hand, until the resistance gives way. The .separa- tion should be distinctly felt, but there should be no jerk, for fear of sending the knife through the skin. As a precaution, the finger of the other hand should be pressed upon the surface in order that the presence of the blade may be detected as the skin is approached. In other ca.ses, if it is close to the insertion of the tendon, the knife is passed tetween it and the skin and the division practiced in the opposite direction. Recently the plan of open section has been advocated, on the ground that it is more thorough and complete, without being more dangerous; but it is question- able whether the .supposed advantage this possesses is sufficient compensation for the time the wound takes in healing, even if there is no more risk. Wounds inflicted with a tenotomy knife are dusted over with a little iodoform and covered with a piece of lint or cotton-wool and a bandage. As a rule, their site can hardly be detected on the fourth day, and suppuration is unknown. The tendon unites, like all other tissues, by the organization of vascular granulation tissue, springing chiefly from the sheath and the tissues around ; itself contains so few blood-ve.s,sels that, like compact bone, it takes at first but little .share in the proceeding ; after a time it, too, becomes more vascular, and then the tissue that lies between the ends slowly shapes itself into the fashion of the structures it joins, and the tendon and its sheath are thoroughly restored. It is a matter of very great importance, so far as the immediate treatment of talipes is concerned, that this process of repair is practically independent of the distance between the ends, so long as it is not extreme. The central and inner parts of the plantar fascia often require division, some- times in more places than one ; it is best accoriiplished by slipping the tenotome between the skin and the fascia and cutting toward the deeper structures. The tendinous part of the abductor hallucis may be cut at the same time by introduc- ing the tenotome just in front of the inner tuberosity of the os calcis and cutting down to the bone. The posterior tibial, the one that usually comes next, lies almost in the mid- point (from front to back) of the leg, just above the internal malleolus. Here it can be easily divided by making a puncture with a sharp-pointed tenotome right down to the tibia, withdrawing it, and passing a blunt-pointed one along its track (with its blade parallel to the leg) until the posterior border of the bone is felt. Then the tenotome is turned round, and the tendon that lies next to the bone, immediately behind it, divided, w^hile the assistant forcibly everts the foot. If the incision is carried a little too far, the tendon of the flexor longus digitorum is divided as well ; and, if further still, the posterior tibial artery. The hemorrhage may, however, always be stopped by means of a pad and a bandage. In Syme's operation the tendon of the posterior tibial is divided just behind its insertion into the scaphoid, below and in front of the internal malleolus, against the bone ; and if, as in many cases of club-foot, the anterior and middle bands of the internal lateral ligament requires section as well, preference should be given to this. The anterior tibial presents much less difficulty, as it can always be felt, in cases of club-foot, standing out distinctly. The points usually selected are either immediately above its insertion, cutting down on to the bone, or higher up where it is prominent on the inner side of the front of the ankle-joint. The tendo-Achillis (unless the case is equinus without varus, or with only the appearance of it) should be left until the foot is in a perfectly unfolded condition, in a right line with the leg. As soon as this is accomplished, it may be divided and the foot brought up. 330 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The usual i)oint is opposite the narrowest i)art of the tendon, not more than an inch al)ove its insertion, in an infant. The foot is hehl by an assistant (the patient \y\\v^ on the face) in a position of moderate i)lantar flexion ; a puncture is made with a sharp tenotome on one side or the other, according to convenience, and the blade of the instrument (i)arallel to the limb) pushed on until it can be felt under the skin, upon the opposite side. It is then turned round, the foot bent up toward the front of the leg to make the tendon tense; a finger of the left hand placed on the skin over it; and the fibres gently divided, rather by the pressure of the l)lade than anything else. Care must be taken that there is no jerk at the end. Division of the Ligaments. — Recently, Parker, Sayre, and others have strongly advocated division of all resisting l)ands [and the plantar fascicX-], especially the shortened and rigid ligaments on the inner side of the foot. A curved tenotome with a short cutting edge is entered just in front of the anterior l)order of the inter- nal malleolus, passed carefully, flatwise, between the ligaments and the skin, and then, by a gentle, sawing action, made to divide everything down to the bone. The foot must be rotated out by an assistant, so as to separate the malleolus as far as possible from the sustentaculum tali and the scaphoid. The same instrument is then gently pushed forward, close to the bone, on the plantar aspect, so as to divide the Fig. 96. — Tin Splint for Slight Cases in Infants. Fig. 97. — Little's Shoe for Slight Cases of Yams. calcaneo-scaphoid ligament and the tendon of the posterior tibial. The long and short jjlantar bands are cut through from the outer side. A straight tenotome is passed in, opposite the calcaneo-cuboid articulation (almost, sometimes, on the sole of the foot), and carefully pushed inward, close to the bone, dividing the ligament as it goes. After Tenotomy. — Until recently, it was always recommended that when the punctures were dressed, the foot should be carefully enveloped with a flannel band- age, and secured to a light splint made of flexible metal in the faulty position. It was feared that inflammation might set in, or that the ends of the tendons might be so far separated that union would not take place between them. In five or six days, when the little wounds were sound, the splint was removed and an extend- ing apparatus applied, in order to stretch by slow degrees the lymph poured out between the cut ends. Parker, however, has clearly shown that there is absolutely no foundation for this; that the displaced position may be rectified at once with perfect safety, and that the long and tedious plan of treatment previously fol- lowed may be effectively supplanted by a much more rapid one. Thomas employs a foot-wreiich, the prongs of which are covered with rubber, for the purpose of reducing deformity as rapidly as possible. If this method of rapid reduction is adopted, all the tendons and ligaments that resist and stand out when the foot is brought into the right position are CONGENITAL TALIPES. Zl^ divided ; the punctures sealed with iodoform and a carefully picked layer of cotton- wool ; a llannel bandage applied from the toes upward ; and then, while the assist- ant holds the foot in as gootl a position as possible, a jjlaster Ijandage placed over the whole. This is left for a week ; at the end of that time it is taken off, the skin thoroughly rubbed, and a fresh casing put on, pressure l)eing used, as before, to twist the foot outward into the normal line. The advantages of this plan over the old one are obvious at the first glance. It may be commenced at once, within a few days of birth, at a time when any appliance, such as Scarpa's shoe, or a metal splint, is practically out of the question ; it avoids the evil effects of local pressure ui)on the skin, which only too often, when the older plan was followed, rendered it necessary to interrupt the treatment for days or weeks together ; it is carried out during the i^eriod when developmental changes are most active ; the longer the case is left, the more difficult the deformity is to rectify, and it effects a greater degree of improvement in weeks than the former plan did in months. As a rule, unless the case is very severe, the foot is practically unfolded by the end of the fourth or fifth week. Opeti Incision. — Phelps adopts the same method, but divides everything in an open wound. An incision, an inch or two in length, according to the age of the patient, is made downward from just in front of the tip of the internal mal- leolus, and everything, tendons, fascia, ligaments, nerves, and, if they are in the way, vessels, divided down to the bone. Esmarch's bandage is used and the limb raised afterward, the wound being covered with protective and enveloped in ab- sorbent dressings. In old cases, the neck of the astragalus is divided too. As soon as the deformity is thoroughly corrected, the splints are left oft" dur- ing the daytime, and the feet exercised at least twice a day, the skin well rubbed, the muscles kneaded, and all the joints worked ; but some appliance is required at night until the tendency to relapse has disappeared — until, that is to say, the shape of the bones is definitely changed. For infants, a light, tin splint is sufficient ; it consists of a trough for the leg, a foot-piece at right angles with it and a little everted ; a soft leather strap to keep the ankle down, and two webbing ones to maintain the position of the leg and foot respectively (Fig. 96). For older children the same appliance made of stouter metal, thin sheet-iron, for example, may be employed, or Little's (Fig. 97) or Scarpe's shoe. The latter is formed of a leather slipper with a leg-iron, and a well-padded, leather strap to fit round the calf. Opposite the ankle is a cog and ratchet arrange- ment in order to alter the angle as required, and attached to the outer side of the sole-plate is a metal spring, by which a certain degree of ever- sion can be secured. The foot is fixed in position first, the heel being held down by a strap passing over the front of the ankle, the calf-piece buckled, and then the sole-plate brought to the required angle with a key (Fig. 98). In older children, especially in those cases which have either never been treated at all, or, what is nearly equally bad, have been allowed to relapse, a properly made boot with an outside iron and a calf-piece must be w^orn for a very con- siderable time after reduction, often for years, or the deformity is almost certain to return. If there is any inward rotation at the knee, the irons must be carried up the limb and fixed to a pelvic girdle (with a proper arrangement of joints) to prevent relapse effectually. Tarsectomy. — An almost hopeless form of club-foot is occasionally met with in children and young adults. Tenotomy has been performed time after time without any permanent benefit ; the bones are hopelessly distorted and peculiarly Fig. -Little's Modification of Scarpa's Shoe for Talipes. 332 DISEASES AND INJURIES OF SPECIAL STRUCTURES. hard, the ligaments shortened, the muscles wasted, and the limb comparatively useless. For such as these there is no alternative l»ut amputation, giving them a stump to wrilk on (which is better than walking on the dorsum of the foot); or tarsectomy, removal of a portion of the tarsus, so that the sole may be brought down to the ground. Various forms of this operation have been devised, but the two that best answer the conditions are excision of the astragalus and the removal of a wedge-shaped portion of bone (taken chiefly from the cuboid and those on either side of it) from the outer border of the foot. Excision of the astragalus is performed through a longitudinal incision on the outer side of the foot, between the tendons of the extensor longus digitorum and the peroneus tertius. The articulation between the scaphoid and astragalus is exposed, and the dorsal astragalo-scaphoid ligament (which may be much thickened) freely divided. The anterior end of the foot is then twisted so as to separate the astragalus from the surrounding bones, the anterior fasciculus of the external lateral ligament of the ankle joint cut through, and a stout, sharply-curved hook with a cutting edge on its concave surface passed between the os calcis and astra- galus until it reaches the posterior extremity of the interosseous band. This must be cut through by steady traction, and then the astragalus is so nearly free that it may almost be tilted out of its socket by forced plantar flexion. The wound is treated in the ordinary manner, the foot being secured at once at right angles to the leg, with the sole in the proper position. Excision of a wedge-shaped portion from the outer border of the foot is pre- ferable if the vanis is the more prominent. An incision, convex downward, is made along the outer border of the foot from the middle of the metatarsal bone of the little toe to the os calcis; the soft parts, tendons, arteries, etc., are carefully lifted off from the dorsal surface, and the peronei if possible pulled to one side. Then a wedge-shaped mass of bone, corresponding in size and shape to the de- formity that is present, is removed with a chisel or with Adams' saw. The base of the wedge faces the upper and outer border of the foot ; the apex points inward, while the sides slant down toward each other, so that the under (plantar) surface is much smaller than the upper. In actual practice the part removed is rarely so geometrical ; roughly it corresponds to the cuboid with a varying amount of the neighboring bones ; the essential point is that it should be of sufficient size to enable the foot to become straight and lie flat. Afterward the wound is thoroughly cleansed, drained if thought advisable, covered with an absorbent antiseptic dress- ing, and fixed with a plaster bandage. How long it should l)e left depends upon the patient's temperature and whether a drainage-tube has been used or not. Fitzgerald, in old cases, divides all the tendons, including the tendo-Achillis and deep ligaments, down to the astragalo-scaphoid articulation. He then makes an incision on the outer side of the foot, from above downward, behind the cal- caneo-cuboid articulation, passes a chisel in front of the ankle joint, down to the neck of the astragalus, divides this, the os calcis, and the scaphoid, and forcibly moulds and wrenches the foot into shape. A splint with a foot-piece is used to retain it in position afterward. These ojierations undoubtedly enable the foot to be brought into a better posi- tion, and are infinitely preferable either to amputation or to progression upon the dorsum with the great toe projecting upward, a condition not uncommon among relapsed cases; but the necessity for them would not arise if they were properly attended to in infancy. Acquired Talipes. Club-foot, apparently resembling the congenital variety, but in reality differ- ing from it in many essential particulars, may be caused by infantile paralysis, spasmodic muscular contraction, fibroid degeneration of muscles consequent on inflammation or injury, and cicatrices following burns; or, again, it may be sec- ondary, as when talipes equinus develops in hip disease owing to the shortening of the limb. Of these the most important and the most common is the first. ACQUIRED TALIPES. ii:!> I . Talipes due to Infantile Paralysis. In congenital club-foot the essential lesion is an arrest of development ; the bones, ligaments, fascine, and muscles all take part in it. In talipes due to infantile paralysis the muscles alone are in fault at first, the bones are well developed, the fasciae and the ligaments are not tense, the sole cause is the loss of power of one or more muscles or groups of muscles. Secondary changes, however, take place in this (unless means are taken to j^revent them) just as they do in the con- genital form. The opposing groui)s of muscles, having lost their antagonists, grad- ually become shortened and rigid ; the bones from constant jn-essure become altered in shape, and even sometimes the ligaments contract (possil)ly owing to local in- flammation, for as a rule they remain quite lax in other joints). The result is that, although the diagnosis between the two varieties is exceedingly easy, so long as the case is recent (in the one the foot can be placed at once in its natural position, in the other it cannot), it may become difficult in the later stages, unless there is a history of the deformity having been present at birth. Other symptoms of infantile paralysis render it, of course, practically definite; if the limb is cold and wasted, Fig. 99. — Talipes Equinus. liable to chilblains, and smaller than the other in all its dimensions, the question may be regarded as settled ; but the presence of one complaint cannot logically be regarded as conclusive proof of the absence of another. Varieties. — These are the same as in the congenital form, but there are certain points of difference. Talipes equinus, for example, often occurs by itself ; indeed, it is the most frequent of all, though mixed and irregular forms are not uncommon. Every grade is met with, from paralysis of all the muscles of the limb, with extreme distortion, to a loss of power that is scarcely perceptible and confined perhaps to a few fibres of a single muscle. As a rule it comes on about the second year, but it may not occur until much later ; on the other hand, in cases of rickets, it may be present before the child begins to walk, so that the defect is often believed by the parents to have been present at birth (Fig. 99). Talipes ecpiinus results from paralysis of the extensors on the front of the leg. If all are involved equally the foot remains straight ; if the tibialis anticus retains any power the inner side is raised and the sole looks inward. In the worst form of infantile paralysis, when the loss of power is complete, the whole foot drops forward, the heel becomes almost vertical, and the astragalus 334 £>ISEASES AND INJURIES OF SPECIAL STRUCTURES. rolls forward from under the tibia until the dorsum drags along the ground. The whole extremity is atrophied and cold, the bones fail to grow, the skin is consUmtly liable to chilblains, and chronic ulcers make their apiJcarance every winter. If the gastrocnemius escapes the heel is dragged uj) and after a time becomes fixed, with usually a certain degree of varus, owing to the natural tendency of the foot to as- sume that position when at rest. Nearly always, however, when the mischief is so extensive as to involve all the muscles on the front, the gastrocnemius and the deep flexors suffer too, not, perhaps, so severely, and the paralysis being general, fixed displacement does not follow. In those not ([uite so bad when the loss of power in the anterior muscles is only partial, the chief displacement usually occurs at the mid-tarsal joint, the ankle itself being less affected. The scaphoid and cuboid are drawn downward and backward, and the head of the astragalus is left projecting on the dorsum almost uncovered. After a time this becomes permanent, the ligaments and fascia on the plantar surface shortening and growing rigid. In some instances the sole of the foot is so much contracted that the anterior half is almost if not (piite at right angles with the posterior, the heel is raised completely off the ground, and the weight borne on the ends of the metatarsal bones. In others, probably when the interossei and the short flexors of the great and little toes are involved, this is associated with a peculiar claw-like condition of the foot, the proximal phalanx being over-extended, the dis- tal ones flexed. In the milder forms when the paralysis is temporary only (as after diphtheria) the distor- tion is very slight ; the heel is merely a little raised, and the sole of the foot a little shortened {talipes arcuatus) ; but if it continues long enough for contraction of the fascia to take place (talipes plan fan's) it may prove the source of great inconvenience; the gait is awkward, there is great pain on standing, corns form be- neath the metatarsals, reflex muscular spasm is not uncommon, and active exercise is very difli- cult. The diagnosis can be made at once by comparing the impression left after standing with that of the opposite foot ; the arch is shorter, very much less of the sole comes into contact with the ground, and the outer part of the tread in particular is narrowed. In long- standing cases the contracted bands can be felt standing out on the inner side of the sole. Analogous deformities are caused by paral- ysis of other groups. Talipes calcaneus is due to loss of power over the muscles of the calf (Fig. loo) ; valgus is said to occur when the tibials are affected, and com- pound forms if more than one group is weakened. Very often these are rendered still more complicated by secondary displacements caused by attempts at progres- sion. Thus inversion and rotation may occur to such an extent in talipes equinus that a condition closely similar to true varus is produced, the foot being displaced laterally to compensate for the want of flexion. In other instances valgus follows, but as a rule these additional deformities can be recognized as such by examining the foot when lifted from the ground ; as soon as the weight of the body is taken off it drops of itself into the straight line. Treatment. — This is entirely different from that of congenital talipes, and depends upon the grade of paralysis and the extent to which deformity has taken place already. [In all cases, however, it is e.ssential that the foot be kept in posi- tion continuously, by an appropriate appliance.] Fig. loo. — T.-ilipes Calcaneus. ACQUIRED TALIPES. 335 In the slighter cases, in whicli the power over one or more groups of muscles is imi)aired without being lost, an attempt must he made to improve the nutrition of the part antl compensate for what is lost by educating and developing all that is left. Warm clothing, douching twice a day with cold water, salt baths, friction, massage, jnnching, galvanism, passive motion, manijnilation, suitably-devised gym- nastics, everything, in short, is advisable that can in any way improve the circula- tion through the part or strengthen the residue of the muscles. If this can be done deformity can be prevented. If, however, the whole of one muscle is destroyed its action must be sup- planted by a mechanical contrivance. The simplest is a rubber accumulator as suggested by Barwell. A thin piece of sheet lead or jwroplastic felt is fastened to the limb, on the anterior surface of the leg, for example, in varus ; a .soft piece of leather is adjusted round the foot (held in position, if it has a tendency to slip, with some emplastrum plumbi or emplastrum ferri) ; a tai)e is fastened on to this so that it shall descend on the inner side of the foot, pass under the sole, and ascend again on the outer side ; and this is connected to the splint with a rubber band of suitable strength. For equinus it is even simpler, as the whole apparatus can be fixed to a boot with side supports maintaining a calf band immediately below the knee. Each case naturally requires a separate plan ; but if the defect is a simple one, and permanent shortening has not yet occurred, some contrivance of this kind can often be devised to enable the patient to get about with comfort and maintain the condition of the other mus- cles and of the rest of the limb unimpaired (Fig. loi). [Prof. Lewis A. Sayre has made a useful modification of this shoe by substituting a ball- and-socket joint for the hinge joint shown in the cut.] In the worst cases, in which it is not so much one muscle or even one group that is affected, but every one, and in which the cir- culation is defective, the bones small and light, the skin cold, even in midsummer, and the joints almost like flails, the same plan may be tried, and sometimes, even in the most hope- less cases, an immense amount of improvement is effected by ceaseless, untiring perseverance ; but more often it means that the limb is almost useless, except as a support in the narrowest sense of the term, and that some contrivance must be devised to enable it to act as such. The particular variety and the height along the limb to which it must be carried naturally vary with each case. A boot with outside and in- side supports and a calf band may be sufficient in the slighter ones ; but in the majority it is necessary to carry the apparatus at least up to the thigh, and not unfrequently up to the pel- vis, with joints suitably arranged, and stops so that the limb can be bent underneath while sitting down. The weight, of course, is con- siderable ; the nutrition of the limb, used merely as the central pillar of a mechanical support, does not improve ; and as the patient grows older the tend- ency to the formation of chronic ulcers not unfrequently become so marked that amputation is preferred. The flaps, as a rule, heal well, but slowly. If the patient is not seen until deformity has already appeared, steps must be taken to rectify it by tenotomy and mechanical extending appliances. Thus, in Fig. ioi. — Barwell's Shoe. 336 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the simplest form of talipes eciuiiuis, where the arch of the foot is exaggerated, the tread narrowed, and standing painful, relief may be obtained almost at once by dividing the contracted bands in the plantar fascia. In all cases, however, of paralytic talipes it is advisable to exercise great discretion in the manner of ten- otomy, or the already weakened limb may become still worse. [The rule is that when the foot can be restored to position by the hand easily, the patient being under an anaesthetic, operative niea.sures are useless, for there is no actual contracture of the .soft structures.] 2. Talipes due to Muscular Rigidity. What is known as " spastic rigidity" of the muscles of the lower limb (and occasionally of the whole body) is sometimes present at or shortly after birth, con- nected, in all i)robability, either with defective development of the nerve-centres, or with injury sustained during parturition ; but the deformities to which it gives rise are rarely limited to the feet ; and even when they are, they present but a remote resemblance to ordinary talipes. Tonic shortening of the gastrocnemius (the so-called right-angled contraction of thetendo-Achillis) is not infrecpient as a consequence of prolonged confinement with the foot pointing forward, whether it is due to a badly set fracture or to the pressure of the bedclothes in the course of some exhausting illness, such as typhoid fever. It can be recognized at once by pressing the knee well back while the leg is extended ; and though it does not appear serious, it causes a very considerable degree of lameness in walking, and not infrequently ends in grave deformity. The movement that cannot take place at one joint must take place at another; and the arch of the foot gradually gives way until a condition clo.sely resembling ordinary flat-foot is produced ; the head of the astragalus and the scaphoid sink together, and in some extreme cases the inner border of the foot becomes convex. Some- times, on the other hand, especially in those instances in which no attempt at walking is made, the foot is twisted into a shape resembling varus, the natural position it assumes when at rest ; but it rarely happens that this is permanent unless there is at the same time paralysis of the extensors. In every case of fracture the foot should be carefully kept at a right angle throughout ; if the toes are allowed to point, serious disablement may be produced before it is noticed ; and attention should be paid to this in cases of exhausting ill- ness ; the bedclothes should not be allowed constantly to weigh the feet down. If it is present already it can usually be cured by massage, passive motion, and the use of an extending rubber band ; but occasionally tenotomy is required. Flat-Foot. The antero-])Osterior arch of the foot is maintained partly by ligaments, partly by muscles ; the former are the inferior and external calcaneo-scaphoid and the anterior fa.sciculus of the internal lateral of the ankle joint ; the latter, the tibialis anticus, the flexors of the toes, and especially the peroneus longus, which i)asses like a strap across it and prevents the anterior pillar slipping forward when the weight of the body rests upon it. Cause. — Neither ligaments nor muscles are capable of maintaining the arch of the foot by themselves ; the combination is essential. Some of the worst cases of flat-foot follow Pott's fracture when the internal lateral ligament of the ankle joint is torn, while, on the other hand, it is often the result of loss of power in some of the muscles ; the rest become tired out, and the ligaments which are not calcu- lated to stand a persistent strain yield and give way under the weight. Independently of accidents, it may occur in infancy, at puberty, or in adult life. At birth the arch has hardly any existence ; it only becomes perfect, like the curves of the spine, when the muscular system becomes active, and if from rickets or any other cause in early childhood the time at which this takes place is FLAT-FOOT. 337 much delayed, the development of the arch is seriously impaired. It is probable that in this matter rickets is of unusual importance ; although the change is not so obvious there can l)e little doubt that tlie osseous nuclei in the tarsus are affected in the same way as those elsewhere, and that the shape of the bones, esijecially when the rickety period is prolonged, may be permanently altered, rendering subsetpient development imperfect. It is not uncommon to find every single member of a family tlat-footed from early childhood. The form of fiat-foot that occurs at puberty is still more common, and is nearly always associated with genu valgum and lateral curvature of the spine. The cau.ses of the three deformities are the same, and naturally they usually occur together. The strength of the bones and ligaments is dependent upon the perfec- tion of muscular development ; at puberty, if growth is rapid, the weight of the body becomes too great for its strength, the muscles give way, the strain falls upon the ligaments, which are already weak and lax, and deformity follows, either in the feet, the knees, or the spine, or in all three together. At first the bones are unaffected, but in a very little while they become altered in shape, and then, short of operation, the condition is permanent. When the food is poor, the hours of labor long, and the patient kept standing without a rest the whole time, deformity is exceedingly rapid. In adults, fiat-foot rarely occurs except as a result of accident (Pott's frac- ture), of rheumatism (gonorrhoeal or not), or of some illness that seriously affects the strength of the muscles, such as diphtheria or typhoid fever. I have known it result from a violent blow on the uj^per part of the fibula injuring the peronei, either directly or through their nerve supply. Symptoms. — The alteration in shape is characteristic. The astragalus slowly sinks forward, slipping, as it were, off the sustentaculum, which sinks with it ; the scaphoid is displaced, or even partially dislocated, the axis of the os calcis is no longer directed upward, the inner side of the foot is lengthened, and when the patient rests his weight upon it the whole of it touches the ground. In the worst cases the outer edge is a little raised and everted, and the peronei tendons stand out like rigid cords. In the rheumatic and gonorrhoial forms the pain is intense ; in the ordinary one that occurs at puberty, the foot is perfectly easy of a morning ; the muscles are rested then and can do their work. By-and-by, however, they become tired, the strain falls upon the ligaments, and the pain as they stretch grows more and more severe. It ceases at once if the foot is raised from the ground. Sometimes in these cases, when the strain is kept up continuously, there is a considerable degree of inflammation, and the astragalus and scaphoid may even become ankylosed. More often the arch sinks completely down, and then the pain subsides ; the weight is borne by the bones directly, and there is no more stretching. In many instances the foot is perfectly flat, even when there is no weight resting upon it ; in doubtful cases it is advisable to let the patient stand for a moment, with his feet just wetted, upon a sheet of colored blotting paper ; the sur- face that comes into contact with the ground w-hen his weight bears upon the arch can be seen at a glance. Treatment. — In the early stages of the deformity, while the arch still per- sists, much may be done by means of massage, cold sponging, and tiptoe exercises. The nutrition of the muscles improves, and if long standing and fatigue are avoided, the cure is often permanent. The heel of the boot should in all cases be deeper upon the inner side than the outer, as recommended by Thomas, of Liver- pool. If the arch is already lowered, and the patient's occupation cannot be changed, cure is practically hopeless ; the cause continues and the effect will grow^ worse. Relief, however, may be obtained by wearing properly contrived supports. In the slighter cases, a valgus pad made of rubber, or, if this is too hard, of leather stuffed with horse hair, may be fixed inside the boot. The heel should be broad and low, the waist fairly rigid, and ample space allowed in front. The pressure 338 DISEASES AND INJURIES OF SPECIAL STRUCTURES. must, it is true, act to a certain extent injuriously upon the tissues in the con- cavity, but it is a choice between two evils. In worse cases, when the foot remains flat, even though no weight is resting ujjon it, this is not enough ; however well made the boot, the foot is sure to rotate in it, and the only way to make it secure is by means of an outside iron. The lower end of this is let into the heel ; opposite the ankle it is jointed, and above it is fastened by a band round the calf. A triangular piece of leather is sewn inside the boot, on its outer Ijorder, so that it passes under the sole of the foot, beneath the astragalo-scaphoid articulation, up the inner side, through a slit in the uppers, and is buckled to the iron. Or a rubber band is used in the same way, after Walsham's plan (Fig. 102). For a time at least this gives relief ; and if tiptoe exercise is diligently practiced, after some months there may be distinct improvement. When the i)ain is very great, and the peronei tendons are tense, this cannot be carried out at first. The foot must be rested and raised, until the tenderness has subsided ; then the patient is placed under an anaesthetic, all the joints worked and wrenched to their full extent, and the foot brought into the best possible position by forced inversion, combined with direct pressure upon the scaphoid. This position is maintained for a week or ten days by means of a plaster bandage, and then the process is repeated until something like an arch is restored. The peronei tendons should not be divided if it can possibly be avoided. In some of those that are worse still tarsectomy and other similar operations are recommended. The head of the astragalus has been exci.sed (Stokes) and the foot forcibly adducted. The astragalo-scaphoid articulation has been opened freely, sufficient bone removed to enable the arch to be restored, and the two bones drilled and fixed with a couple of ivory pegs passed through them (Ogston) ; and the scaphoid has been excised by others. It is possible that in some cases in which there is persistent pain these operations may be of some use ; they un- doubtedly restore the shape of the arch, although it is probable that bony anky- losis always occurs (in Ogston 's this is partly the object) ; but seeing that they can only be recommended for extreme cases, and that these have for the most part already passed the painful stage, the number for which they are advisable is very small. When the arch has once become flat, so that the inner border of the foot rests upon the ground, the gait is very ungainly, it is true, but the inconvenience is rarely sufficient to recommend an operation which practically must lay the patient up for many months. [And even after the operation the shoe will, never- theless, have to be worn for a long period, so that the operation is obviously of extremely doubtful utility.] Fig. 102. — Walsham's Shoe. Deformities of the Toes. Hammer- Toe. This name has been given to a peculiar deformity which affects the second toe in ])articular, but .sometimes all. The first phalanx is retracted at the meta- tarso-phalangeal articulation, the second is flexed at right angles to the first, and the third bent so that its true extremity is directed downward. In the earlier stages of the disease the parts can l)e placed in the normal position without diffi- culty, but after a little while the ligaments contract and the displacement is per- DEFORMITIES OF THE TOES. 339 niancnt, tlie first i)halangeal joint Itecoming rigid, as a rule, before the metatarso- phalangeal one. The cause of this deformity is unknown in most cases. It is not unfre- quently congenital and even hereditary ; usually it is symmetrical and often con- fined to the second toe. It may be associated with the slighter forms of talipes ecjuinus (talipes arcuatus and plantaris) and caused l)y contraction of the ])lantar fascia ; or the rest of the foot may be absolutely normal. That it can be produced by wasting of the interossei there is no doubt, as it is not unfrequently seen in cases of progressive muscular atrophy ; these muscles flex the nietatarso-])halangeal articulation and extend the other two, and when they alone are paralyzed, the various segments naturally assume the opposite position. In the vast majority of instances, however, no evidence of paralysis is present. The lower part of the lateral ligaments of the first jjhalangeal joint is always much shortened and con- tracted, and it has been suggested that the deformity is due to chronic inflamma- tion beginning in this articulation ; but it is equally possible that the change is a secondary one, caused by permanent fixation in an unnatural position. The changes in the other structures of the joint, no doubt, are secondary. Whether it can be caused by ill-fitting boots is equally uncertain ; it is probable they aggravate the deformity, but as it is occasionally present at birth (though it more frequently develops at puberty), and as it is not more common in one class of life than another, hospital patients suffering as frequently as those in a better station, the influence they possess is doubtful. Treatment. — In the slighter cases, in which contraction has not yet taken place, relief may be obtained by wearing suitable boots, sufficiently broad in front, with low heels, and by massage and friction. If this does not succeed, an attempt may be made to keep the toes extended by means of a metal sole-plate, worn at night, and as long during the day as practicable. The portion that comes under the toes is provided with slits through which little elastic and leather bands are passed, so as to draw the toes down ; or the plate may be double, one part above the foot and the other below, wnth little screws and pads, so that direct pressure can be exerted upon the joints from above. In most cases, however, the time for such simple remedies as this is already past. The contraction of the ligaments and fascia is too rigid to admit of gradual extension, and the toes are distorted and deformed with callosities. The choice then lies between division of the lateral ligaments, excision of the proximal end of the offending phalanx, and amputation. Of these the second is the only one that holds out a definite prospect of relief without risk of relapse and without the mutilation involved in amputation. Subcutaneous section of the lateral ligaments, however, is such a simple proceeding and lays the patient up for such a short time that it may reasonably be tried first. Deformities of the Great Toe. (a) Hallux Flexiis. — This deformity, described by Davis-Colley, closely resembles hammer-toe in many respects. It occurs under the same conditions ; it is apparently not, like hallux rigidus, dependent upon flat-foot, and it usually develops at puberty ; but the metatarso-phalangeal joint is flexed instead of being over-extended, and the toe is wholly bent downward, so that the patient is com- pelled to walk upon the outer side of the foot. The suggestion that the difference is to be accounted for by the different development of the great toe, the metatarso- phalangeal joint corresponding to the interphalangeal of the others, is attractive, iDut probably not correct, as true hammer-toe is sometimes met with. (J)) Hallux Rigidus. — This name has been given to a peculiar stiff and painful condition of the metatarso-phalangeal articulation. Considerable doubt exists as to whether it is not identical with the former (although the toe is kept in a straight line with the foot) ; it differs, however, in being nearly always associated with flat- foot, and probably dependent upon it, inflammation of the joint being caused by 340 DISEASES AND INJURIES OF SPECIAL STRUCTURES. repeated slight injury from ill-fitting boots. A similar condition is sometimes pro- duced by osteoarthritis. It is usually met with at puberty and in boys who have to stand for many hours together. In the early stages there is often a certain amount of inflammation, but it is rarely very marked or prolonged. Nearly always the toe is cold, stiff, and rigidly extended, sometimes cjuite straight, sometimes with a certain degree of valgus. The least attempt at flexion causes severe pain, and in all but the slightest cases there is distinct enlargement with lipping and hypertrojjhy of the articular ends. The nature of the deformity can often be detected at once by noticing the condition of the boot ; the arch is flat ; there is a projection in front where the toe presses against it, and there are no wrinkles in the leather, .showing that the joint is never used. The treatment of this affection, like that of hallux flexus and hallux valgus, is very unsatisfactory. If seen in time, it may be cured by restoration of the arch of the foot, but nearly always extensive changes have made their appearance in the articular surfaces before the patient is aware of the extent of the mischief. The question then turns upon the amount of pain ; if it is only slight a well-made, roomy boot, with a valgus-pad, may answer; but if it is more severe, particularly if it prevents the patient taking a fair amount of exercise, the best plan of treatment is to remove a sufficient portion from the proximal end of the first phalanx. The same thing must be done for hal- lux flexus. {c) Hallux Valgus. — The deform- ity affects the same joint, but the toe is bent outward, either over or under the others, until it may be at right angles to its normal direction. This, there is no doubt, is always due to ill- fitting boots. The articular changes in the early stages are the same as in hallux rigidus and in other forms of chronic traumatic arthritis; but after a time gouty or rheumatic inflamma- tion usually follows, and urate of soda is deposited, or immense lips of bone are formed and the surface becomes hard and polished from friction. Hallux valgus derives much of its importance from its association with bunion, a bursa developed over the inner side of the joint from the constant pressure and friction of the boot. This may be found in all stages of inflammation ; when it is recent there is merely a thin-walled sac, filled with clear fluid ; after repeated attacks it becomes thick and fibrous, until, with the corn that lies upon it, it forms an almost solid swelling ; or else it suppurates, and then it becomes serious, from the fact that it nearly always communicates with the joint. In most cases, how- ever, by this time the cartilages have disappeared and there is nothing left but two hard, bony surfaces, held together by a tough, fibrous capsule. The treatment in the earlier stages is very simple; the boot must be made the shape of the foot — straight, that is to say, upon the inner side ; and at night, and whenever it is convenient, a sole-plate must be worn with a spring upon its inner border to draw the toe into line again. If matters have gone too far for this, all that can be done is to prevent further injury. Should sup- puration occur in connection with the joint, a free opening must be made upon the inner side, and a sufficient portion of the ba.se of the first phalanx removed to bring the toe into the right line again. The metatarsal itself is better left untouched, but a fair amount of bone must be taken away or osseous ankylosis will ensue. Osteotomy of the neck of the first metatarsal is recommended Fig. 103. — Lever for Relief of Hallux Valgus. GENU VALGUM. 341 for simple hallux valj;us, l)ringiiig the toe into line at once, and as it can be done almost subcutaneoiisly is not a serious operation ; but it rarely happens that patients consitler the deformity alone a sufficient reason, as it seldom causes much discom- fort until a bunion is develoj^ed. Gknu Valgum. Knock-knee, like the other deformities due to want of strength, may occur either in childhood or at puberty. In the former case it is always associated with rickets ; in the latter it is usually met with in conjunction with flat-foot and lateral curvature of the spine. Owing to the width of the pelvis the natural direction of the femur is from above obliquely downward and inward, and this determines the direction of the deformity ; the disproportion l)etween the weight to be carried and the strength of the muscles (upon which the perfection of the ligaments and bones depends) regulates the amount; and when it once has commenced it natur- ally advances at a much more rapid rate. The nature of the deformity is obvious at once, but the extent requires careful measurement. The lower margin of the internal condyle is prolonged downward far below the level of the external ; but it does not project in the least backward. Consecpiently the legs are perfectly parallel when the knees are bent, and diverge only when they are extended. The essential change is an overgrowth of the inner border of the diaphysis, although the internal condyle may be itself somewhat elongated. That it is solely due to obliquity of pressure and consecutive alteration in the shape of the bone is shown by the similar distortion that occurs when one thigh has been amputated in a child and no artificial limb has been worn. From con- stantly bringing the remaining leg under the centre of gravity of the body, so that the crutches may be swung forward, it assumes a condition of extreme genu valgum, the inner condyle being prolonged downward and not backward in pre- cisely the same manner. The two worst cases I have ever seen were caused by this ; the method of production is identical with that of the ordinary form which develops at puberty ; the cause is somewhat different. Treatment. — This depends upon the degree of deformity and the length of time it has lasted. In any case a certain amount of rest is the first consideration ; the cause, as in lateral curvature, is excessive work ; the strength is not equal to the weight, and so long as the weight is allowed to press upon the knees and drive them inward the deformity must grow worse. (^a) In children in whom there is other evidence of rickets the prognosis is good unless the hardening stage has set in, and buttresses of compact tis.sue have been dei:)Osi ted in the concavities of all the bones ; if this has occurred the condi- tion is permanent, short of operation. Cod-liver oil, iron, good food, meat, eggs, and milk are es.sential. In the slighter cases it is impossible to confine the child to bed, but it should never be allowed to tire itself; the nutrition of the legs and of the muscles in particular must be maintained by rubbing with oil night and morn- ing, bathing with salt water, friction, massage, warmth, and galvanism. If this is thoroughly carried out the limbs gradually become straight of themselves. If the condition is more serious — that is to .say, if there is a definite interval of some inches between the malleoli when the knees are extended — the same plan must be pursued ; the child must be kept in bed and splints applied every day, to draw the knees slightly outward. Too much pressure should not be used ; the skin is exceedingly delicate and sores are easily formed ; but, on the other hand, unless the parts are well fixed, children can always twist their legs round until by slightly flexing the knees they escape pressure altogether. Where trouble is no object the splints should be removed night and morning, an inside one being worn at night, an outside one in the daytime ; and every time they are changed the skin should be thoroughly rubbed, the muscles kneaded,' and the part manipulated into the right direction with as much force as is consistent with avoiding pain. 342 DISEASES AND INJURIES OF SPECIAI STRUCTURES. An extraordinary degree of improvement can be effected in this way in a very short space of time, 'rhe muscles gain size and strength ; the tone of the limb improves; the legs grow straighter and the inequality between the condyles dis- appears. 1 have more than once seen a leg become perfectly straight while a child was lying in bed recovering from an osteotomy performed upon the other one. It is, however, of little or no good after sclerosis has set in. (/') The form of knock-knee that develops at puberty must be treated on the same principles. It is nearly always met with in those whose occupations compel them, just at the time they are growing most, to stand many hours a day ; and it is nearly always associated with flat feet. Of course, if the occupation is con- tinued very little can be done ; the deformity will grow worse until a kind of equi- librium is reached ; but if this can be changed, and the tendency to flat-foot checked either by a valgus-pad or by Thomas's obliquely-cut heel, the limbs can generally be brought into the right line. In worse cases, in which the period of growth is ended, or in which the deformity when the knees are extended is considerable, osteotomy affords the better promise. At this age it is not possible to effect any considerable change in the shape of the bones, as it is in children and especially in rickety children. If pres- sure is persisted in, the fibrous structures on the outer side of the joint, the exter- nal lateral ligaments, and the ilio-tibial band are very likely to yield, and allow the external condyle to separate itself from the tibia, so that when the splints are removed and the patient is allowed to stand upright, he is merely propped upon the internal condyle in a most insecure manner. Rickets. In rickets many deformities of bones are met with besides genu valgum. The femur is often bowed outward and forward ; the tibia is bent, especially at its lower extremity where, it is weakest, until the convexity of the curve seems to hang over the ankle ; and in other cases again the femur and tibia together are curved outward, so that exactly the opposite condition to genu valgum is produced — bow- leg, or genu extrorsum. The particular kind of deformity is regulated partly by the natural curve of the bones, partly by the attitude and habits of the child, whether it is old enough to run about, or sits tailor-wise upon the ground. In some rare instances genu valgum on one side is associated with the o])posite deflec- tion upon the other, but this is more usually a product of later life, caused by accidental deformity. The treatment is the same as that for genu valgum. If the bones are still soft and the weight is taken off them, and if the strength of the child and the condi- tion of its muscles can be sufficiently improved, the deformity disappears of itself. Splints are of no use in the majority of cases ; the antero-posterior curvature of the tibia, for example, does not admit of pressure being applied ; and it is cjuestionable whether the fashion of fastening them on so that they project below the feet and prevent walking does not do more harm than good ; for not unfrequently the child learns to shuffle about with its limbs in a worse position than they were before. If the rickety stage is passed, and deformity is left, it can only be rectified by osteotomy. Osteotomy. — Section of a bone for reduction of deformity, or osteotomy, is performed either with a chisel or a saw. The former, as a rule, is preferable, not so much because of the dust caused by the teeth, as because of the almost unavoidable laceration of the soft parts ; and MacEwen's chisels, made of solid metal throughout and graduated, are the best. If a saw is used, no instrument has superseded that devised by Adams for subcutaneous section of the neck of the femur. The operation is subcutaneous so far as it is possible to make it. The limb is thoroughly cleansed and embedded firmly on a sand-bag covered over with a rub- ber sheet. A small incision, parallel to the most important structures, is made RICKETS. 343 down to the bone at the spot at which it is intended to divide it, and the chisel or saw passed down by the side of it before it is withdrawn. If a chisel is used, care must be taken always to work away from important structures ; with a little prac- tice, the different sensation as it passes from compact to cancellous bone or vice versa can be appreciated at once ; but there is no object in running any risk. MacEwen recommends that the surgeon should always cut toward instead of from himself, and that, if the structure to be divided is very wide, and the chisel deeply buried, a narrower one should be substituted for it as soon as the first incision is made ; it is impossible to form a correct impression if the instrument is fixed, like a wedge, by the sides of the cut. The chisel must be held in a firm grasp, and should be loosened in its bed from time to time as required by an upward and downward movement, not a transverse one, for fear of splintering. The general rule is to divide the compact tissue opposite the point of entrance of the chisel first ; then (if it is working from the side) that on the upper and under surface of the bone ; and finally the soft central portion, leaving in this way the part on the furthest side uncut. If the bone is very wide the last part may be effected with a narrower chisel, which wall produce something of the effect of a wedge-shaped wound. As soon as the division is considered sufficiently complete, the chisel is withdrawn from the bone with an upward and downward movement, gradually loosening it, a sponge placed over the wound, and the remaining part of the compact shell fractured. Some iodoform is then dusted over the sur- face ; a catgut suture inserted if necessary ; then an absorbent dressing, and a suitable splint, taking care to move the limb as little as possible while it is being applied. Operations for Genu Valgum. — Many operations have been devised for the correction of this deformity ; but except in special cases, MacEwen's is the one that is usually practiced. It consists in subcutaneous section of the lower end of the femur, immediately above the condyles, with a special chisel. The cutaneous incision commences at the junction of a line drawn transversely a finger's breadth above the external condyle with a longitudinal one half-an-inch in front of the tendon of the adductor magnus. The scalpel is carried down to the bone and the incision prolonged sufiliciently to admit the osteotome. This (beginning with the largest) is introduced by the side of the scalpel before it is withdrawn, and then turned round through a right angle. The posterior internal border is the part first divided, the chisel pointing forward and outward ; then the internal border ; and after that toward the. outer posterior angle, working always from the artery. After the compact layer is cut through it is advisable to change the osteotome for one with a narrower blade, especially in the case of an adult. Then the residue of the bone is fractured, the limb brought into a straight line, and a suitable splint applied. In children, the most convenient apparatus is one of the ornamental flower-pot holders made of diagonal bars ; it can be placed in position at once ; and it is sufficiently flexible to fit accurately over the dressing. If the little wound is sealed with iodoform-collodion and covered with wood-wool, there is no need to disturb' it until the fracture is sound. In Ogston's operation the internal condyle of the femur is detached and pushed further up the shaft. It may be performed either with a chisel or a saw. A long-bladed tenotomy knife is introduced two or three inches above the internal condyle and pushed through the tissues until it can be felt in the inter-condyloid space ; the soft structures are then divided down to the bone, Adams' saw passed by its side, and the tenotome withdrawn. The internal condyle is sawni about three-quarters through from above downward, and the fracture completed by forcibly straightening the limb. The same precautions and the same after-treat- ment are required as before. Reeves, who uses round-edged chisels without angles, modifies this by dividing the bone only and leaving the cartilage to be ruptured. Redresseme7it (forcible straightening) was practiced largely at one time, but though the limb can often be brought into a straight line, it is impossible to 344 DISEASES AND IXJURIES OE SPECIAL STRUCTURES. say what yields ; it may l)e tlie epiphysial line, or the lower end of the shaft, or the ligaments. Whatever forni of operation is used, the limb requires support for many months. It must not be forgotten that, though the deformity is cured, the causes that gave rise to it are probably there still, and that, unless precautions are taken, it will infallibly return. Rickety deformities of bones are treated on the same ])rinciples. Subcuta- neous fracture (either manual or with an osteoclast) succeeds sometimes, the bone breaking (or if it is still soft, bending) at the weakest spot, and enabling the limb 31 Fig. 104. — The Osteoclast of Rizzoli. to be brought straight at once. In most cases, however, osteotomy is preferred, either simple linear division, or, if the deformity is very great, cuneiform — that is to say, the excision of a wedge. [Osteoclasis. — This consists in fracturing the bone with the osteoclast invented by Rizzoli, and in special cases it is preferable to osteotomy; the difference in the respective wounds being that between a simple fracture and an open (compound) one, except that in osteotomy there is a clean-cut incision instead of an irregular or serrated break. Repair is apparently more speedy after osteoclasis.] FRACTURES. 345 SHCTION II.— INJUKIHS OF BONHS. 1 RACTURES. A fracture is a sudden interruption in the continuity of a bone, produced by violence. For convenience of description, this definition is allowed to include other injuries similar in character, such as separation of the costal cartilages from the ribs, and in young subjects separation of epiphyses. Fractures are divided into two classes, simple z\\(\. coinpimnd."^- In the former the skin is unbroken, the fragments are never exposed to the air, there is no ri.sk of absori)tion, and the injury is repaired like a wound that lieals by the first intention ; in the latter, the broken ends are laid bare at some time or other, away is opened up for the absorption of foreign substances, and there is (so long as the wound is open) the constant danger of cellulitis, necrosis, phlebitis, pyaemia, and other infectious diseases. A fracture may be compound at the time of the accident, or may become so at a later period from sloughing of the skin and soft tissues over the broken ends. When it is compound from the first, either the wound and the fracture are produced together by the same force — a cart- __ wheel, for example, pa.ssing over a limb and tearing the skin f from off the bone as it crushes it; or the pointed end of one | of the fragments is driven from underneath through the skin, \ owing to involuntary muscular contraction at the time of the accident, or want of care in handling the part afterward. In \ tlti'l; the former case {compound by direct violence'), the injury to the | ^vfy, soft parts is generally extensive ; they are bruised and cru.shed | i^b for a considerable distance on either side; in the latter {com- \ pound by indirect violence^ there is only a puncture, the wound* 1 ^ may close at once, and the fracture become, to all intents and r, purposes, a simple one. *J The danger is less when the fracture becomes compound % secondarily from sloughing or other causes. Absorption from I the surface is not so easy ; the gaping channels that are present fv^'iViij in a recent wound are sealed by the lymph already thrown \\ v^M out, and the current sets rather from the deeper parts out- tJ^*'\ ward, so that, provided the sloughing is local and limited, the risk of septic poisoning is not so immediate. Fractures, simple or compound, are said to be complicated '.,%^ when the viscera or other important structures near are in- <:v^« volved ; when, for instance, the ribs are driven into the lungs or liver, or when a large artery is punctured or torn across. — - Fractures are complete, if the bone is broken entirely f,g. 105— Transverse Sub- through ; incomplete, if the injury falls short of this in any way; Periosteal Fracture of Fe- , . J J J mur, wuh Beginning of and sub periosteal, if, as often happens in children, the tough Callus. From an infant, periosteum remains untorn (Fig. 105). The cancellous tissue of a bone, for example, may be crushed and compressed, or a splinter may be chipped off from the side ; or the compact tissue may be fissured in one or more directions, without any fragment being actually detached. A peculiar form is common in children, affecting the long bones, especially the clavicle. The osseous tissue in them is so soft and elastic that it can bend, in some [* The term, " compound," so long applied to these fractures, is a meaningless one ; the German term, open fracture, is much more expressive.] 23 346 DISEASES AND INJURIES OF SPECIAL SIR UC TURKS. cases almost to a right angle, without breaking, and regain its shape coni|)letely as soon as the pressure is removed. (Generally, however, before this point is reac hed, longitudinal fissures make their ai)pearance in the bones, and then, if the force continues, the periosteum and the compact tissue at the apex of the curve begin to tear, until the fracture extends perhaps half across. These are called ^rr^«- stick fractures, as the bone is not actually broken in two ; they do not regain their shape when the force is spent, and often, owing to the jagged nature of the end and the way they fit against each other, there is considerable difficulty in straighten- ing them again (Fig. io6). A fracture is single when the bone is broken f^ in only one place, multiple when it gives way in ^M'i:'^\ more than one, and cotnminuted when there is a ' number of small fragments at one spot. It may ■\y»'>. Fig. io6 — Greenstick Fracture of Radius, Showing the Longi- tudinal Splintering. In this case it ran down to the epiphysis, which has been separated by maceration. Fig. 107. — Comminuted Fracture of Clavicle. Fk.. 1 — I —liaped Fracture of Lower Knd of Humerus. vary in direction aS well as in extent, and be transverse, oblique, or longitudinal. Sometimes, as in the patella, it is stellate ; sometimes serrated, like the teeth of a saw; or it may run round a long bone in the form of a spiral. It is T-shaped when there is a transverse fracture immediately above a joint and the smaller of the fragments is split vertically into two (Fig. io8) ; punctured, when there is a Avound in the substance of the bones; o.x\(\ perforated, when it goes right through. Finally, if one fragment is driven into the substance of the other — if, for example, the compact wall of the shaft is driven into the soft, cancellous tissue of one of the articular ends, so that the two are locked together, it is said to be impacted. Influence of Age. — Fractures are met w^ith in all periods of life, but with very different degrees of frequency at different ages. Intra-uterine fractures are not uncommon, lliey may be caused by muscu- lar contraction of the walls; but in most cases they can be traced directly to a severe fall or a violent blow upon the abdomen during pregnancy. The long bones, especially those of the leg, suffer most frecjuently, the skull from its pro- tected position and its elasticity generally escaping ; sometimes they are compound and a scar is found upon the skin corresjjonding to the point at which it was per- forated by the bone. The degree of union depends upon the time ; as a rule, it is fairly firm, though the position may be faulty. Multiple fractures (and in some instances an enormous number has been recorded) rarely occur, except in the case of intra-uterine disease, possibly hereditary syphilis. It is noteworthy that in quite half the cases in which the leg is found at birth to be bent at an angle, as if it had 1 een broken, and even when there is the appearance of a cicatrix at the point, the fibula and the toes on the outer side of the foot are deficient. Talipes is often present at the same time ; the limb is im- jierfectly grown, and frequently remains more or le.ss stunted throughout life. FRACTURES. 347 In inhincv, the clavicle and the fenmr are the bones that suffer most fre- (juentlv, and the fractures arc often greenstick or sub-i)eriosteal. Separation of the eiMphyses is common in chiltlhood, but may be met with up to one or two and twenty years of age. In adult life, much depends uj)on the sex and occupation. The bones are harder and more dense than they are at earlier periods. Fissured fractures occur more easily, and, as a consequence, the joints are more often in- volved. Old age is specially characterized by two varieties, fracture of the neck of the femur and (particularly in women) feicture of the lower end of the radius from falls upon the hantl. Causes. The causes of fractures are predisposing and immediate. The former include all those conditions which render the bone more fragile ; the latter, the actual breaking force. If this is unusually slight, so that the bone gives way without (apparently) sufficient reason, the fracture is said to be spontaneous. I. Predisposing Causes These may involve the whole length of a bone (and even the whole skeleton) or may be local, affecting the structure and impairing the strength at one part only. (a) General. — Simple atrophy is the most common. When a limb is kept at rest for any length of time-frigidly confined in splints, for example, owing to disease of some neighbouring joint — the bones gradually waste away, the cancellous tissue becomes more and more open, the medullary canal enlarges, and the com- pact layer is absorbed from the interior, until, in extreme cases, a thin shell of solid substance is all that is left. It is in a certain measure owing to this, that if a bone once broken gives way a second time before repair is complete, it nearly always yields — not at, but close to, the seat of the original injury. Atrophy is also said sometimes to follow injury to the nutrient artery. /// old age the bones are affected in a similar way, and in addition the propor- tion of lime-salts to the organic basis appears to increase, so that they become more brittle. This cannot, however, be called pathological unless the change reaches an extreme degree, so that an unusually slight amount of violence is sufficient to make them give way. Infantile paralysis, owing to the feeble nutrition of the limb, leads to the same result. The bones never attain their full development ; they remain slender and feeble ; the surface is smooth, without any muscular ridges to act as supports, and they are deficient in weight and strength. Fractures are very prone to occur in certain affections of t/ie nervous system. The nutrition of the bone suffers whether the limbs are kept at rest or not ; there is no tendency to inflammation, but two-thirds of the inorganic material (especially the phosphate of lime) may disappear ; the cortex becomes exceedingly thin, and the medulla replaced by fat, until in some cases the bony substance is so soft that it can be cut with a knife. This has been noticed particularly in locomotor ataxy, affecting chiefly the lower limbs, and appearing even before the incoordination ; in general paralysis, where the ribs seem to suffer most, and also in some cases of dilatation of the central canal of the spinal cord. It is singular that if the bones do give way under these conditions, union often takes place easily and with an exceptionally large amount of callus. Rickets is another common cause. The intermediate layer of cartilage becomes abnormally thick ; instead of there being merely a line of soft tissue ready to be replaced by bone, it may form a broad band of gelatinous material, in some cases nearly as thick as the cartilage of the epiphysis itself. The deeper layer of the periosteum is affected in the same way ; and, as the process of absorption from the interior continues with unabated vigor, the strength of the bone at last becomes impaired to such an extent that it is unable to bear any strain. Owing to the thin- 348 DISEASES AND INJURES OE SPECIAL STRUCTURES. ness of the compact tissue in comparison with the thick layer of soft material on the outside, subjieriosteal and jjartial or greenstick fractures are very common, especially at those places where the bones are naturally curved. So long as the rickets is actively progressing, the amount of callus is only small ; afterward, it is thrown out in great excess, particularly on the concave side. In osteomalacia the l)ones, if they are ex])Osed to any force, do not break so much as double upon themselves and bend. The compact tissue is softened and disappears ; the Haversian spaces and the medullary canal grow larger and larger, until at length in the more severe forms, all that is left is a cylinder of osseous tissue, as thin as paper, fdled with a kind of reddish-brown pulp, and unable to resist a strain of any kind. In certain people the bones are peculiarly liable to break, without its being possible to assign a reason for it. Their health is to all appearance perfectly good, and the fractures unite without difficulty. This condition, which sometimes affects several members in one family, and which may be hereditary, for want of a better name is known as Eragilitas ossii/m. (/>) Local. — These are for the most part connected either with inflammation, or with the presence of some new growth of or in the neighborhood of the bone. Inflammation, if the process of repair does not keep pace with that of destruc- tion, of necessity renders the bone more likely to give way. In acute suppurative osteomyelitis, for example, total necrosis and separation of a portion of the shaft may take place before a sheath of new bone can form ; or, after this has been thrown out by the periosteum, it may be so weak as to bend or break almost of itself as soon as tlie sequestrum is removed. The same accident sometimes com- plicates inflammation and suppuration in the medullary canal, even when there is no secpiestrum of appreciable size ; and it has been known to occur from rarefying ostitis gradually eating away the interior of the shaft without any corresponding deposit being formed on the exterior. Caries involves the shafts of bones so rarely that in this respect it is of little importance, except in the case of the ribs and the odontoid process. Separation of an epiphysis, due to softening of the cartilage, is sometimes discovered unexpectedly in the course of acute periostitis and osteomyelitis. It is most often met with at the upper end of the tibia, and union may have taken place in a faulty position before it is noticed. The most common local cause is the presence of some new i^nnotli, such as sarcoma or carcinoma. Sometimes the fracture is preceded by swelling or by con- stant pain, but it is not unusual for there to be no .suspicion of anything wrong until one of the bones unaccountably gives way. Central sarcomata are the most important. They grow from the interior, very often at the ei)iphysial ends, and replace the bone until there is nothing left but a soft, vascular mass, which may retain the shai)e of the part, or cause it to expand into a thin-walled cyst. Periosteal ones, as a rule, do not interfere to a sufficient extent with the structure of the bone. Secondary deposits of carcinoma, especially after scirrhus of the breast, may lead to the same result. Apart from the local growth there is no evidence that either the cancerous or the sarcomatous cachexia has any special influence on the stability of the skeleton. Enchondromata, cysts, and echinococci occasionally weaken the bone in which they grow, so that it gives way unexpectedly ; and sometimes the same result follows from absorption due to the pressure of external tumors, such as an aneurysm. Syphilis occasionally acts as a predisposing cause by the local changes it induces — caries, or much more often gummatous infiltration of the periosteum or bone. .Sr//77y; hardly seems to have any influence, except perhaps in the case of the costal cartilages. It is stated that when it is very severe these are liable to be detached, owing to changes which take place at the ends of the ribs, and which are often associated with hemorrhagic periostitis. I^RACTLRES. 349 Changes of a similar character occur at the ends of tlie long bones (particularly the lower epii)hysis of the humerus) in young infants, as a result of hereditary syi)hilis, and more rarely scurvy, so that the growing ends are liable to be separated by very slight degrees of violence. Some of these may be genuine examples of detached epiphyses ; in others it is probable the line of separation runs through the softened and infiltrated layer of bone bordering the end of the shaft. 2 . Jmmciliatc Causes. These are eitlier external violence, or muscular contraction, or in some in- stances a combination of the two. ((/) External Violence. — This may be direct or indirect. In fractures by direct violence the bone is broken at the .seat of the injury, as when a limb is run over and crushed by a heavy wheel ; the fracture is often comminuted and the soft parts seriously injured from the way in which they are ground between the offending object and the bone. In the other variety the fracture occurs at some other, per- haps far-distant, point, where the strength of the bone or chain of bones is least, and the soft tissues may escape almost entirely. In falls, for example, upon the outstretched hand, the shock is transmitted through the arm to the clavicle, and this gives way at its .veakest point. The two ends are driven together and the bone is bent more and more until the limit is reached. Fractures at the base of the skull and fractures by what is known as contrecoup (where the bone is broken exactly opposite the point on which the violence falls) are caused in the same way. The skull, which is exceedingly elastic, is compressed in one of its diameters, the vertical, if the force falls on the vault, and proportion- ately lengthened in the others ; and the bone breaks where it is weakest and most brittle, generally at the base. In other instances, however, as in falls upon the feet, the fracture occurs from the impact of the base of the skull upon the vertebral column, as when the head of a hammer is driven home upon the handle by smartly striking the latter on the ground. {b) Muscular Contraction. — If it were not for the patella, which very fre- quently gives way from this cause alone, fractures due solely to muscular contrac- tion would be regarded as uncommon. Sometimes, however, bony prominences, such as the acromion, or the tubercle of the tibia, are torn off by violent muscular action, and occasionally the long bones themselves snap quite suddenly. Many instances are recorded in which this has happened to the humerus, clavicle, and femur, but in the ca.se of other bones it is exceedingly rare. In most the fracture seems to have been due to the sudden arrest of rapid action, as in striking out at an object without hitting it, and, therefore, to have been caused, in part at least, by the weight and momentum of the arm. Repair. Fractures are repaired, like other injuries, by the effusion and organization of lymph. It is not clear how far this is derived from the blood-vessels, and how far it is the product of the tissues around. It is certain that the medulla and the deeper la3^ers of the periosteum possess the power of causing the development or new bone when transplanted into other parts; but, according to McF^wen, the superficial ones are quite inert. I. Union in Simple Fractures. Early Changes. — There is nothing peculiar about these ; the injured parts swell up at once, owing to the extravasation, which is always extensive ; the blood pours out from the torn vessels, and spreads in the central cavity, and in the loose cellular tissue around, until it is checked by the tension it creates. After a time it coagulates, and the ends of the vessels become sealed ; the fibrin and corpuscles 350 DISEASES AND INJURIES OF SPECIAL STRUCTURES. form a loose, ilark-colored mass, which fills up all the interstices; the serum is carried away by the lymphatics (the neighboring glands are often swollen at this stage), or, if it is excessive in amount, escapes through the skin and raises up the epidermis in great blebs. While this is going on, the vessels around the injured area begin to dilate, those in the soft parts first, in the compact bone last, and lymph pours out through their walls ; the skin, if the fracture is near the surface, grows warm and red ; the blood circulates more rapidly ; all the tissues around become softer and more open ; the fat is absorbed, and the medulla resumes its embryonic character. Almost from the first day the coagulated blood begins to lose its color. The red corpuscles break down ; the hemoglobin soaks into and stains all the tissues near, and the stroma and fibrin disappear little by little before the advancing lymph. Probably the white corpuscles share the same fate, though, as in other cases of extravasation, .some few on the outside may remain. Meanwhile the lymph grows in from all sides, spreading further and further, until it finds its way between the fragments into the medullary canal, and joins with that which is developed there. At this stage, up to the seventh or tenth day, the bone itself is almost un- changed ; only the surface near the seat of injury is slightly more porous ; the periosteum is swollen and thickened, its fibres are softened and separated from each other by masses of lymph, so that its deeper layers are almost gelatinous, and it strips off more readily from the bone beneath. Between the fragments, and lying in the central space, is the debris of the old extravasation ; and round the whole is an ill-defined, soft mass of vascular granulation-tissue, mixed with old blood-clot, and inseparably fused with the torn shreds of the muscles and other structures near. The amoutit of lymph thrown out is regulated mainly by the extent and duration of the injury. In children, it is true, owing to the activity with which all tissue-changes are carried on, the quantity is relatively greater than at other periods of life ; but it rarely happens, even in old age, that it is>insufficient for the purpose. On the other hand, the wider the extent of the injury, the more the soft parts around the broken ends are crushed and bruised, so long as they are not actually destroyed, and the oftener the injury is repeated, the greater the amount produced. Where a bone is simply broken, with no displacement or extensive laceration of the periosteum, and where the parts are kept at ])erfect rest (as, for example, in fissures of the cranium), the lymph merely unites the broken surfaces, fills up some of the medullary space, and causes a little thickening of the perios- teum. On the other hand, in children ; in animals; where there is a thick layer of soft tissue on the bone (and if it is on one side, as in the case of the tibia, on that side only) ; where the fragments are allowed to move one on the other, as in the ribs ; and where there is a number of splinters wounding all the jjarts around, — a huge mass may be formed, welding everything together, and filling up the medul- lary canal so completely that it is divided into two. Callus. — This effused lymph becomes ossified, and is known as callus. At first it is soft and porous, very irregular in shape, and perforated in every direc- tion by a number of vessels running from all sides toward the centre; later, it shrinks and becomes more dense, the outer layers remain fibrous, and fuse with the periosteum at either end ; the rest is slowly absorbed, until there is only suffi- cient left to restore the strength of the fractured bone. That part of it which surrounds the broken ends and fills up the medullary canal was formerly called provisional ; it is formed earlier, and mechanically acts as a kind of splint ; that which directly unites the broken ends is dcfinitiz^e (Dupuytren) ; it is not developed until the other has already a.ssumed the form of spongy bone, and after this has disappeared it forms the permanent bond of union. The former comes from the periosteum and surrounding tissues, and, perhaps, to some extent, from the medulla, the latter from the bone itself; but there is tio real distinction between them. The difference in the time of their appearance is FRACTURES. 351 clue to the relative ease with which the changes after injury take place in soft, cellular tissue, and dense, unyielding bone ; and the difference in the direction of their vessels depends solely on the position of the old ones from which the new ones spring ; they are mainly transverse in the outside callus, because they con- verge from all points on the exterior toward the fractured spot ; and they are longitudinal in the intermediate part when this is once developed, because the old ones lie above and below. Provisional callus is not thrown out, as its name implies, to act as a tem])orary support, until the definitive can appear and take its place. It is the real bond of union between the broken ends, an attempt to restore the strength of the part with as little delay as possible. If a splinter is detached from the side of a bone, and the periosteum replaced, the hollow is very soon filled with spongy callus, in great excess because its strength is so much less than that of the solid part that has been lost. The bone is weakened and an attempt is made to restore its strength as soon as possible ; cancellous tissue can be formed almost at once, while compact cannot, but a greater quantity is required. By degrees, when the vessels in the old bone have had time to dilate, and buds of lymph can grow out from the Haversian canals, some of the newly-formed cancellous bone becomes compact and modeled on the old lines, and then the excess is removed by absorption and the original shape restored. The same thing occurs in a transverse fracture. Soft callus is thrown out round the ends, because this can be done at once ; and the bulk is greater to make up for its feebler strength. Later, when there has been time for the central ring to become compact, the outside part, having no further purpose, is removed, and the original shape regained. The ossification of callus may be preceded by the formation of cartilage or not, but in any case it follows strictly the physiological type of normal growth. The first deposit of lime makes its appearance on the tenth to the fourteenth day, in the layer of the periosteum that lies nearest to the old bone. Almost from the first, the cells that occupy this part are larger than the rest ; many of them are stellate, with one or more nuclei, and all have a large amount of granular proto- plasm. The lime is deposited around these, so that if the periosteum is stripped up from the old bone, this is not only porous, but rough, from a covering of little spines and points. Far away from the fracture, at the boundary of the unaltered periosteum, the callus is converted directly into bone, even in animals. The intercellular substance at a distance from the vessels becomes darker ; granular patches make their appearance in it, and grow larger and larger until they join together ; and a network of trabeculse, enclosing spaces of the most irregular shape, is built up by degrees. In these lie the vessels, with the cells arranged in con- centric masses around. Gradually more and more bone is deposited, layer after layer of cells becomes infiltrated with inorganic material, always closing in toward the centre, until at length the spaces become narrowed down into Haversian canals, lined with lamellae of soft but true bone. In dogs and rabbits a very large proportion of the callus, internal as well as external, is converted into cartilage. In infants, too, this takes place to a very considerable extent, but in adults only islets of it are formed here and there, close to the broken ends, rarely or never between them or in the medullary canal. A great deal of it, however, is not true hyaline cartilage ; near the perio.steum it shades off gradually into fibrous tissue, and in other parts the ground substance differs from the matrix of true cartilage in the way it stains with carmine. In places, too, it becomes converted directly, into bone, the cells becoming smaller and stellate, and lime being deposited in the substance between them. Only here and there are there true capsules, which, as in normal cartilaginous ossifica- tion, become replaced by vascular buds of small cells, growing in from the surrounding parts. Absorption begins long before the process of o.ssification is complete, work- ing in both directions, from the interior of the medulla and the exterior of the jj- DTSEASES AND INJURIES OF SPECIAL STRUCTURES. ■J Fig. callus, toward the shaft. (]iant-cells are abundant, esj^ecially in the medullary part, but they may also be found here and there, under the newly-finished periosteum, and in the superficial layers of the callus, eating it away irregularly until, by slow degrees, it is reduced to its i)ermanent dimensions. T/ie Pennanftit Form of the Bone. — 'I'he lines upon which a l;one is built, as shown by its shape and by the direction of its traljecuKne, are governed by the strains it has to meet. After a fracture, if the ends are so accurately adjusted that the axis is not altered, the original shape and construction are restored, becau.se the strains the bone has to bear after the accident are identical with those it received before. But if it is not well set, so that its two ends overlap or form an angle with each other, the forces may still be the same, but they no longer act in the same way. The shape becomes modified, even that of the old bone, and the lines are altered to those which under the circum.stances are best adapted to the Avork ; and it often happens that they are very different from the original one (Fig. 109). If the ends are in api)Osition, but form an angle with each other, the medullary canal may be re-estab- lished, but it will not lie in the centre. The compact tissue on the convexity is thinned ; that in the concavity becomes thicker. If thev overlap, the central cavity is ''?:^.;:l^l'it:i^^:^:^^. never restored, each end remaining sealed. The ad- of the meduiiarj- canal and the jacent surfaces of boue either fuse together or are held immense increase in density and 1 ■ ^ 1 11 /-\ r^ ^\ \ 1 strength of the bone along the sccure by periosteal callus. Often they become cancel- iine of direct pressure. lous, bccausc the transverse section of the whole is so much larger that porous bone is strong enough for the work ; and the trabeculae, both in the old and the new bone, become arranged in curves, as regular and as even as those in the neck of the femur. Intra-articidar Fractures. — Repair is frecjuently imperfect when the line of fracture lies inside the synovial cavity of a joint ; either bony union does not take place, or perfect freedom of movement is not regained. The extrava.sation is the first obstacle. Sometimes the blood collects in the interior, and, as in transverse fractures .of the patella, forces the two fragments so far apart that no bridge of callus can be formed between them ; or it coagulates and lies for weeks between the broken surfaces, so that it is impossible to bring them together. In other cases it lines the interior of the cavity like a false membrane, and interferes with its secretion ; or it makes the capsule stiff and unyielding, and it may even, as Hunter first suggested, remain detached and form the nucleus of a foreign body. Then the amount of callus thrown out is frequently deficient. None is formed by that part of the bone which is covered with cartilage, and very little, as a rule, by the periosteum inside the joint. In some bones, according to Bidder, there is no osteogenic substance here at all, the fibrous layer merely being continued from the shaft to the cartilage of the epiphysis. The only part that takes any active share is the broken surface, and, unless the ends are held absolutely in contact by impaction or other means, this is not sufficient, and either union is fibrous or it fails altogether, and the surfaces become dense and hard from long-continued friction. This is certain to happen if one fragment is very small, or if, as in intracap- sular fractures of the neck of the femur, it is cut off from its blood-supply. The chief nutrient vessels of the head of the bone enter the under surface of the neck ; the branch running with the round ligament, even if it does reach so far, is not large enough to be of much service, and consequently, though it does not undergo FRACTURES. 353 necrosis, the vitality of the fragment is so feeble that, unless there is imjiaction, union never takes place. Fractures Tlirou}:;h Cartilage. — In the case of the costal cartilages the broken ends are generally held together by a ring of fibrous tissue, formed from the peri- chondrium and the cellular tissue outside it. Sometimes this is converted into bone and the cartilages themselves are calcified. In young subjects it seems probable that the cartilage corpuscles at a little distance from the seat of injury take some share in the process ; those immediately bordering on it break down and disappear. When the articular cartilage of a joint is split, as in T-sIiaped fractures, the cleft is filled in after a time by fibrous tissue; and the same thing hapjjens, only very slowly, when a portion is completely detached, the fragment itself remaining as a foreign body. 2 . Union in Compound Fractures. In compound fractures the process of repair depends upon the beha\ior of the wound. If this heals by the first intention, or if it is sealed successfully, the tissue-changes are essentially the same as those described already. A certain amount of blood is extravasated, some of the tissues are disorganized and require to be repaired or replaced, but unless the crushing is so severe that the part sloughs en masse, the debris is carried away little by little ; granulation tissue grows into the space that is left, and fills it, and there is only a slight degree of hypergemia and swelling, corresponding to the increase in the activity of the circulation. If, on the other hand, the breach of surface is not closed in at once, union takes place more slowly, and is attended by suppuration of a more extensive char- acter. In the slighter cases, in which the soft parts are not much bruised, or the bone si)lintered, and in which there is free exit for all discharges, the wound soon begins to fill. The vessels dilate, lymph pours out into the periosteum and the loose tissues around, until they are so swollen that it is not easy to distinguish one from another ; the fibrin coagulates on the surface, the serum drains away, and as the new vessels are formed the broken ends of the bone become surrounded and enclosed by a mass of vascular granulation-tissue which grows until the cavity is obliterated. At first the surface of the bone, if the periosteum is stripped off, shows but little change ; in a few days a number of minute red dots appear upon it ; then each of these enlarges into a little bud of vascular granulation-tissue, spring- ing from the side openings of the Haversian canals, and at length it becomes as porous as the cancellous part, and is covered over with a layer of vascular lymph, continuous with that formed from the structures around. The granulation tissue is converted directly into bone, without passing through any intermediate stage, and without the formation of cartilage. The lime salts make their appearance first, as in simple fractures, between the cells on the surface of the old bone at the boundary of the injury. From this they advance by degrees toward the injured part, until each of the fragments is surrounded by a ring of soft, spongy callus. These gradually increase in size, approach nearer and nearer until they join across, and unite at length with that which is developed from the medulla. The shape at first is very irregular and the amount excessive, while openings persist here and there in the newly-formed sheath for the discharge of pus ; but if there are no sequestra these soon close in and the whole becomes firm and dense. In many cases, however, the result is not so fortunate. Sometimes it is due to the severity of the original injury ; even in simple fractures it occasionally happens that the parts are so crushed and bruised that they slough ; much more often it is the result of some fresh additional cause. The wound itself is of a peculiarly unfavorable character, nearly always deep and irregular in shape, divided by the layers of fascia into many strata, the openings of which do not correspond ; the external orifice is often small, while the external cavity is always a great deal larger than it appears to be, and it is filled with a material exceedingly prone to decom- 354 DISEASES AND INJURIES OF SPECIAL STRUCTURES. position. If this occurs before the barrier of lymph is thrown out, the products poison all the tissues near, inflammation of the most intense description follows, and unless checked in time spreads up and down the limb until it is thoroughly dis- organized, or life itself is lost. The i>eriosteum and medulla quickly become involved ; in the neighborhood of the wound itself, where the process is most intense, they may be completely destroyed. Sjjlinters jjerish at once, and are thrown off ; the ends of the bone, deprived of their blood-supply, undergo necrosis, and enormous masses of callus are thrown out round them by the more distant parts which suffer less. If this happens, when nothing worse results, months often pass before union is complete. A line of demarcation must form round the necrosed fragments ; granulations must be thrown out by the living compact bone before the sequestra can be moved ; and often, long before this takes place, callus has grown round them and locked them in, so that an operation is necessary to release them. I have known them work their way out more than fifty years after the original injury. Firm union is often established months before the wounds have closed, and sinuses leading down to the interior of the bone sometimes persist for the rest of life. I.MPERFECT ReP.\IR. The amount of callus thrown out may be excessive. This is more likely to happen after compound fractures, or when there is a large number of splinters and the tissues around are much irritated. As a rule, it is not of material consequence ; the outline of the limb is altered, and the action of the muscles slightly impaired ; but the inconvenience is not great, and the excess is soon removed by absorption. .Sometimes, however, a nerve is compressed, and paralysis or wasting sets in ; or a joint is locked and useless, owing to outgrowths of bone around it ; or two parallel bones, such as the radius and ulna, are joined together so that pronation and supi- nation are lost. When this occurs, more active measures are required, and it is generally necessary to cut down upon the offending portion and excise it. These cases of overgrowth must be clearly distinguished from callus tumors fenchondro- mata and osteomata chiefly), of which a very few have been recorded, occurring, for the most part, at a much later period. Occasionally, the callus becomes soft again, and is absorbed to a great extent, so that the deformity reappears. This may be due entirely to local causes — necro- sis, for example, taking place, at the seat of injury ; or it may happen during an attack of erysipelas, and in the course of acute specific fevers. In one or two extraordinary instances the absorption has not been limited to the callus, but has extended to the fractured bone itself. As a rule, only recent fractures, in which consolidation has hardly taken place yet, are afTfected. It is more common for the amount to be deficient from the first, or for the process of ossification to fail. Bony union, then, is either delayed, or else never takes place at all ; no distinct line can be drawn between them ; the causes that occasion the one will, if they act with sufficient persistence and vigor, equally give rise to the other. I. Delayed union, as might have been expected, is met with much more fre- quently than complete failure. In simple fractures of the leg it is not uncommon to find at the end of four or five weeks that the fragments are apparently unal- tered, as easily moved as they were at first. Sometimes a definite cause can be found ; but more often there is nothing of the kind. Generally in these cases there has been very little displacement, with little injury to the surrounding parts, and consequently the amount of provisional callus is exceedingly small. Or the fragments may appear to be united, there may be no pain or undue mobility when the limb is tested ; but a few days after the patient is allowed to get up the union begins to bend, and it is clear that the callus is not sufficiently firm. In the vast majority of instances this gets well of itself ; the limb is straightened ; a fixed apparatus, rather stronger than usual, is applied ; and the patient is allowed to FRACTURES. 355 get about on crutches, with a strict injiinctioii not to let tiic injureti limh touch the grountl under any circumstances ; but every now and then the reverse takes place, the caUus becomes absorbed, from too erly movement, the union becomes weaker and weaker, and a false joint results. 2. Non-union. — When there is no bony i.nion at all, the ends may remain separate and distinct, without so much as a band between them ; or they may be connected together by fibrous tissue of various degrees of strength ; or they may lie in apposition, held by a capsule of connective tissue, so that a more or less perfect joint is formed. [Interposition of muscles between the fragments may sometimes cause non- union.] {ii) Absolute non-union is rarel)' met with except in intracapsular fracture of the neck of the femur, and in some cases of fractured ])atella. It is nearly always due to wide separation of the fragments. I'he medullary spaces become closed ; Fig. lie. — Ununiled Fracture of Ulna. Fig. Ill . — Ununited Fracture of Tibia with Consecutive Bending and Strengthening of Fibula. Fig. 112. — False Joint in Tibia from a Fracture, Probably at Birth. the ends become rounded and wasted ; the surfaces, if they are in contact with other hard structures, become dense and polished ; and the callus that is thrown out after the fracture is absorbed again. (J)) Fibrous or imperfect miion is much more common. Sometimes it is exceedingly firm ; the ends of the bones are well nourished ; the broken surfaces face each other ; the fibres that pass across are short and strong, with, perhaps, islets of cartilage and even of bone scattered among them, so that it is difficult to be certain that perfect union has not taken place. Sometimes, on the other hand the fibres are long and weak, formed rather by a condensation of the connective tissue around the ends than from a layer of callus directly connecting them ; and the bones are thin and conical, with their ends much wasted. Every grade, in short, maybe found, between union that is nearly as strong as bone and absolute failure. (/) False joints (pseudarthroses) strictly so called, are rarely met w'ith. 356 DISEASES AND INJURIES OF SPECIAL STRUCIURES. They appear to be formed out of false union in simple fractures by constant movement for months together. In some cases they are almost perfect ; the ends are moulded so that they fit each other accurately ; they are surrounded and held together by a tough ligamentous cai)sule ; this is lined with a layer of flattened connective-tissue corpuscles like an endothelium, and is filled with a fluid which, as in the case of adventitious bursa;, closely resembles synovia. Sometimes islets of cartilage, hyaline or fibrous, may be found \\\>o\\ the apposed surfaces, probably the remains of the callus that was thrown out shortly after the fracture. More often the surface is dense and polished, as in joints affected with arthritis defor- mans ; and lips, fringes, and even loose bodies are occasionally found around the margin. False joints of this descri])tion are most frequently met with in the humerus and femur, possibly owing to the peculiarly dense character of the compact tissue. They have been known to occur in children, especially in the leg, and to lead to impairment in the growth of the limb. When they occur in adults, the bones and muscles are often well nourished, much better than they are in cases of fibrous union. Causes. — The causes of delayed union and false joints may be general or local ; but the latter are by far the more important. Fig. 113 — Position Assumed by the Limb in this Case before it was Amputated. 1. General Causes. — Very few can be regarded as more than occasional ; union is sometimes delayed ; but more often than not it takes place as quickly as in health. Fevers, Bright's disease, diabetes, scurvy, starvation, advanced syphilis or carcinoma, pregnancy, lactation, any severe cache.Kia, in short, may check the progress of repair, but though undoubted instances are recorded, it is rare to find that any one of these is sufficient by itself. Sometimes the urine has been found to be alkaline and loaded with phosphates, and it has been thought that this was the reason, and in a very few cases it has seemed as if the fault lay with the nervous system. Old age is certainly not a cause ; fractures unite as well in peo[)le over seventy as in younger ones, with the exception of intra-capsular fracture of the neck of the femur, the reasons for which are probably entirely local. Complete failure may nearly always be traced to local causes. 2. Local Causes. — Some of these, like the general ones already mentioned, merely delay union ; others prevent it altogether ; but with a few exceptions it cannot be said even of these that they are invariaiile ; and in a large proportion of cases it is impossible to give a definite reason why union fails. {a^ Separation of the Broken Surfaces. — This is the most imjiortant ; if the space between the fragments is filled up with other structures, whether muscle, tendon, joint-capsule, or blood-clot, so that they cannot be brought together, failure is almost certain. It does not matter how the separation is produced ; FRACTURES. 357 the ends may be driven into the substance of other structures near ; or drawn apart by the action of muscles ; or made to overlap so that the periosteal surfaces only are in contact ; unless they are i)roperly adjusted the result is almost certain. Non-union is more frequent in compound fractures than simple ones, owing to the amount of bone that is sometimes lost by resecting the ends, or from necrosis. (/-') Afovcfitcnf. — In other instances the method is in fault ; either the frag- ments are not properly secured, and the neighboring joints not fixed as they should be, or movement is allowed too foon, and the callus is absorbed again. This happens in a variety of ways: the bandages may become loose from shrinking of the limb ; the patient may be delirious ; surrounding circumstances may be unfavor- able, or a neighboring joint may become stiff, so that when the limb is used an undue strain falls upon the seat of fracture. One of the favorite sites is the middle of the shaft of the humerus, and it is certainly not uncommon to find in the.se cases that the elbow is stiff ; but I am disposed to think that more importance should be attached to the peculiarly dense character of the bone at this spot, and to the possibility of slips of the neighboring muscles getting in the way. In the case of sailors, among whom cases of ununited fracture are unusually frecpient, full allowance must be made for defective hygienic conditions, although, admittedly, fractures of the ribs rarely fail to unite in them. [The e.xperience of the editor in many years' service in the Marine Hospitals of the United States does not sustain this view as to the frequency of non-union in fractures among sailors, although he cannot recall a single instance of non-union of the ribs, as having fallen under his observation. The cases of non-union among sailors that he has seen were of the long bones, and were due to either lack of proper attention on shipboard before arriving in hospital, or to constitutional syphilis. In the latter, there was no effusion of callus, nor could exudation be excited by ordinary means of treatment.] (<:) Malmitritio?i. — The prolonged application of cold, ligature of the main artery, tight bandaging so as to interfere with the circulation, thrombosis of the veins, leading to oedema, and rupture of the nutrient vessels, are all cited as occa- sional causes ; and no doubt they are not without some influence, although it is difficult to believe they are sufficient of themselves. It has not been proved that the nerves exert any direct effect. {d) Disease of the done itself is an occasional cause. Necrosis has been already mentioned as especially frequent in compound fractures ; but tertiary syph- ilitic nodes, mollities ossium, atrophy, hydatid cysts, sarcomata, and chronic abscesses sometimes lead to the same result. Diagnosis. — This rests mainly upon the degree of mobility that is present. In cases of delayed union it is usually slight, though the amount of deformity may be considerable, and it is always painful ; in fibrous union or false joint, on the other hand, it is free and nearly painless. The probability of the latter increases greatly with the length of time since the accident ; but union of a fractured femur has been known to take place without operation after as long an interval as twenty- two months. Treatment. — Like the causes, this is general as well as local ; but while the former may prove serviceable in mere delay, it is entirely without effect in genuine cases of false joint. I. Constitutional. — This naturally varies with the requirements of each case. Nourishing food and fresh air are essential in all ; tonics are often needed to im- prove digestion ; a fair amount of stimulants is advisable, especially in those who are accustomed to them ; and iron, cod-liver oil, and other remedies may be given to improve the general health \ but there is no proof that the administration of lime or of phosphorus in any shape has any effect upon the deposition or the ossi- fication of callus. In cases of syphilis, mercury and iodide of potash must be given according to the general rules ; and mercury has been given experimentally with success where no history could be obtained ; but, apart from the presence of gum- mata upon the bones, it very rarely happens that union is in any way delayed by this disorder. Vegetables and lime-juice are equally important if there is any suspicion 358 DISEASES AND INJURIES OE SPECIAL STRUCTURES. of scurvy; and a woman who is suckling should be directed to wean her infant; but, beyond general considerations of this character, nothing can be done. There is no evidence that any drug has the least direct influence on the rapidity with which union takes place. 2. Local. — Readjustment. — The first thing, if the ordinary time has elai)sed and the fragments are still movable, is to reset them, bring them into apjjosition with each other, and secure them in some form of splint (a fixed one generally) that will ensure absolute immobility, and at the same time enable the patient to get into the open air. This alone is sufficient in a large j^roportion of cases, especially those in which the chief cause is want of rest. Only it is necessary to make cer- tain once for all that the fragments are really in apposition, and that nothing has slipped in between. Should this have happened, union is almost certain to fail ; and unless the ends can in some way be disengaged and brought together, it is scarcely worth while wasting time in trying measures that must be ineffectual. Coitiiter-irritatioTi. — This may be combined in some instances with the use of counter-irritants — tincture of iodine, for example, painted once every night, or light blisters. These no doubt do increase the amount of blood flowing through the parts beneath ; the exact form of a blister painted on the thorax may be traced sometimes upon the costal pleura ; and where a bone is near the surface, as in the case of the leg, the periosteum would almost certainly be stimulated to increased action ; but at the best they can only be of very limited application. Mechanical Stimulation. — If this procedure fails, an attempt may be made to excite a certain degree of inflammation by friction or percussion, and then to ob- tain union by securing the fracture in a plaster case. One method is to rub the ends of the bones together every day, until a certain amount of heat and swelling is produced around the seat of fracture. Another aims at the same effect by ham- mering them with a mallet, the skin being protected from injury by a piece of felt. A third, which is sometimes successful, not only in delayed union, but even in case of false joint of long standing, consists in encasing the limb in an apparatus so con- trived that the patient may get about, while the fragments are held rigidly fixed and in contact with each other. This is especially useful in fractures of the lower limb, where there is already a fair amount of union, and where the direction is not too oblique. The appliance, which must be worn night and day, naturally must be fairly strong, and must fit with the greatest accuracy. The best are made of leather, with lateral iron supports, jointed in the proper situations, and let into the boot beneath. The health of the ])atient improves; the nutrition of the limb becomes more .satisfactory ; and the constant friction of the ends of the bones stimulates them to such an extent that in many instances the fracture unites and becomes firm without anything further being required. Puncture and Injectioii. — When it is no longer a question merely of delay, the same kind of treatment may be adopted, but in a more vigorous manner. If the bone lies near the surface, it sometimes answers to drive a number of stout needles directly through the skin into the space between the fragments, and leave them there for a week or ten days. In other cases the injection of various kinds of fluid, tincture of iodine, carbolic acid, and alcohol has been tried. Or the negative pole of a galvanic battery has been attached to a needle inserted between the fragments, and a current as strong as the patient could bear without an anfesthetic passed through it ; or the ends have been scarified with a tenotome, or perforated with a drill, with the view of exciting sufficient inflammation about the part to fix the fragments in the exudation. None of these, however, can be advocated very strongly ; acupuncture and drilling the ends are perhaps the most .satisfactory, but they are not so devoid of danger as they seem to be, especially as the large blood- vessels are often adherent to the fragments, and their action is by no means certain. Setons should certainly not l)e used. Pegging. — Of all the methods that act in this way, the one that has enjoyed the greatest amount of success is that first practiced by Dieffenbach. According to his directions, a small incision is made through the soft parts down to the bone, FRACTURES. 359 on the side that is most accessible, and both fragments are drilled completely through ; then an ivory peg is driven into each with a wooden hammer, until its end can be felt projecting on the other side, and the fracture secured in a plaster casing. The pegs may be left in for ten days or a fortnight, according to the amount of reaction they cause. It is generally found when the pegs are removed that the surface is deeply eroded (after the fashion of Howship's lacunae) by the cells in the medulla ; and it is much simpler to break them off short, and leave them in the substance of the bone, to be absorbed there ; they do not of themselves excite suppuration, the skin wound can be closed at once, and there is much less chance of inflammatory com- plications setting in. In very oblique fractures, where the ends of the bones over- lap, an additional amount of security maybe obtained by driving the pegs through both, so as to pin them together ; and steel screws may be used in the same way, the handles being detached after they are fixed, so that the whole can be covered up in one dressing ■ but if measures of this kind are adopted, it is more satisfactory to expose the ends of the bone thoroughly, resect them if necessary, and adjust them accurately. The operation is scarcely, if at all, more severe and the result is decidedly more certain. Resection and Wiring. — In a large number of cases this is the only plan that offers a reasonable prospect of success. Where there is a false joint of long stand- ing, or great displacement of the ends, or when some foreign substance has become entangled in the fracture so that the bone cannot be released, nothing else can be of any avail. The immediate-neighborhood of a joint is no objection ; if the tissues themselves are healthy, and if there is no great amount of inflammatory exudation around the part already, there is no reason why suppuration should occur. A cer- tain amount of stiff'ness may result, it is true, either from the formation of adhesions or from excess of callus, but it is rarely of any extent, and, of course, such an operation as this is not done unless the usefulness of the limb is seriously impaired. The operation itself, especially in the case of a deeply-seated bone, is by no means easy. The limb is rendered bloodless ; the parts thoroughly exposed by a longitudinal incision, if possible, through one of the inter-muscular septa, so as to avoid injury to other structures, all intervening tissue removed, taking especial care to preserve every fragment of periosteum, and the ends either sawn off" or thoroughly freshened. It is of little or no use unless they are made to fit each other accurately, over a surface of some extent, and are firmly held together. They may be secured in various ways according to their shape; sometimes, when they are both oblique, they may be pegged through with wire or ivory needles ; in other cases they may be dovetailed or wedged into each other ; in one example the lower end of the fibula was driven into the medullary canal of the upper end of the tibia with a very good result ; or if the central canal of both fragments is exposed, an ivory peg may be fixed, first in the one and then in the other, so as to hold them in the same straight line ; but the ordinary method is to drill them both, and suture them to- gether, either with silver wire (the ends of which can be hammered down) or kan- garoo tendon. Especial care must be taken to provide sufficient drainage ; owing to the amount of manipulation to which the parts must be subjected in an operation of this kind the oozing is in general very extensive. Even this is not always successful. A great deal depends upon the condition of the bones ; if they are much wasted, and if the ends are sharp and pointed, failure is not at all unlikely. Sometimes, when a first attempt under strict antiseptic pre- cautions does not succeed, a second without is more satisfactory, and union has taken place after an attack of erysipelas. Perhaps the best thing, if the opera- tion fails, is to put the limb up in some apparatus that will allow it to be used to a certain extent, in the hope that, though this may not improve the chance of union, the bones will be better nourished, and then another attempt may be made later on. Transpla7itatioii. — Nussbaum, in two instances in which there was a great deficiency in the ulna, separated a portion of bone from one of the ends, leaving 36o DISEASES AND INJURIES OE SPECIAL STRUCTURES. it attached by periosteum, ami reflected it, so that it filled up the interval. If this is attempted, the circulation through the bone must first of all be stimulated by inserting needles into it, and great care must be taken to prepare the bed for the new fragment. Grafting. — MacEwen has carried the process further still, and by dint of re- peatedly grafting in fragments of bone obtained by osteotomy, succeeded, in a child, three years old, in causing the reproduction of nearly the whole of the shaft of the humerus. Fragments of bone and periosteum obtained from animals have also been used, and with success; in one instance, a gap of two and three- quarters inches in the clavicle was gradually filled up by grafts of bone from dogs, three successive series being used; and, in another (.\IcCjill), thirteen fragments of bone from the femur of a rabbit were transplanted into a gap in the radius, with a perfect result. It is possible, of course, that this may be due merely to the irritating effect of a foreign body ; but it is difficult to believe that the nature of the foreign body is of no importance. Sy.mptoms and Diagnosis. A fractured limb must be made secure at once, to avoid further injury. Full and detailed examination is better postponed until the splints and other appli- ances are ready, that the fracture may be set, without being handled a second time. The extent to which it is advisable to carry the investigation and the question of an anaesthetic, vary in each case, and must be left to the discretion of the surgeon. In some instances, such as fracture of the neck of the femur in an old person, manipulation should never be attempted ; on the other hand, in an injury to the lower extremity of the humerus, it is absolutely essential to find out the e.xact position and direction, if serious deformity is not to result. The possibility that neighboring structures, especially arteries and joints, are injured too, should never be forgotten, and a careful examination into their con- dition should be made in every case ; they may easily be wounded by splinters and in other ways, and, if overlooked, may lead to very grave complications. Method. — No pains should be spared to obtain a clear account of the acci- dent, whether the injury was the result of direct or indirect violence, or if it was due to muscular action — sometimes a sound is heard at the moment that the bone gives way — then what happened afterward, whether the limb was used again, or if all power over it was gone, and where the pain was most acute. In many cases a shrewd suspicion may be formed from this alone, not merely as to the part of the body which has been hurt, but even as to the kind of injury sustained. Then, before it is touched further than is required for the removal of the clothes (which should be cut wherever necessary), it must be inspected with the greatest care, and compared, point for point, with the corresponding part of the opposite side. Often, the position is characteristic of some special kind of injury ; sometimes the outline is greatly changed, natural hollows perhaps are obliterated, or bony prominences have disappeared, or measurement even by the eye reveals an amount of shortening or displacement that can be accounted for in no other way. Xot till this is finished may the part be handled, and then as lightly as pos- sible, beginning at some distance from the supposed seat of injury, and tracing down with the finger the prominent ridges or crests of bone. One spot may be more tender than the rest ; nearly always there is swelling either from the extrava- sation of blood, or from displacement of the broken ends ; sometimes, there is dis- coloration, or the skin is abraded and even torn. All this must be noted before any attempt is made to move the part, either for the purpose of eliciting crepitus, or of ascertaining the presence of abnormal mobility. This, if it cannot be avoided altogether, must be postponed to the last. It must never be forgotten that, in all cases, a great deal (in fractures by indirect violence nearly the whole) of the injury sustained by the soft parts is due to the movement of the broken ends. FRACTURES. 361 Symptoms. — -'rhe three distinetive signs of fracture are an alteration in the shape of the i)art due to the displacement of the broken ends, undue mobility, and the rough, grating sensation, or crepitus, felt when one broken surface is rubbed against another. The presence of any one of them is enough ; when they are all three wanting, as in fissures of the cranium, the existence of a fracture is only a matter of inference. 1. Drfonnity. — ( )f these three displacement is the most valuable, as it requires little manipulation, and is the one most often present. Sometimes it is so con- siderable, that it is visible to the eye at once; more often it can be felt beneath the skin, but, in most instances, it is only possible to make certain by means of measurement. In the limbs, comparison with the opposite side of the body is an absolute rule. In some cases, a fairly accurate estimate may be made with the hands alone, grasping, for example, the anterior superior spines of the ilium, in a case of injury to the upper extremity of the femur, and measuring with the fingers the relative position of the trochanters on each side. In general, as the displace- ment is so often longitudinal, it. is done much better with a measuring-tape or a sliding graduated rod. The points selected on the two sides should be well marked, and must absolutely correspond ; the position of the limbs must be identically the same, and, as asymmetry is not at all uncommon, it is often advisable to measure not only the length of the whole limb, but that of the individual segments. This is particularly necessary in the lower extremity ; whether from previous injury or disease, or from some difference in the rate of growth, it is not at all uncommon to find one of the lower limbs considerably longer than the other. The direction of the displacement depends chiefly on the character of the part that is injured. It may be angular, as in a greenstick fracture ; transverse, or lateral, when a flat bone is concerned ; circular, as in fractures of the lower extremity, with eversion of the foot ; or longitudinal, the ends either being drawn apart as in transverse fractures of the patella, or approximated so that they lie side by side and override each other. In some cases, when, for example, one is so driven into the substance of the other that it becomes impacted there, deformity is the only one of the three cardinal symptoms present ; occasionally, it is absent, as in fissures of the cranium, or when only one of a pair of bones is broken. In impacted fractures, the displacement is entirely the result of the original force ; in other cases, it depends to a great extent on causes which continue to act after the bone is broken, so that it grows worse and worse the longer the fracture is left to itself. The most serious is the contraction of the muscles, not merely the tonic shortening which results naturally as soon as they are released from their state of tension, but violent and continued spasmodic contraction, due no doubt to the irritation caused by the broken ends. This is responsible almost altogether for the separation when a bony projection is wrenched off, and for the shortening which is nearly invariable in fractures of the long bones of the limbs, and, therefore, in cases of paralysis, displacement is always slight. In other in- juries, the weight of the limb and, what is a great deal worse, subsequent attempts at moving the part, either by the patient himself or by others, often add seriously to it. Indeed, it is in great measure owing to these two last-mentioned causes that so many fractures by indirect violence become compound. 2. Abnormal Mobility. — Abnormal mobility, when it is present, is conclu- sive, but, if the degree is slight, or if the fracture is in the neighborhood of a joint, it is very hard to appreciate, and, if there is impaction, it is wanting altogether. It is most plain in transverse fractures of the shaft of long bones, where there is only one ; in injuries of short bones, or where one fragment is so small or so deeply placed that it cannot be fixed, it is of little or no assistance, and, though it is nearly always present when one of a pair of bones has given way, special manipulation is generally required to show it. If, for example, the radius is in question, the thumb of one hand must be placed upon the head of the bone, while the other alternately pronates and supinates the forearm ; if the lower end of the fibula, a finger must be pressed firmly on the suspected spot, 24 362 DISEASES AND INJURIES OE SPECIAL STRUCTURES. while the upper part of the two bones are squeezed together, or the foot is forcibly inverted and everted. Manipulation of this kind must be carried out with the greatest gentleness, not merelv because it is so painful (this may be prevented by an ana;sthetic), but because it inflicts such injury on surrounding structures. For this reason, in some fractures, of the spine, for example, any attempt should be absolutely pro- hibited. 3. Crepitus. — Crepitus, the peculiar sensation, partly felt, partly heard, when one broken surface is made to rub upon another, is still more limited in its appli- cation, for in order to produce it the fragments must not only be freely movable, but in actual contact, or at least so close that they can be made to touch. If they are fixed or widely separated, or if a piece of fascia or muscle, or even blood- clot, has slipped between, it fails completely, and when an epiphysis is detached, especially in very young children, it is so soft and faint that it can scarcely be recognized. Other sounds, too, resemble it more or less closely ; if a synovial sheath or bursa is inflamed, or if there is a collection of e.xtravasated blood be- neath a layer of dense fascia, such as is not uncommon in the region of the shoulder, direct pressure may cause a sensation that is almost identical ; but, as a rule, it only does so once, and the sensation cannot be repeated at the same spot till some little time has elapsed. Single clicks, too, something similar in charac- ter, may often be felt near joints that have been injured when they are moved in certain directions; and sometimes, as in the elbows of children, in whom the bony prominences are naturally low, and often still further concealed by swelling, they may be so clear as to cause a momentary doubt. In rheumatoid arthritis, when the cartilage has disappeared from the articular surfaces, and the polished bones are rubbed upon each other in every movement of the joint, the sound is almost identical, but the feeling is much smoother, and the surfaces do not grate on each other in the same way. The sudden sound that is sometimes heard at the moment of the accident, not only by the patient, but even by those standing near, is rarely of any assistance in diagnosis, as it only occurs when a long bone is broken, in circumstances that nearly always cause much displacement. Fain. — In addition to these, there are other symptoms which are not confined to fractures, and which, therefore, can only be regarded as proof when there is other evidence in support of them. Intense pain at the seat of injury, for ex- ample, is nearly invariable, but to be of any use in diagnosis it must be constant and limited to one particular spot. If, for example, pressure on one part of a rib always causes pain at another, or if after the foot has been twisted an exceed- ingly painful spot is found on the fibula, an inch or two above the ankle joint, fracture more or less complete is almost certain ; there is nothing else that can explain localized tenderness so far from the seat of injury. Ecchymosis. — Extensive ecchymosis again is a common occurrence in cases of fracture, but is of little use in diagnosis, unless it has the support of other signs. Hemorrhage from the ear, for example, is generally present in fractures through the middle fossa of the skull, but it is only conclusive when it is sudden and profuse ; and staining of the skin is not in any way peculiar, unless it is accompanied by localized tenderness and it is certain that the part itself was not directly hurt. Helplcsstiess. — Inability to make use of the part is very general, but by no means invariable. It depends, of course, upon the size and importance of the injured bone and the extent to which it is hurt. If the ends are impacted, or the periosteum is not torn, or if only one bone of a pair is broken, the limb may still be used to a certain extent, though not without pain. In some ca.ses of fracture of the clavicle, it is quite possible to raise the arm above the head, and persons with impacted fracture of the neck of the femur have been known to walk about for days. When, on the other hand, the bony support for the leverage of the muscles is lost, this is absolutely impossible. Unhappily, this symptom is not confined to FRA CTURES. 363 fractures, ])ut is present in other injuries, too, particularly in those which present the closest resemblance to them. Diagnosis. — The diagnosis of fracture has to be made from separation of epiphyses, dislocations, and contusions. Injuries in the neighborhood of joints, therefore, present the greatest difficulty, and if the examination is delayed until swelling has set in, or if the joint has been previously the seat of disease, particu- larly of rheumatoid arthritis, it may be necessary to wait for some days and to watch the progress of the case before a definite opinion can be given. In such a case the injury must always be treated as if it was certain that the bone was really broken. The separation of an epiphysis is distinguished by the locality, by the age at which it occurs, and by the peculiar soft character of the crepitus, when it is pres- ent : in infants it may be absent altogether, as the line of detachment in them lies in the substance of the cartilage. The amount of displacement is rarely very great, as the periosteum belonging to the shaft is closely attached to the epiphysis, and is so tough that it is seldom torn completely in two ; but sometimes, when the end of the shaft is near the skin, its smooth and rounded shape can be dis- tinguished from the sharp outline of a fracture. The diagnosis is important, be- cause in a certain number of cases this accident is followed by an arrest of growth, and it is advisable that the possibility of such an occurrence should be pointed out at the time, ^^"hen there is only one bone, as in the arm, there is merely a certain degree of shortening, and if the upper end is in question, some restriction in over-hand movements ; but when the lower end of the radius fails to grow, the styloid process of the ulna projects further and further until the use of the hand is seriously interfered with and the appearance is very unsightly. Dislocations rarely present any difficulty if the injury is seen shortly after the accident, before swelling has set in and the bony prominences are obscured. If displacement is once rectified, there is no tendency for it to return ; true crep- itus is Avanting, though sometimes there is a very fair imitation, and there is no abnormal mobility. The position of the limb is fixed, and can only be altered by the exercise of a certain degree of force. It must not be forgotten, however, that fractures sometimes occur with dislocations, and that, particularly in the case of the elbow, fractures into joints may be accompanied by a degree of displacement that produces a very close resemblance. Severe contusions, in which there is complete loss of power over the limb or a considerable extravasation of blood, in many cases cannot be distinguished from impacted fractures, and should be treated as such. It is impossible to prove that the crushing force has been expended entirely on the soft parts, and has not reached the bone, without handling the part to an extent which, in such injuries, is certainly not advisable. Course and General Complications. Shock. — All fractures of any consequence are attended by shock and followed by a certain degree of fever. The former of these is dependent, not only on the fracture itself, but on the extent of the injury the soft parts have sustained, the way in which the accident happened, and the condition, mental as well as bodily, of the patient at the time. I have known a man whose great toe was run over by a railway engine, so collapsed that twenty-four hours passed before the reaction was sufficiently good to justify an operation. Retention. — Retention of urine for a day or two is present in a large number of cases, especially when the fracture involves the pelvis or the femur, and when the patient is confined to bed. Fever. — In simple fractures, and in compound ones in which the wound heals by the first intention, the fever rarely reaches any height. It is traumatic fever in the strictest sense of the term. The same evening there is, generally speak- ing, a fall of temperature due to the shock ; the next day it is slightly raised, and 364 DISEASES AND INJURIES OF SPECIAL STRUCTURES. it reaches its maximum, 100° or 101° K., by the evening of the second day. To some extent it is due to the pain and tension ui)on the sensory nerves of the part, and, as a rule, it is projjortionate to the amount of extravasation ; but the main cause is the gradual absorption into the circulation of the blood ferment set free by the injured tissues, and the broken-down clot which fills the wound. If, on the other hand, the fracture is compound and the wound does not heal by the first intention, or if, as very rarely happens, the limb is so injured that, though the skin is unbroken, it becomes gangrenous, no rule can be laid down either as to the kind or the degree of the fever. It depends entirely on the com- plications that set in and the extent and severity of the inflammation by which they are accompanied. Fat Embolism. — Fat embolism occurs probably in every fracture. It comes, no doubt, mainly from the medulla, but as the amount found in the lungs is some- times too great to be accounted for in this way, it may be derived to a certain extent from the subcutaneous tissue as well. Large veins are torn across, their ends are held open, the pressure in their interior is exceedingly low, that in the space around from various causes much higher, and as a consequence the contents of the broken fat-cells and the extravasated blood are taken up and carried away by the current. It commences almost at once. I found abundant evidence of its presence in the lungs of a man whose death was almost instantaneous from a broken neck ; and it continues for some weeks, the drops of fat circulating in the vessels becoming broken up as they pass through the capillaries, and reuniting again in the larger trunks until they are finally excreted by the kidneys. The clinical significance of this complication has been very variously esti- mated. There can be no doubt that in the vast majority of instances it gives rise to no symptoms at all, and animals, at least, are not materially affected when four times the quantity of fat contained in a femur is suddenly injected into one of the larger veins. When the amount is greater than this, there is a conspicuous lower- ing of temperature, difficult)' of respiration, and evidence of heart-failure. The same symptoms have occasionally been observed after simple fractures in man, and may, with a fair amount of probability, be assigned to this. Collapse is always prominent, not immediate, as if it were due to shock, but coming on after an interval of some hours ; the pulse is small and quick, respiration hurried and shal- low, the temperature falls rapidly, the face becomes pale, there is a feeling of great weakness, the senses gradually become more and more dull until death ensues, per- haps preceded by convulsive attacks. In the case of compound fractures it is, generally speaking, impossible to decide how much is due merely to the mechanical influence of fat embolism, and how much to acute septic intoxication, which is frequently present in the same kind of case.* It is a very old observation that sometimes after fractures an oily scum forms upon the surface of the urine after it has been allowed to stand, and it seems probable, when this happens, that it is due to the particles of fat which are excreted by the kidneys in a state of molecular subdivision. It is not common, however, for the amount to be sufficient to produce this effect. Oily and albuminous casts have also been described, but their presence is certainly unusual. The further course of a simple fracture is, as a rule, quite uneventful. The swelling of the limb gradually subsides and becomes localized to the immediate seat of injury, where, owing to the callus that is thrown out around the broken ends, it may persist for months. The extravasated blood is slowly absorbed, the discoloration sometimes showing itself in far distant parts of the limb. Occa- sionally blebs filled with serum, more or less deeply stained, make their appearance by the side of pads where there is little or no pressure. These should be pricked, their contents absorbed with wool or blotting paper, and carefully dried, or, par- ticularly if there is much oedema, they may prove the starting point for some inflammatory process. * See Paper by author in British Medical Journal iox July, 1881. FRA CTURES. 365 Thrombosis. — 'riiroinl)osis of the veins is not unconmujn after fracture. It involves most frecjuently the deep veins of the leg, especially in oUl people and in those whose circulation is not very vigorous, starting either from the seat of injury or from some ])art where a vein is compressed or irritated by the edge of a band- age. The limb becomes (jcdematous, even before it is allowed to hang down ; it pits with pressure (but only if this is firm and long continued), and it feels cold, heavy, and helpless. When once this is developed, it is exceedingly obstinate ; it may interfere with the union of the fracture, and it has been known to spread until even the vena cava became involved. If a fragment is detached, the con- sequences are exceedingly grave ; so long as it is small, it merely causes a transient attack of dyspncea, due to the blocking of a branch of the pulmonary artery ; but when it is large, either the trunk of the vessel itself is suddenly occluded, or the embolus is coiled up in the cavity of the right ventricle. In either case death is immediate. When this occurs, there has generally l^een something to detach a portion of the clot, some sudden movement, either of the patient or the limb ; and, consequently, it is most likely to happen when the fracture is nearly consolidated and the patient is beginning to move about. [These cases require active stimulation as soon as the condition is recognized.] Constipation is a very general complaint. It may be due to a slight extent, perhaps, to the fever, but mainly it is the result of the confinement to bed and the sluggish circulation through the liver. Sometimes it ends in an attack of gout or jaundice. Congestian of tlic lungs a-nd hypostatic pneumonia are often brought on in the same way, especially in old people, many of whom never really lie down at all. If they meet with any accident their circulation, already feeble, is so affected by the shock that passive congestion and oedema set in and rapidly prove fatal. Bed-sofes, too, are very prone to occur from the same cause, especially if the patient is not kept scrupulously clean. Over the sacrum is the most common situa- tion, but they may form anywhere over bony prominences if care is not taken in fitting the splints. The back of the heel, for example, is a very favorite locality in fractures of the leg, and a sore is sure to form unless proper precautions are taken. One great advantage of fixed apparatus is that by enabling the patient to sit up and change his position from time to time all these troubles due to rigid confinement are very greatly mitigated. Special Complications. The local complications that occur in connection with fractures are immediate or remote. The former depend upon the injury inflicted on surrounding structures at the time of the accident, the latter result from the changes that take place sub- sequently during the progress of the case. Cases of injury to important viscera must be treated by themselves. Laceration. — Laceration of the soft tissues and extravasation of blood are so general that they can scarcely be called complications, unless exceptionally severe. In simple fractures the skin is sometimes stripped up from the fascia beneath, and floats, as it were, upon the surface of a hematoma ; but unless some large vessel has given way, this is readily checked by compression or position, and soon dis- appears of itself. Suppuration rarel}" occurs. In compound fractures the danger is greater, for if inflammation once breaks out, it is only too likely to spread along the track so well prepared for it ; and in severe cases, where there is much lacera- tion, and the extravasation extends along the limb, it is often a wise precaution to enlarge the opening, and even make fresh incisions for the purpose of washing out the extravasated blood and securing effectual drainage. Rupture of Arteries. — When the main artery of a limb is concerned, the ques- tion is much more serious. It ma}- be compressed by one of the fragments ; the sharp edge of the lower end of the femur, for example, may be pressed against the popliteal ; or it may be punctured by a splinter, or crushed so that the two inner 366 DISEASES AND I XJ CRIES OF SPECIAL STRUCTURES. coats give way and curl up in the interior of the vessel ; or it may be torn com- l^letely in tvvo. Sometimes, therefore, it is blocked (though it may give way later), and sometimes it continues to bleed until it is stopped by the tension of the tissues around or by the failure of the heart. If there is a wound, the nature of the complication is generally evident at once, though when the external opening is very small and tortuous the stream may be continuous instead of coming in jets. In simple fractures the symptoms depend upon the size of the artery and the nature of the injury. If one of the main trunks is torn across, a tense, elastic swelling forms with great rapiditv, there is the most excruciating pain, the pulse below is comi)letely lost, and the limb becomes cold, cedematous, and numbed. If, on the other hand, there is only a puncture, so that the continuity of the vessel is not interrupted, this takes place more slowly ; a certain amount of indistinct pulsation may be felt for a time, and sometimes, at least, a low murmur may be distinguished, synchronous with the pulse. {a) In Compound Fractures. — In the case of a compound fracture, if the vessel is of any size or importance, the choice of treatment is very limited ; either the wounded artery must be found and tied above and below, or the limb must be amputated. Which of these alternatives is adopted in any particular case depends upon the patient, on the particular artery that is wounded, and on the extent of the injury inflicted on the other structures around. Obviously, a much greater risk may be run with a child than with an adult, though children bear hemorrhage badly ; there is much more hope when the upper limb is in question ; and the prognosis is much better when the fracture has been caused by indirect violence than when the soft parts are cnished, the collateral circulation destroyed, and the neighboring joints torn open. The hemorrhage must first be checked by a tourniquet, or other means suited to the part, the wound enlarged, all clots turned out and a thorough search made. Sometimes this is successful, but finding a torn vessel under conditions such as these is always a matter of the greatest difficulty. Ligature of the vessel higher up can- not be recommended ; if the collateral circulation is good, the bleeding continues ; if it is not. gangrene sets in. (J)) In Simple Fractures. — In simple fractures the question turns upon the collateral circulation and the limitation of the extravasation. If the swelling is tense and diffuse, so that the limb below is cold and pulseless, amputation must be performed at once before gangrene sets in. The only exception is where the sur- rounding structures are but little injured, and the interruption to the circulation is due more to the tension than to the destruction of the collateral vessels. Occa- sionally this happens to the popliteal; an attempt may then be made, provided everything else is favorable, to find and tie the injured artery, but it must be recol- lected that this makes the fracture a compound one. and that very often it extends into the knee joint. If, on the other hand, the circulation is not completely interrupted, if the limb still retains some warmth and sensation, there is some hope either that a trau- matic aneurysm will form, or that, better still, the wound in the artery may close, and the blood riuietly become absorbed without further trouble. I have known this happen even when it was practically certain, from the extent of the extravasa- tion, that the brachial artery had been torn across. The limb should be raised, kept quiet, jjlaced in as comfortable a position as possible, and wrapped in cotton- wool to maintain the temperature. No firm bandages or splints may be applied, merely something to protect the part against incautious movement ; the l>est hope lies in perfect rest and gentle compression. In the case of the anterior tibial the symptoms sometimes disapjjear of them- selves ; more often the swelling continues to pulsate without extending very rapidly, and a wall, more or less perfect, is gradually formed around the hematoma until it becomes a traumatic aneurysm. This may be cured at any time by any of the ordinary methods ; compression maybe tried first; if this fails the artery may be tied above, or the sac may be laid open and both ends of the vessel secured. Care- FRACTURES. 367 fill examination for pulsation should be made in every case of localized swelling that makes its api)earance after a fracture ; very often there is a certain amount of redness and inllammation round a traumatic aneurysm, and many of them have been laid open in mistake for abscesses, especially as they are sometimes met with at some distance from the seat of injury. When the posterior tibial is wounded, it is rare for the swelling either to sub- side or become localized. If the limb continues warm, digital compression of the femoral may be tried ; at least it places the patient in no greater danger, for if gangrene supervenes amputation can always be performed at the seat of injury ; and ligature in Scarpa's triangle has proved successful in a few instances. If, how- ever, the swelling is rapid, and there is evidence of venous congestion ; or if the part is plainly becoming colder, an attempt may be made to tie the vessel, but in all probability the limb will have to be amputated. When the popliteal is in ques- tion, owing to the space round the vessel, the swelling, as I have mentioned already, is always diffuse. Rupture of Veins. — Rupture or puncture of a large vein is a very unusual and a very grave complication. The poj^liteal is occasionally torn or compressed at the same time as the artery, and the subclavian is sometimes, but very rarely, injured in fractures of the clavicle ; in other cases the vein usually escapes, unless the limb is utterly disorganized. The symptoms, with the exception of the pulsation, are almost the same as those of ruptured artery, and gangrene is even more likely to occur. If the limb is growing cold, the only course is to lay the swelling open, turn out all the extravasated blood, and try to secure the two ends as soon as pos- sible, and failing this, amputate. Seco/idary Hemorrhage. — Secondary hemorrhage may occur after compound fractures, just as it may after any other injury, and from the same causes. In addi- tion, however, there is always the danger of simple as well as compound ones, that a loose splinter may be driven into an artery or vein by some incautious movement, or that the wall of the artery may ulcerate through from pressure. I have known this occur in the case of the popliteal a twelvemonth after the original accident ; the lower end of the upper fragment was displaced backward, so that it came into contact with the vessel and gradually wore a hole through its coats, long after recovery was thought to be complete. Injury to A^erves. — Large nerve-trunks are so strong that they are seldom torn, but they often suffer in other ways. They may be contused or wounded by splinters ; sometimes they are caught between the bones so as even to prevent union, or they slip into a cleft in one of the fragments, or^what is much more fre- quent, they are enclosed in the callus that is thrown out after the injury, and slowly but surely constricted until their physiological continuity is destroyed. More than half the cases on record refer to the musculo-spiral nerve : but, con- sidering the rarity of fractures of the upper end of the fibula, the peroneal seems to suffer almost as often. The symptoms presented by this complication vary according to whether the nerve is irritated or only compressed. Tetanus, spas- modic contraction, hyperaesthesia, and intense neuralgia are occasioned by the former ; loss of power, wasting, diminution of sensibility, and constant pain until the nerve has undergone degeneration, are met with in the latter. If the com- pression is only transient, the prognosis is, generally speaking, good, though in a few instances the loss of power has been permanent ; if it is continuous, as when the nerve is compressed by callus, atrophy sets in, the fibres disappear, and only a cord is left. Release of the nerve by chiseling through the callus or sawing off part of the bone has proved successful even in advanced cases ; and in some instances, resec- tion of a portion that could not be set free has been performed with the same result. The prognosis depends upon the extent to which degeneration has occurred ; if the electric excitability of the parts below is not completely lost, early recovery may be expected, though it may not be perfect for some consider- able time. 368 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Injury to Joints. — Extension of the fracture into a neighlx^ring joint is always a t,'rave complication, even when the skin is unbroken. The synovial cavity is filled with blood ; it is often difficult to restore the fragments to their ]jroper position, and still more to keep them there ; and for fear of the joint becoming stiff, passive motion has to be commenced at a very early period, long before the union is sound enough for use. Moreover, later in life, a joint that has been injured in this way is very liable to be attacked by an obstinate form of osteo- arthritis. When the fracture is compound, the danger is greater still. 'l"he cavity that is oiiened up is often of very great size and very irregular in shaj^e ; and it is lined with a membrane exceedingly i)rone to absorb any poisonous material that is present. Under these circumstances, it is .scarcely sur])rising that the danger of accute suppurative arthritis is so great. Dislocation is occasionally, but very rarely, associated with fracture, the bone being forced from its socket, and then broken by the continuance of the same force. No pains should be spared to effect reduction. The patient must be placed under an anaesthetic, the limbs secured by means of splints, and the dis- placed part of the bone, if possible, pushed back. If this does not succeed, either the joint must be laid open and the head of the bone dislodged and restored to its position, or the fracture must be set and another attempt made later when the bone is firmly united. Inflammation. — Inflammation in the course of a simple fracture is quite ex- ceptional. Sometimes, when the extravasation is very extensive, the htematoma slowly suppurates, as it does occasionally in contusions ; or inflammation starts from the blebs that form on the surface of the skin ; and sometimes a slow, chronic form of ostitis sets in afterward, akin, perhaps, to the arthritis that follows contusions about joints ; but this does not occur unless some additional cau.se is at work. In compound fractures, on the other hand, if the wound does not heal at once, it often proves a most serious complication. Erysipelas, cellulitis spreading through the deeper planes of areolar tissue, as well as the superficial ones, diffuse suppuration, acute periostitis, osteo-myelitis, septicaemia, pyaemia, hectic, every form of wound disease, in short, may break out in the course of treatment, and either delay recovery indefinitely by the sloughing and necro.sis it causes, or itself prove fatal. Sioitg/iing. — Sloughing of the skin and cellular tissue may be caused by the violence to which the part is subjected at the moment of the accident; or may occur, as already mentioned, from the pressure of badly-made splints on bony prominences. In the former case the fracture is almost certain to become com- pound if it was not so already ; in the latter the slough often bears no relation to the seat of injury, and, so long as it is limited, may be treated as an ordinary bed- sore. All pressure must be removed, so far as is consistent with safety ; the posi- tion of the limb must be adjusted so that the circulation is unimpeded, and putre- faction prevented. If the cause is removed and no fresh irritant allowed to appear, the sore that is left soon granulates up. Gangrene. — Traumatic gangrene may be local or spreading. In the former case it may arise from the actual crushing, even when the fracture is a simple one, or from thrombosis, rupture of the main vessels, or tight bandaging ; but whatever the reason, if an attem])t has l)een made to save the limb, and it is j)lainly becom- ing colder, amputation should be ])erformed at once. The most difficult cases are those which hang in the balance for a day or two, sometimes warmer, sometimes colder, before it is possible to be certain. Spreading traumatic gangrene may result solel)' from the defective nutrition of the tissues — the vitality of the i)art is so low from renal disea.se, diabetes, cold, exposure, or other causes, that the structures perish even if they are only bruised — or much more frequently from the action of irritants that make their appearance subsequently in the wound. Septic decomposition, high tension and suppuration acting together cause the most fearfiil form. Putrefaction takes place in the FRACTURES. 369 wound ; the ])oisons producetl arc driven l)y the tension into the celhilar inter- spaces, destroying everything they touch, and the microorganisms of suppuration comi)lete the destruction. Hospital gangrene, wliich was the worst form ever known, was simply the product of these agents acting under ]>eculiarly favorable conditions. Solid CEiiema. — Solid (edema, due to lymphatic and venous obstruction, is often present after fractures, especially comjjound ones, in which there has been inflammation or sloughing of the cellular tissues. The nutrition of the whole limb sufters ; it remains cold and hard ; the skin is tightly bound down to the parts beneath ; ulcers are liable to form, and though they may be cured by atten- tion to position and rest in bed, they invariably break out again as soon as the limb is used. In one case I removed a leg, at the patient's request, seven years after a severe compound fracture, in which resection had been performed ; the ulcer, which was exceedingly ])ainful, had broken out nine times, and he had spent more than four years of the seven in bed. Muscular Atrophy. — Muscular atrophy is present in most cases of fracture. If it is merely the result of inactivity, recovery is, generally speaking, rapid and easy ; but sometimes, when the limb has been severely crushed, or when there has been much inflammation, the fibres are so matted together, and the tendons so crippled by adhesions, that the process is very tedious. In other cases there are special reasons for it ; the lower part of the vastus internus, for example, never quite regains its size after fracture of the patella. According to Volkmann, paralysis and contracture are sometimes caused by the prolonged constriction of the blood-vessels ; the muscles become stiff and hard ; all control over them is lost ; and movement becomes intensely painful. It is said that this is due to the breaking up of the contractile substance in consequence of the deficient supply of blood. In other cases again, shortening, sometimes of a very obstinate descrip- tion, is brought on through malposition during treatment. Ankylosis. — Stiffness of the joints is very common even when they ha\e escaped direct injury. Bonnet and others have described very extensive alterations as taking place in them merely from prolonged rest, the cartilage disappearing, and the opposing surfaces becoming united by dense, fibrous tissue. Such changes, however, occurring independently of inflammation, are very rare. As a rule, the joint becomes stiff because passive motion is not resorted to sufficiently early ; the capsule becomes rigid ; the amount of synovia is deficient ; the soft tissues around grow hard and thick ; and the folds and fringes become adherent to each other, and no longer accommodate themselves to the changes in pressure as the bones are moved. The ti.ssues, in short, are so badly nourished that they are unable to do their share of work. Residual abscesses occasionally make their appearance in compound fractures many years after the original accident, and sometimes minute sequestra are found inside them; in some cases, perhaps, they are small fragments that have been locked in during the process of repair. Atrophy of the bone has also been known to follow without apparent reason, and cases of malignant disease starting from the seat of injury are not so uncommon as might be exjjccted. Treatment (Immediate). In every case of fracture the first thing is to prevent further injury. The limb must be placed in a suitable position ; the clothes removed, always beginning with the sound side, and where it is necessary, slitting up the seams ; and the injured part thoroughly exposed. A small wound is better sealed at once ; dried blood-clot is an excellent protection ; if it is large, means must be taken to check the hemorrhage before anything else. Then the limb must be secured so that the patient may be moved with the least amount of risk. In fractures of the ujjper extremity there is no difficulty ; the arm can be bound to the side of the body with one handkerchiet" and the hand and wrist 370 DISEASES AND INJURIES OF SPECIAL STRUCTURES. supported with another tied round the neck to form a sling. In the case of the leg and thigh, however, some form of splint must be extemporized. It may be made out of almost anything : laths or wood, bundles of straw, rolls of newsi)ai)er, umbrellas, or whatever else is to be had at the moment ; the only requirement is that it should be sufficiently long and rigid to keep the limb steady in the most comfortable position. A broken leg should be laid on its outer side with the knee and hip flexed ; the thigh may either be placed in the same position, or the two limbs may be tied together and secured to a splint made out of a broomstick with some cloths round it, long enough to reach from the armpit to below the knee. Only in the case of the spine and pelvis nothing of the kind should be attempted ; the patient is merely to be placed perfectly straight in the recuml)ent position until he can be lifted on to a stretcher. To raise an adult with a broken leg comfortably, at least three persons are necessary : one to take charge of the limb, the others one on each side, facing each other, with their hands well beneath the hips and shoulders ; the .stretcher should be placed at the patient's head, as it is more easy to lift him over the end. Bearers should be cautioned against keeping step, and if the lower extremity is broken, care must be taken that the shoulders are not raised higher than the feet. A fracture bed should be narrow, so that the patient may be reached from either side, firm and elastic without being soft, and if the spine or the upper part of the leg is involved, so arranged that nothing is disturbed' when the bowels act. Woven wire mattresses with a hair one on the top are the best ; sinking at the hip may be prevented by a board underneath extending from side to side. In injuries of the spine, and in any case in an old person, water-cushions under the pelvis are essential. Very many contrivances have been devised for the use of the bed- pan : one of the best is a circular opening in the mattress protected round the edges with oiled silk, immediately under the nates ; this is filled up from beneath with a cushion which, when occasion requires, can be lowered by means of a screw attached to the side of the bed and replaced by the pan. Two sheets, of course, must be used, folded double, one beneath the shoulders, the other at the lower end of the bed, the folded margins meeting over the opening. In other cases a conical wedge of the mattress may be made to slide in and out from the side. Or the opposite plan may be adopted : a very stout piece of canvas, perforated in the centre, is laid over the mattress and fastened all round to a strong wooden frame, a little smaller than the bed itself. When it is not in use, this rests upon the framework of the bed ; but it is so contrived that when the pan is required it can be raised with screws or pulleys six inches or so from the mattress with the patient lying on it. The same precautions must be taken in lifting the patient on to the bed ; then the clothes must be removed, the skin thoroughly washed and dried, all temporary appliances taken away, and the limb either secured with sand-bags or laid upon a pillow lengthwise and tied up in it. Treatment (Permanent). Fractures should in all cases be set as soon as possible ; the only exception is when the swelling and tension are already so extreme as to threaten gangrene. If there is the least danger of .such a complication, it is better to avoid manipulation, and merely to raise the limb and place it in a comfortable position, secured by sand-bags or tied up in a pillow. In other circumstances there is nothing to be gained by waiting, or by the application of cooling lotions ; the difficulty increases every hour ; the swelling becomes greater and greater ; the muscles, which at first are relaxed, grow more and more rigid ; and there is always the risk that by some incautious movement the injury may be made a great deal worse. FRACTURES. 371 I . Rciiiiction of tJic Fraciiirc. The first thing is to disengage the fragments and restore them to their proper position. If they are impacted, and it is considered advisable to separate them, a certain amount of force must be used, and where a bone is only partly broken, as in greenstick fractures, it is generally impossible to restore the shape without consider- able pressure, sometimes even making the fracture complete; but in all ordinary cases, where the displacement is due either to the weight of the part or to muscular contraction, the less force that is used the better. Gravity must be counterbalanced by arranging the patient so that it a.ssists in the reduction of the deformity, instead of being a source of difficulty, and the muscles must in some way or other be induced to relax. {a) Aniesthctics. — In many cases an anaesthetic is essential. The rigidity dis- appears at once, the limb can be thoroughly examined without causing pain, and if the bone is set immediately, before consciousness is restored, while the muscles are still at rest, the spasmodic contraction does not return. The only objection is that, particularly in men who are accustomed to a large amount of stimulants, and whose struggles are sometimes very violent, the injured limb may be seriously hurt unless it is very firmly held. Where gas and ether are used the risk is not nearly so great. {F) Jenotomy. — Tenotomy may be employed when one muscle in particular is in fault. The tendo-Achillis, for example, may be divided when there is obstinate spasm of the gastrocnemius, or when the lower end of the femur is detached from the shaft and rotated backward, so that it is in danger of pressing upon the popli- teal artery or vein, but it is seldom required in other cases. {/) Positio7i. — It is of the utmost importance to place the limb in a position that will secure the maximum degree of muscular relaxation. In Pott's fracture, for instance, the knee is flexed to prevent displacement of the foot by the gastroc- nemius ; and when the femur is broken immediately below the trochanter, the whole limb is placed upon an inclined plane if the upper fragment is raised to any degree by the ilio-psoas. The opposite muscles are stretched, it is true, but in most of the cases their action upon the fragments is insignificant in comparison, and unless they are irritated by the broken ends and made to contract, they gener- ally yield without trouble. {d^ Extension. — When the deformity cannot be reduced in this way, exten- sion and counter-extension must be employed, either for the time only, until the limb is secured by a splint, or during the whole period of treatment. In tem- porary extension one part (generally speaking that nearer the trunk) is held by an assistant, the other is grasped by the surgeon, and steady traction made in the axis of the limb until the fragments are unlocked and the length and shape restored. Often it is necessary to sway the part gently from side to side, or to rotate it a little so as to disengage the ends, and sometimes it is better for the extension to be made by the a.ssistant, while the surgeon manipulates the part himself; in any case the pull must be absolutely steady and continuous, without violent movement or jerking of any kind. When a sufficiently good hold can be obtained, the grasp should be made on the ends of the fractured bone, and the interposition of a joint avoided ; the soft parts are not so liable to be injured, but the rule is not absolute. In fractures of the femur, for example, extension must be made from the leg and counter-extension fromthe pelvis ; and when the leg is broken it is very much better to use a slight degree of extension with the knee flexed (so as to relax the muscles of the calf) than to pull it into position by main force. The amount of force used and the extent to which manipulation is carried must be left to the discretion of the surgeon. In some cases the fragments are too firmly impacted to be separated ; in others a splinter is so far displaced from its normal situation that it cannot be restored ; or again, the sharp-pointed ends have been pushed so far into the soft parts by the contraction of the muscles, that it is impossible to disengage them and bring them into apposition. So long as the 372 DISEASES AND INJURIES OF SPECIAL STRUCTURES. fracture is a simple one, it is better to leave these alone, in spite of the prospect of deformity, and the possibility in the last mentioned case of failure of union, than to run the risk of inflicting even greater injury on the patient. If the fracture is already compound, the question, of course, is entirely different. Continuous extension is recpiired for those cases in which the displacement is maintained by muscular contraction, as in fractures of the thigh. If the femur is broken obliquely, especially in an adult, it is only possible to restore the limb to its normal length by placing the ])atient under an anaesthetic, or tiring the muscles out. Extension for a time only is of little or no u.se, but, if it is kept up steadily and continuou.sly, even though the force is only slight, the contraction gradually gives way, and the liml) regains, or nearly regains, its normal length. 2. F/r7'cn/io/i of Return of Displacement. As soon as the deformity is rectified and broken ends adjusted, the part mast be secured against displacement a second time. The same forces are still acting ; however quiet the patient may lie, it is impossible to avoid involuntary movements, the influence of gravity is always at work, tending to disjjlace one fragment from another, and, even when there is no spasmodic contraction, the muscles cannot help growing shorter and shorter when the rigid framework is once broken. The means used to prevent this depend chiefly upon the degree and nature of the deformity. In fractures of the bones of the face, for example (the lower jaw excepted), the tendency to displacement is so slight that, if the fragments can be restored to their proi)er situation, little more than protection is required ; and where one bone in a series has given way, a rib, for instance, or one of the meta- carpals, a bandage is, generally speaking, sufficient. lOven if there is only a pair, as in the leg, the uninjured one nearly always prevents any serious degree of dis- placement. On the other hand, in fracture of the bones of the extremities, where the muscles are very powerful, and the deformity often exceedingly difficult to rectify, it is rarely possible to keep the broken ends in apposition without the aid of bandages and splints. Bandages. — Roller and triangular bandages are the ones in common use, though many other varieties are employed in s])ecial ca.ses. The former answer best where firm and continued pressure is required, and are made of unbleached calico torn in strips, from four to six yards long, and two to four inches wide, or of flannel, domette, or other loosely woven material, according to the nature of the case and the amount of yielding desired. The latter are most easily made from a square yard of calico cut in two diagonally, and are chiefly of use for retaining dressings in position and as slings for the support of the arm or hand. Splints. — Splints may be made of almost anything, but invariably the simpler they are, the better. Their object is to keep the broken ends in thorough appo- sition and at i)erfect rest; they must, therefore, fit the limb accurately; they must be well padded, so that the pressure is uniform, and does not fall too heavily on the bony prominences or the injured part ; they must, as far as possible, fix the neighboring joints ; they must be arranged so that, at any rate at first, the seat of fracture can be easily examined, and they must not interfere with the circula- tion. Bandages, or webbing straps and buckles, are used to secure them round the limb. No constricting band should ever be applied directly to the limb beneath. The circulation is already impeded by the swelling and extravasation ; the veins are compressed more than the arteries, owing to the thinness of their walls ; blood continues to pour into the i)art, without being able to return, and, if there is an unyielding bandage round the limb, strangulation and gangrene are very likely to follow. For the same reason, when a single, flat splint is used, however well it is padded, it should never be secured to a fractured limb with strapping. Below the seat of injury, there is not the same ol)jection. When the humerus is broken, for example, a bandage may be applied with advantage to the hand and forearm, to jtrevent the passive oedema and swelling that are caused by the obstruc- FRACTURES. 373 tion ; but even then it is advisable to leave the tips of the fingers exposed, so that there may be no doubt as to the condition of the circulation. Ordinary pads are much too hard, especially when made with tow ; they ought to be sufficiently soft to press evenly on all the surface of a limb, and not harshly on any part. Absorbent cotton-wool, folded in sheets, answers best. Movable Splints. — The simplest splints are made from soft, light wood, gen- erally deal, as it can be worked easily. If they are flat, they should be a little wider than the limb, to take off the pressure, but it is more comfortable to have them hollowed out, especially opposite bony projections, and beveled at the edges. Others are of metal, sometimes perforated on account of the weight. They may be trough-shaped, rigid, and provided with hinges to allow a limited range of movement, or made of some flexible material, such as zinc, or woven wire, so as to fit into all the curves of the part. Where strength is not of imijortance, as in the upper limb, and in the case of children, lighter materials are used, pasteboard, gutta-percha, or, what is much better, as it is porous and weighs less, felt steeped in resin, so that it becomes hard when cool. The two last are especially useful, as by warming they can be readily moulded to fit any part, and felt splints can be obtained in sizes, roughly shaped already, so that a very slight degree of modeling is required. Immovable Splinfs. — Other kinds are made by surrounding the limb with a woven material, such as muslin, calico, or flannel, and saturating this with sub- stances which set, or become hard when they dry. Starch-paste was one of the first employed. The limb is enclosed in a thick layer of cotton-wool, over this are placed longitudinal strips of torn pasteboard soaked in starch, so close together that only a small space is left between, and these are bound together with layer after layer of bandages saturated with the paste, as many as may be required. Sometimes, strips of tin are inserted opposite the joints to give additional rigidity. Then, the limb is fixed on a splint until the starch is dry. In this way a firm and even casing is obtained, but the process of hardening is very tedious, even when the temperature is maintained ; the outer layers dry first, and prevent evaporation from those beneath, so that, where special thickness is required, it may be some days before the splint is thoroughly firm. Plaster-of- Paris is free from this objection. The ordinary bandages are made of a coarse, crinoline muslin, and may be kept in a tin case ready for use. The powder is rubbed into their meshes while they are being rolled, and they only re- quire to be placed upright in water for a minute or two, until the bubbles of air have escaped. A flannel bandage is put on first ; cotton-wool does not answer so well, as it is very difficult to keep it sufficiently smooth ; and then the prepared bandages are rolled round the limb, without employing any pressure or making any reverses. Generally speaking, two layers are enough, some loose powder being rubbed in between them, and a little more, with plenty of water, over the surface of the last. Strips of tin may be employed, as wath starch, and, especially for children, the splint may be made waterproof with paraffin. The setting of the plaster can be delayed by adding mucilage or borax to the water, and accelerated to some extent by alum ; but, if there is any doubt as to the freshness of the powder, it should be rebaked. For many purposes, plaster splints can be made more conveniently with absor- bent cotton-wool, as recommended by Gamgee. The limb must be first invested with a sheet of wool, and then strips of the same material, cut to shape, are dipped in plaster and water, the consistence of cream (made by sprinkling the powder into a basin of water, stirring all the while), and fastened round with absorbent bandages. As soon as it is set, these are cut, and the shells lined with the first layer fall apart from the limb. Gum and chalk — powdered chalk rubbed dowai with mucilage, until it is the consistence of thick gruel — answers better in some cases. It does not dry so quickly, it is true, but it is lighter, firmer, less apt to crack and crumble at the edges, and is more elastic. A flannel bandage is applied first, then an ordinary 374 DISEASES AND INJURIES OF SPECIAL STRUCTURES. calico one, into which the mixture is well rubbed ; a second is placed over this the whole is given a final coating, and it is then left to dry. Silicate of soda, of the consistence of syrup, is applied in the same way. but it is better to roll the bandages in the solution, and keep them in it until required. It dries rather more quickly. Tripolith differs very little in its uses from ordinary plaster. It has the ad- vantage of being rather lighter, and of not softening to the same e.xtent if moist- ened after it has once set. It is said, too, to set more rai^idly ; but this depends a great deal upon the amount of water with which it is mixed. t*araffin is rarely employed. The most convenient method is to steep long strips of cotton-wool in the melted fluid, in the same way as with plaster cream, and, when sufficiently cool, to mould them to the limb. They must then be fixed with a bandage and allowed to harden. A very exact cast of the part may be taken in this way, but it is not so rigid as plaster, or gum and chalk, and, unless the jjaraffin is one that only melts at a high temperature, it is liable to become soft from the heat of the body. Care must be taken to keep the limb well raised while these splints are drying, as most of them contract a little during the process, and the extremities must always be left exposed, in order to judge the condition of the circulation. If the fingers or toes look blue, or become cold and numbed, or if the blood does not return immediately when driven from the matrix of a nail by a little pressure, the splint must be slit and removed at once. In recent injuries watchfulness is even more imperative; swelling sometimes .sets in very rapidly, and, if the constric- tion is not relieved, the circulation may be stopped altogether, and strangulation and gangrene be caused in a few hours. After they have been on some time the opposite result generally happens, and the splints become too loose from absorption of the extravasation and wasting of the muscles. [This, indeed, is one of the most serious objections to the immediate applica- tion of immovable splints, for it is obvious that as the swelling subsides, the splint, at first accurately fitting, becomes loose, and free motion between the fragments is alloived, with sometimes very bad results.] Movable V. Ivwiovable. — There is no doubt that splints made in this way are admirably suited to fractures that have already united in part ; but the question is whether it is wi.se to ajjply them while the injury is recent, before the swelling has subsided and the danger of inflammation is past. When well made they fit to per- fection ; they do not require to be readjusted as often as other splints ; movement or displacement is hardly possible ; the uniform pressure checks muscular .spasm and lessens the tendency to swelling and oedema ; the patient is able to get about earlier than he otherwise would ; and the risk of bed-sores and pneumonia is avoided. In short, they answer every requisite of a splint but one ; they do not allow the seat of injury to be inspected ; the whole limb is surrounded so that if anything were to happen gangrene might occur before it was found out, especially as in such cases pain is sometimes conspicuously absent. This danger is lessened by using a thick layer of cotton-wool instead of a flannel bandage, so that the pressure is uniform and elastic ; but it can be prevented entirely by making the splint in such a way that it can be loosened or removed at a moment's notice. It may be either cut down one side and fastened with a lace or bandage, or, better, made in two halves. Modified in this way, a fixed apparatus may be adopted in many cases from the first ; only, of course, care must be used in the selection and they must be well watched. The advantages are immense ; reduction is immediate ; there is no spasmodic contraction ; the extrava.sation is kept within bounds ; blebs cannot form, and a check is placed upon the inflammatory swelling. But the pads must fit accurately and be thick enough ; the pressure must be soft and perfectly uniform ; and the case must be made in at least two pieces, so that it can be removed easily and at once if there is of congestion or any needfear for any readjustment. FRACTURES. 375 In fractures of the femur it does not answer, except in the transverse ones of infants and children. Longitudinal displacement is too easy, and the bony points are not sufficiently marked. These must be left three or four weeks, until there is a certain amount of consolidation and the tendency to shortening is lessened. In the leg, it is more suitable so far as the limb is concerned ; the foot and the knee can be easily secured, while the hip cannot ; the bone is not so thickly covered, and the muscular contraction is more easily controlled ; but the question does not rest on this altogether. The condition of the skin, and the extent to which the soft parts are injured, are more important. If the fracture is comminuted, and some time has passed since the accident, so that already there is a great deal of ex- travasation ; if a big vessel has given way ; if the skin and the subjacent tissues are badly bruised, and it is doubtful if they can live ; or if there is any danger of the fracture becoming compound, — it is better to take the leg entirely out of the patient's control by means of a swing and the ordinary back and side splints. With such an injury, confinement to bed for several weeks is absolutely necessary, whatever appliance the patient wears. It is not necessary to sacrifice the benefits of uniform compression over the whole surface ; the blebs, which often form the starting-point for inflammation, and are never found under splints, but always at their edges, can be prevented equally well by using a sufficient amount of absor- bent cotton-wool in addition to and between the splints ; but these must be arranged so that it is possible to examine the injured part as often as may be wished, without disturbing one of them or relaxing the grasp on the limb. In other cases, when, for example, the bone is broken transversely and there is not much displacement, when only one of a pair has given way, and when the structures around are but little hurt, this plan should be adopted from the first. Treatment of Fractures that are Compound by Indirect Violence. The treatment of open fractures is guided by the nature and extent of the injury inflicted on the surrounding structures. When the skin is merely punc- tured from beneath by the sharp end of a broken bone, no plan is more successful than that advocated by Astley Cooper. If the opening is already closed by a clot, every effort must be made to preserve it ; but if blood is still oozing out or if the wound is unavoidably reopened by the manipulation necessary to reduce the fracture the skin around is to be thoroughly cleansed with antiseptics (corrosive sublimate i in 500, or carbolic acid i in 20), the edges carefully adjusted, iodoform powder dusted in, and then a soft absorbent pad of wood-w^ool or prepared moss laid over it. Sometimes, especially in the leg, the bone is still protruding, tightly grasped by the skin ; and occasionally there is some little difficulty in reducing it, even when the patient is under an anaesthetic. The opening may then be slightly enlarged and a further attempt made ; if this is unsuccessful, particularly if it is a long, pointed spine that is likely to give trouble afterward, or if the periosteum has been stripped back from it, it is better to cut it off at once with bone forceps. The w^ound should then be thoroughly washed out and treated in the same way. Even if there is comminution, or if the fracture extends into a neighboring joint, this plan in actual practice gives results that have not been surpassed. In all compound fractures, except in the case of the smallest bones, the patient should be confined to bed until it can be seen what course events are likely to take. If the wound is only a puncture, a fixed apparatus may be applied at once ; but the splint must be arranged so that the dressing can be easily removed. Either a window must be cut, or, what is better, an opening left while the splint is being applied ; and to prevent the tissues becoming oedematous and projecting outward through this, a small but firm pad should be fitted into it. If the temperature rises, the dressing must be removed at once. In all other cases interrupted splints are used, the pads being covered with oiled silk, and so arranged as to interfere with drainage as little as possible. Fixed 376 DISEASES AND INJURIES OF SPECIAL STRUCTURES. apparatus should be reserved until the bones are beginninj,^ to unite and any wound that is i)resent has healed. TrEATMKNT of FRACrURES I HAT ARE COMPOL'ND HY DlRECT \'l()LEXCE. In fractures by direct violence where the soft parts are crushed, the bone per- haps comminuted, and the skin torn and lacerated, the question is different. The first thing to decide is whether the injury is consistent with life. In many cases, such as railway accidents in which both thighs have been crushed, the shock is so great that the patient never rallies, and any attempt at operating merely precipitates the end ; or other injuries of an even more serious description are inflicted at the same time. In such as these, all that can be done is to prevent hemorrhage (even capillary oozing is serious) and check the tendency to putrefac- tion, which is particularly jjrone to occur in the region of the bone. Arteries rarely bleed under these conditions, but if they do, or the. veins, they should be tied or clamped ; then the wound must be thoroughly washed out with a solution of corrosive sublimate as hot as can be borne, and wrapped in an absorbent dress- ing. Loose clots may be allowed to float away ; others should be left untouched. Hemorrhage from the bone, which is often very persistent, must be stopped by elevation or pressure. Meanwhile, every effort must be made to tide the patient over the shock ; the blankets must be warmed, hot bottles placed all round the body, the limbs ban- daged, and stimulants, brandy and ammonia, administered freely, or even injected under the skin. If reaction definitely sets in, and the temperature begins to rise, it becomes a question whether amputation should be performed at once, or an attempt made to save the limb. I. Aviputaiion. {a) The Patient. — The age and constitution of the patient are the first things to be considered. In children much more may be attempted than in adults ; their tissues heal more readily, and they have no anxieties ; but in sound old age the power of recovery is often surprisingly good. The condition of the viscera, par- ticularly of the kidneys, is of greater importance. Sloughing and diffuse inflam- mation are almost sure to occur, if the urine is albuminous or the specific gravity persistently low. The vitality of the tissues, if they are crushed or bruised, is too feeble to resist, and the only chance of life lies in the complete removal of all the damaged part. Even when no change in the secreting power of the kidnevs can be directly proved, it is distinctly unfavorable if the aspect of the patient is such as to suggest over-indulgence either in food or drink. ij)) The Injury. — The locality of the injury and the complications that are present, as a rule, are final. The Upper Extremity. — In the hand and forearm the jjart must be almost disor- ganized to justify amputation. The wrist joint may be opened, the carpal bones crushed, and the hand cut to pieces, without such an extreme measure being neces- sary, if only a single movable finger is likely to be left. I have known such injuries as this treated with corrosive sublimate baths for an hour each day recover without a single febrile symptom. If, however, the large nerve-trunks are injured beyond repair, or if the skin is torn off round the whole circumference for even a short distance, the limb never recovers so as to be of any use. In the former case it remains cold and helpless, often ulcerated or the seat of severe pain ; in the latter, it swells up to such a size from solid cedema and becomes so hard and stift' that it is merely a useless log. The extent of the injury to the soft parts is equally decisive in the case of the arm or elbow. The artery may be wounded, the joint laid open, and the ends of the bone badly comminuted, and yet the vessel may be tied, the fragments of bone removed, and an informal kind of excision performed w^ith an excellent result, so far as utility is concerned, if only the surrounding structures are not too FRACTURES. zii badly bruised. Unhajipily, such accidents generally occur from direct violence, and then the skin is stripped up, the muscles are torn and bruised, and everything is crushed to such an extent that no alternative is possible. The Lower Extremity. — Amputation is more fre(]uently required in compound fractures of the lower limb. The circulation is not .so active as it is in the ujjper, repair is not carried on with the .same degree of energy, there is a greater risk of gangrene and of diffuse inflammation, the joints are larger and more complex, and the need for stability is much greater. In the ca.se of the foot, for example, everything must be sacrificed to gain a firm support. In the hand it is a rule never to remove anything that can by any possibility recover ; a fragment of a thumb is infinitely more useful than an artifi- cial one ; in the foot free removal is often the better i)lan. Yet even here much may be done sometimes by judicious conservatism. In a case under my care, in which the contents of a gun had passed completely through the foot, so that an opening was left into which three fingers could have been placed, recovery was so perfect that the patient could walk three or four miles without inconvenience six months after the accident. The bases of the first two metatarsal bones with the corresponding portions of the internal and middle cuneiform were blown com- pletely away ; but the external plantar artery in all probability remained intact and the tread of the sole was uninjured. When there is a compound fracture of the leg, the question is generally decided by the condition of the soft parts, especially the skin and the blood- vessels. The ankle joint maybe opened and the bones comminuted, but so long as the circulation is good, and the skin is not destroyed, a very useful limb may be obtained by resetting the broken ends and removing splinters that are loosened too much to live. Similar injuries in the case of the knee joint are much more serious ; compound fractures of the patella only may be treated in this way with a fair prospect of success, even though the cavity of the joint is widely opened ; but when the lower end of the femur or the upper end of the tibia is badly com- minuted, the injury is, generally speaking, too severe. Even here, however, primary resection has been performed with success in the case of gunshot wounds. Compound fractures of the femur are still more serious. If they are caused by direct violence the injury is almost hopeless so far as the limb is concerned. Very often it is much worse than at first sight it appears to be ; the muscles are torn and crushed so that they protrude from their sheaths ; the deep planes of areolar tissue are laid open, and the skin stripped up from the fascia beneath and bruised beyond recovery for a distance above the seat of injury almost equal to the diameter of the part. When the injury involves the upper part of the thigh or the hip joint, the shock is nearly always fatal ; and even if the patient rallies it is very questionable whether primary amputation in the upper third or disarticulation should be per- formed. It is true that there are a few successful cases on record ; but certainly in gunshot wounds, if the head of the bone is shattered, better results are obtained by removing the fragments, securing perfect drainage, and amputating later, when the period of acute suppuration is past. Probably in the majority of those in- stances in which the patient does rally sufficiently, the best chance lies in merely removing the part that is injured (for which Paquelin's cautery is of excellent service), leaving the wound open, and by means of antiseptics and drainage, limiting the amount of septic ab.sorption as much as possible. Even in other parts of the body this plan may sometimes be followed with advantage ; it is true there is usually a large amount of suppuration, but the shock is not nearly so great as when a formal amputation is performed, and owing to the nature of the wound the amount of septic absorption is much less than might be expected. 37S DISEASES AND INJURIES OF SPECIAI STRUCTURES. • 2. Preservation. If it is determinetl to try and save the part the fracture must be reduced and the same general princij^les of treatment followed, interrupted splints and jiads covered with oiled silk being used. The presence of a wound, however, and of more or less serious injury to the other structures in the limb — muscles, arteries, cellular tissue, etc. — necessitates something more. Hemorrhage must be checked at once. The limb must be raised, all con- striction removed, the main artery, if necessary, placed under control, all loose clots washed away, and any bleeding i)oint secured, (leneral oozing is checked by washing out the wound with an anti.septic solution (tincture of iodine or corro- sive sul)limate) as hot as can be borne, and ajjplying gentle pressure afterward. Splinters that are quite loose and detached should be removed, and if the ends of the bone cannot be readjusted, especially if they are stripped of their perios- teum, they may be resected. Large fragments that are firmly adherent should be left. An exception may be made in the case of gunshot wounds caused by pro- jectiles of high velocity ; in these it has recently been shown that, if a commence- ment is once made, it is very difficult to stop ; removing one fragment seems to loosen all the rest, so that if the drainage is good it is better to leave them until a certain amount of consolidation has taken place. If much is removed care must be taken to bring the broken ends well together, or union may fail. The looiind must be thoroughly cleansed, so that no poisonous material can form, and thoroughly drained, so that if it does it may escape externally, and not be absorbed. The principles on which this is to be done are easily laid down ; the details vary naturally with each case. The skin for some distance around must be cleansed with turpentine and a strong solution (i in 500) of corrosive sublimate. All dirt must be picked out; if it is so much ground in it that it is impossible, the tissue should be cut away, unless it is skin. The dirt is always on the outside of this, and it can be rendered inert without destroying the whole thickness and endangering cicatrization. If the wound is foul, or such that it cannot be sealed at once, it must be cleared of all foreign matter and blood-clot, and washed out with an antisei)tic, using a rubber drainage-tulie or a catheter to conduct the fluid into all the recesses. At the same time, care must be taken to make the opening sufficiently free, and if necessary to make others, so that the fluid is not retained and absorbed. Immedi- ately after an injury of this kind, when the planes of fascia are torn across at different levels, and all the lymphatic spaces are gaping widely, a poisonous amount can easily get into the circulation, and either cause local sloughing or lead to constitutional symptoms. Tincture of iodine (i in 80), carbolic acid (i in 40), or corrosive sublimate (i in Tooo) are the most used : the last is the most effectual, but at the same time the most dangerous if retained. If there is any capillary oozing they should be injected at a temperature of 120° to 140° F., so as to leave the wound thoroughly dry ; it is of great importance to reduce the amount of discharge as much as possible, and keep the cavity free from any putrescible matter. With this object Gamgee recommended ecjual i)arts of spirit and water, or a saturated solution of borax with about one-eighth of its l)ulk of glycerine, in preference to the watery solution of any antisejitic. After this iodoform may be dusted lightly over the surface. It is true that grave doubt has been thrown on its merits as a germicide, and that in some in- stances, when too much has been used or the patient has been i)eculiarly susce])tible, serious symptoms have followed its employment, but there can be no question that in some way it possesses the power of limiting the amount of exudation and dis- couraging decomposition. As soon as everything is .satisfactory, the deeper parts must be brought into the best apposition jiossible, buried sutures of catgut being used, if necessary, both in the bones themselves and in the dense sheets of fascia. If the wound were a FRACTURES. 379 simple incised one this would be enough, l)ut it is always irregular in shape; the tissues are badly bruised and crushed, not cut, and the necessary cleansing and the antiseptics injure them still more. As a result, a large amount of fluid is sure to collect ; absori)tion, even when aided by pressure, cannot keep pace with exudation, and unless free exit is i)rovided tension and inflammation must follow. If there is a dependent opening, })erfectly straight and wide, it may be left, with an absorbent dressing properly arranged (that is to say, a piece of protective first, as large as the wound), and all the fluid will be sucked out ; but such a con- dition is rare in a compound fracture. Almost always the internal wound is very large, and tlie external very small, and at the top, or at least very rarely at the bottom. Under these circumstances counter-openings must l)e made wherever there is the least indication (and advantage may be taken of these to get rid of as much of the extrava.sated blood as possible), drainage-tubes of sufficient size must be inserted, and the edges of the skin wound must be left widely open, sutures only being used to retain torn flaps in position. All the points at which fluid can exude should be covered with waterproof or protective to prevent the dressing sticking to the surface and becoming clogged. The more absorbent the material used to envelop the part the better. Wood-wool and prepared moss are some of the best ; Lister's gauze, owing, in a measure, to the resinous substance with which it is impregnated, takes up too little, and absorbent cotton-wool by itself is apt to cake if there is much discharge. Decom- position of the exudation can hardly take place in the dressings, owing to its con- centration, and it mayj^e rendered impossible by having the material prepared with some non-volatile antiseptic. If this has been successful the dressing may be left untouched for two or three weeks. Drainage-tubes, however, cannot remain so long ; as a rule, they must be removed by the third day, as they are very liable to become plugged with coagula and rendered useless. After this the longer the second dressing is postponed the better. Every time the fracture is touched it gives pain, causes irritation, and delays repair. The wound, if the treatment is carried out thor- oughly, and the patient's tissues are fairly sound, fills up from the bottom, and when at length it is exposed, it is either already skinned over, or else is level with the surrounding surface, perfectly smooth, pale, and, perhaps, just moistened by a trace of pus. Inflammation, the result of continued irritation (whether by tension, want of rest, foreign substance, or decomposition), has been successfully prevented. In many cases, especially where the foot and hand are concerned, or where a joint is involved, or where from any other cause the prospect of limiting the amount of exudation is doubtful, the whole part may be immersed in a bath. Sometimes, when a hand is crushed, it is impossible to tell what will live and what will not ; more than is necessary may be cut away, or, on the other hand, some part that is already dead and beginning to slough may be left. Such cases may be placed in a warm bath of corrosive sublimate and left with perfect safety, always provided the whole cavity of the wound is laid open. If this is not done, putrefaction may still go on in the interior. I have known this happen in a com- pound dislocation of the wrist ; a large cavity filled with extravasated blood was overlooked under the deep palmar fascia, and putrefaction and suppuration con- tinued unchecked, although the hand was kept in a continuous bath ; the fluid never penetrated into it. If the bath is continuous, one part in ten thousand is sufficient ; if it is only used for an hour or two in the course of the day, it should be at least one in a thousand ; and a few drops of hydrochloric acid or ammonium chloride should be added. Careful watch must, of course, be kept upon the patient's teeth, and if there is any diarrhrea, the corrosive sublimate should be stopped at once and boracic acid substituted ; but though I have treated many cases in this way, I have never known any serious consequence of this kind result. The limb should be 3So DISEASES AND INJURIES OF SPECIAL STRUCTURES. fastened lightly on a splint, the wound left widely open, and, if necessary, coun- ter-openings freely made. There is no decomposition ; the dead tissues absorb and retain so much of the antiseptic that they do not become putrid ; the sloughs are, it is true, somewhat slow in sejjarating, but when granulations have once formed, recovery is rapid, and the only tissue lost is that which has been killed by injury ; none is destroyed by inflanuiiation. Sometimes, however, in spite of all precauti(jns, or because they are adopted too late, the temperature begins to rise, the patient becomes feverish and restless; redness shows itself round the wound, and the limb becomes hot, swollen, and tense. Inflammation has set in. The treatment of this depends upon the cause. If it is really due to a broken- down constitution ; if, as sometimes happens, even with simple fractures, the tissues are so badly nourished in consequence of diabetes, renal disease, chronic alcohol- ism, cold, exposure, and other causes acting together, that the least injury makes them slough, the prognosis is exceedingly grave ; operation is hopeless ; the dress- ing must be taken off, the limb raised and kept at an even temperature, all con- striction removed, decomposition prevented as far as possible, and the jjatient's strength husbanded in every way, in the hope that the sloughing may cease and a line of demarcation form. Too often it becomes a case of spreading traumatic gangrene ; the temperature falls, the face becomes dusky, and the patient sinks into a semi-comatose condition, which proves fatal in the course of forty-eight hours. If, on the other hand, the inflammation is the result of local causes, there is some hope of being able to save the limb. Free exit must be provided for all discharges, the wound must be thoroughly washed out again, incisions made wherever the skin is tense and cedematous, especially on the inner side, and where the tissues are saturated with extravasated blood, and large drainage-tubes inserted, as the secretion is sure to be profuse. It is no use waiting for the boggy sensation of impending suppuration. If the inflammation is acute, the continuous application of cold, though it is not so comfortable at first, is better than warmth. An ice-bag should be laid along the course of the main artery, and a number of drip pots containing spirit and lead lotion arranged over the injured part, so that there may be constant evaporation from the surface. Any degree of cold that is desired may be obtained in this way ; the vessels become so constricted and the amount of blood flowing through the limb so reduced that the exudation comes to an end and the inflammation cannot spread. Care, indeed, must be taken not to carry the proceeding too far ; I have known a limb cooled down to such a degree that there was some fear of gangrene. Meanwhile, the constitutional treatment requires no less attention. It very rarely happens that the patients in whom this comj^lication occurs arc such as would stand depletion or blood-letting. Much more freciuently they are utterly broken- down in health, often on the verge of delirium, and quite incapable of taking the requisite amount of nourishment. Stimulants generally have to be administered freely — brandy in ordinary cases, bottled stout if there is any sign of delirium tremens ; pain and sleeplessness must be controlled by sedatives ; opium is by far the most useful, but great care must be taken in its administration, as many of these patients are already the subjects of advanced renal disease ; the bowels must be kei)t open, and quinine given freely, if the temperature is high or if rigors set in. ICverything depends upon maintaining the patient's strength until further absorption of the poison can be checked by energetic local treatment. Secondary Amputation. — If it can possibly be avoided, amputation should not be performed at this stage. If the attempt to save the limb has failed, and the time before the inflammation commenced has been lost, it is best, if it can be done, to wait until the fall of the temperature in the morning shows that the tissues are getting the better of the contest, and are forming a line of demarcation. Then the operation is very successful, and it often happens that a patient who appears I FRACTURE OF BONES OF THE FACE. 38 1 to be dying from exhaustion and fever sleeps well the following night, and re- covers from that moment. Sometimes, however, it must l)e done at once ; it gives the only chance of saving a life threatened l)y absorption from an inflamed and partly gangrenous limb. The condition may appear to be desperate, but the free removal of the whole source of the poison is the only thing left, and occa- sionally, even when the flaj^s are sodden and oedematous, and the pulse too tpiick to be counted, it meets with surprising success. Compound Fractures into Joint.s. The treatment must be carried out on exactly the same plan, only it must be remembered that now, no matter how small the wound of the skin may be, its real extent corresponds to the size of the synovial membrane. If there is only a punc- ture (such as is sometimes i)roduced by a splinter of bone), and the opening does not appear direct, or if it is merely a clean incision, an attempt may be made to close the wound, as already described, and prevent inflammation by cold, eleva- tion, rest, and every other means that may be available ; but careful watch must be kept upon the condition of the joint and the temperature of the patient, so that suppuration may not set in unawares. If it does, the only hope lies in free incision and thorough drainage. In all other cases, especially where the force is direct, and the skin perhaps torn or ground in with dirt, it is better to enlarge the wound at once, wash out the joint thoroughly with corrosive sublimate solution (or immerse the part bodily in a bath), and make counter-openings for drainage wherever there is a chance of any pocket forming. The question as to the ad- visability of excision or amputation must be determined in each case, partly by the constitution of the patient, partly by the amount of injury ; if the bone is extensively comminuted, but the skin fairly sound, and the circulation not seriously interfered with, primary excision may be attended with the greatest success, even in the largest joints ; under other circumstances (except in the case of the hip) amputation affords the only chance. Other complications that occur in the course of treatment of fractures must be dealt with by themselves. Injuries to important viscera, such as the lungs, require special consideration ; cellulitis, erysipelas, pyaemia, and other forms of diffuse inflammation are described elsewhere. Abscesses may have to be opened and sequestra removed years after the original accident ; passive motion and the breaking down of adhesions are often required before it is possible to make use of the joints or tendons ; ma.ssage and galvanism may be needed to restore strength to the muscles ; friction and bandaging may be necessary to relieve the obstinate oedema that sometimes follows, and to prevent ulceration ; and even amputation may be required after all ; either the limb is useless and the seat of constant pain, or there is such an amount of suppuration that the patient is in danger of sinking from hectic and exhaustion. FRACTURE OF THE BOXES OF THE FACE. The Nasal Bones. The nasal bones often suffer from direct violence : the fracture may be com- pound, either externally, internally, or both, or it may be comminuted, and the injury may be limited to the bones themselves, or the septum may be bent or crushed in, or the other bones that surround the nasal cavities may be involved as well. I have known the greater part of the cribriform plate of the ethmoid com- minuted and removed in splinters through an opening in the nose, so that the dura mater was plainly visible. Hemorrhage is always profuse ; emphysema is occasionally present from the escape of air into the tissues, and deformity and swelling are generally very con- siderable. No pains should be spared to effect reduction as early as possible. 382 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Manipulation is exceed inj^lv paiiiful, so that, if the displacement is at all extensive, it is advisable to give an anivsthetic. The bleeding, which is sure to be profuse, must be checked afterward by injecting ice-cold water, or by the application of an ice-bag. Elevation from within with a steel director, or a jjair of dressing- forceps, may be tried first, but they are not of much service in really bad cases. In some instances it is necessary to gras[) the fragments with smooth-bladed forceps, bent so as not to pinch the soft tissues near the nostril, and twist them into posi- tion. Later on a great deal may be done to correct any deformity that is left by means of pressure. A spring truss may be used, especially at night, outside the face, or, as Krichsen suggests, india-rubber bags may be introduced into the nostril and inflated. Suppuration is not uncommon, but it is rarely .serious; ozjena and necrosis, however, occasionally occur, and when the fracture extends on to the face, so as to involve the nasal process of the superior maxilla, stricture of the lachrymal duct generally follows. Fracture of the Superior Maxilla. The anterior wall of the antrum may be driven in by a blow with the fist, or from a cricket-ball, loosening the teeth and leaving a serious degree of disfigure- ment. Hemorrhage is always profuse, and surgical emphysema may occur, but rarely to any extent. Or the whole bone may l)e driven in and crushed, and the injury may extend to the other bones of the face, and even to the base of the skull. The deformity in these cases is very often extreme, and in many of them very little can be done to reduce it. The prognosis must always be guarded, as it is not uncommon for serious injuries of this character to be associated with con- cussion of the brain and fracture of the bones of the skull. Fracture of the Malar Bone. The zygoma is occasionally broken by direct violence, and it has given way from within. Unless it is driven so far inward as to interfere with the action of the temporal muscle or the lower jaw, treatment is scarcely necessary. Fracture of the Lower Jaw. These may be the result of direct or indirect violence. Blows with the fist and kicks are the most common cause, but occasionally they are due to lateral compression. Fracture near the condyles is produced either by a fall upon the chin, or by a blow on the side of the face ; in the former case there may be at the same time injury to the external auditory meatus, or to the base of the skull ; in the latter it is usually associated with a fi.ssure through the opposite ramus. Seat of hijury. — The most fre(|uent seat of injury is immediately in front of the mental foramen close to the canine tooth, owing to the way in which the bone is hollowed out to form the socket for its fang; but suppuration may take i)laceat or near the symphysis, and the angle, the neck of the condyle, and even the coro- noid process have been known to give way occasionally. Multiple and commi- nuted fractures are common, and with few exceptions they are compound into the mouth. Teeth are often loo.sened and sometimes detached completely. Symptoms. — Displaccmnit. — The nature and degree of the displacement depend upon the seat of injury, the ol)li "~~ jaw by fastening to it a strip of pasteboard, poroplastic felt, or tin covered over with ,-'"'-., wash-leather. As it is intended to prevent '~'^" '^"^ — "^ rather than to exert pressure, it should be a f.g. ..4.-Gutta-percha Spiint for Lower ja^v. little wider than the part of the jaw to which it is fitted, and the ends should be bent up on either side. Gutta-percha is cum- bersome, uncomfortable from retaining perspiration, and encourages suppuration, especially if the tissues are bruised (Fig. 114). Interdental Splints. — Interdental splints are occasionally required when the teeth are absolutely perfect, in order that the patient may be fed ; the space that exists behind the last molar is rarely sufficient for the purpose, and its position is exceedingly inconvenient. In many cases they may be used with great advantage to retain the fragments in position. The simplest, but one that is very efficient, is made of gutta-percha moulded directly on to the teeth. Two wedge-shaped pieces are used, one for each side, 3S4 n/SEASES AND JXJi'RlES OE SPECIAL STRUCTURES. and one of them must t)e long enough to reach from the last molar to Ix^vond the fracture. The giitta-iKTcha is merely softened, introduced into the mouth, and the teeth of both jaws pressed down into it, while the outer and inner surfaces are smoothed down and moulded as much as possible by the aid of the fingers. A certain amount of shaping is required afterward ; redundant portions have to be cut away, and angles rounded off to avoid pressure, but an excellent splint, hold- ing each fragment firmly on to the upper jaw, is obtained in this way, and abun- dant room left either at the front or on one of the sides for feeding purposes. The quieter the part can be kept, the cpiicker union takes place ; talking must be prevented as far as possible, no attempt at mastication may be allowed until the fragments are fairly well united, that is to say, after four or five weeks. All food must be either fluid or semi-fluid, as even movements of the tongue are injurious ; and, to avoid the accumulation of decomposing particles, the mouth must be washed out frequently with a weak carbolic or other antiseptic solution, and the teeth cleansed at least once a day with some soft linen. In a large number of cases, however, owing either to the obliquity of the broken surface or the comminution of the fragments, a more complicated apparatus is required. If the teeth are fairly good and numerous, Hammond's wire splint or an interdental plate of vulcanite is the most satisfactory. In either case it is essential to take a wax mould of the alveolar arch, and from this form a plaster cast. The easiest way is to take each fragment separately, and combine the casts together, so as to get a fair representation of the arch before the accident ; but sometimes a mould must be taken of the whole at once, and the cast sawn in two and readjusted afterward. Whichever plan is adopted, the splint must be formed upon the cast, and must be made to fit it in every detail. Hammond's consists of a stout piece of wire bent into the shape of a horseshoe. The ends are soldered together, and it is twisted and turned un- til it fits perfectly into every irregularity of the teeth, both on the outside and the inside of the arch. When this framework is allowed to settle down well upon the necks of the teeth, and is secured here and there at convenient distances, with finer wires passing from one bar of the Fig. 113. — Wire Splint for Fracture of Lower Jaw. i- ^ ^ ^l ^u i_ ,. ^u ^ ..l •' splint to the other between the teeth, movement is scarcely possible (Fig. 115). Vulcanite splints are made to fit upon the crowns so that the teeth sink into deep sockets and interlacing wires are not required ; they are equally secure, but the rubber from which they are made requires special skill during the process of manufacture, and they are more cumbersome. Moreover, they cannot so well be trusted without a retaining band outside the face, and particles of food are more likely to collect beneath them and become offensive from decomposition. The same objection holds good with regard to metal plates, which have been employed in a few instances with considerable success. Wiring. — It must be admitted that in some obstinate cases there is a great temptation to try and secure the fragments by fastening the teeth together with wire or silk, but it rarely succeeds. The process is not nearly so simple as it appears to be ; it is very difficult to get the wire sufficiently tight, and even when it is it has very little real hold upon the fragments. But the most serious objec- tion is that it tends to irritate the gums and to loosen and even cut into the substance of the teeth. The plan advocated by Thomas is the least objectionable. A hole is drilled through the alveolar margin of the jaw on one side of the fracture and the ends of a loop of wire passed through this in opposite directions, so that it embraces a tooth belonging to the other fragment. The FRACTURE OF THE CLAVICLE. 385 ^r Fic. 116 — fracture of Lower Jaw Wired, after Thomas's Plan. ends are not fastened toj^ether, but merely coiled up on a twister so that they can he tightened as required (Fig. 116). When, however, measures of this kind are necessary it seems better at once to drill and wire the fragments themselves. I have adoptctl this plan on several occa- sions in which the median part carrying the incisor teeth was com- l)letely separated from the rest. There is no difficulty about the operation, especially with the American dentist drill ; the wires can be passed through and either twisted as Thomas suggests or tied and clamped with shot ; and I should not hesitate to adopt it when, from obliquity of the frag- ments or other causes, it was difficult to retain the ends in position by ordinary measures. Combined Inte7'nal and External Splints. — Many attempts have been made to fix the broken portions between an interdental plate made of ivory, metal, or vulcanite, and a splint below the jaw. Lonsdale's clamp is made upon this plan, with or without side-pieces to fit along the cheeks, the two splints being connected together by means of a screw outside the mouth. In other cases stout metal bars are fastened to the interdental plate and then curved round the lips at the angles of the mouth and fastened to the under piece. But though these may be of .service in exceptional instances, chiefly when the fracture is near the symphysis, it rarely happens that the tissues beneath the jaw remain in a condition fit to stand much pressure during the critical period of the treatment. Nearly always they are too tender and too much swollen, and they very soon become inflamed. Moreover, all these appliances have the serious disadvantage of projecting outside the mouth, so that they are very liable to accidental displacement, especially during sleep. When the fracture is situated far back the difficulty of retaining accurate adjustment is greater still, and many of these cases tax the ingenuity of the sur- geon to the utmost. It has even been necessary to drill and wire together opposite teeth in the upper and lower jaws. Fortunately, however, these cases are not often met with, and it is not uncommon for fractures which at first look perfectly hopeless, so far as adjustment is concerned, to improve gradually as the callus grows firmer, until the position is, comparatively speaking, good. Complete failure of union is very rare, but it has been known to occur from necrosis and from accidental displacement of teeth. If a false joint is formed and from its position the jaw is disabled, the ends must be exposed, thoroughly re-freshed, and wired together. Complications during treatment are of common occurrence. The health of the patient sometimes suffers considerably, especially when there is much discharge into the mouth. Abscesses form beneath the jaw and have to be opened and drained. Fragments of bone necrose and must be removed, and the same thing often happens to the teeth when they have been loosened at the time of the accident. One or two cases of permanent paralysis of the inferior dental nerve have been recorded. FRACTURE OF THE CL.WICLE. Cause. — These are the commonest of all fractures, and more than half take place in children under six years old. Occasionally they are due to direct violence, and then any part of the bone gives way, and the fracture may be transverse, oblique, comminuted, or even compound. Much more often the force is indirect 386 DISEASES AND INJURES OF SPECIAL STRUCTURES. (from a fall out of bed, for example), and the line of separation either runs through the middle of the bone, as in children, or just external to it, where the two curves meet, as in adults. In a few instances the clavicle has been broken, even in men who to all appearar.ce were jjerfectly healthy, by the sudden arrest of the momentum of the arm ; and sometimes it has given way genuinely from muscular contraction, probably of the pectoralis major and deltoid. The scapula and the upper extremity are held off from the thorax by the clavicle, as by an outrigger, so that the arm may have a wider range of movement and the muscles better leverage ; but, as a result, the whole force of any shock that falls upon the point of the shoulder or upon the outstretched arm is borne by this bone alone ; if it is soft, it bends ; if firm and hard, as in adults, it breaks at the point of least resistance midway between the two fixed points. Were it not for the peculiarity of its shape and its great elasticity, fractures would be even more common than they are. Fractures in other parts of the bone are rare, unless they are caused by blows or other direct violence ; but they may take jjlace either at the sternal end, in the region of the coraco-clavicular ligaments, or outside them, and I have seen one case in which, so far as could be ascertained at the time, the epiphysis had been detached. In infants many of the cases are merely partial or greenstick fractures ; in adults they are usually complete and oblicjue from above downward and inward. Comijlications are very rare, but occasionally the skin gives way, generally from sloughing over a projecting fragment of bone ; and a few cxses are on record in which the subclavian vein or artery, the brachial plexus, the pleura, and even the first rib have been injured at the same time. Displacement. — In greenstick fractures there is merely an elevation about the middle of the bone, projecting upward and backward. In complete ones the displacement is in the same direction, but more extensive. The inner fragment held by the rhomboid ligament and the costo-coracoid membrane on the one side, and the sterno-mastoid muscle on the other, is rarely much affected, but sometimes the outer end is raised so that it projects beneath the skin. This may be due to the pressure of the outer fragment on its under surface ; the rhomboid ligament varies, however, very much in strength, and I have known it replaced by an arthrodial joint with a small .separate synovial membrane. The outer fragment, on the other hand, is drawn inward by the action of the muscles passing from the thorax to the arm, so that there is a distinct amount of shortening, one fragment slipping beneath the other; it is rotated forward at its outer end by the serratus magnus and the pectorals until it forms an angle with the true axis of the bone, and it is depressed to some extent by the weight of the arm. Of these three, the shortening is the most serious and the most difficult to rectify. Depression is often more apparent than real. Owing to the shape of the thorax, the shoulder in the living subject, as soon as it has lost the sole bony supi)ort, sinks in toward the middle line of the body, and its outline becomes more sloping, so that it gives the appearance of depression ; but though this is often real and very considerable, in ^ / ^ _-"^_ ~^''^*>y MJ many ca.ses it is almost, if not altogether, absent. v^r--^»^^>^_^i^ jn fractures through other parts of the "^ '■'fLy'''''^ ywi bone the degree and nature of the deformity ' are very variable. When it is close to the sternal end the fracture is usually transverse, and the disi)lacement only concerns the outer fragment ; if it lies in the region of the coraco- clavicular ligaments there may be none at all. Fig. 117. — Displacement in Fracture of the i -i ■ r .i • i i . • i ^i • i i _ Clavicle. while if the acromial end outside them is broken off, the small portion that is detached may be rotated to such an extent as to be almost at right angles to the rest. FRACTURE OF THE CLAVICLE. 387 Symptoms. — The ordinary sij^ns of fracture are usually all present, and well marked. The patient stands with his head inclined toward the injured side and supports the elbow with the other hand. 'I'he outline of the shoulder is altered ; it is more sloi)ing, and the point of it is brought much nearer the middle line of the body. The .projection can often be seen at once, or it may be necessary to run the fingers along the bone. Crepitus is present in all but greenstick fractures, and may be elicited by drawing the shoulders backward so that one fragment rubs against the other ; but, as a rule, it is scarcely worth while giving the patient so much pain. The same may be said of undue mobility. Fractures through the coraco- clavicular ligaments are an exception, as in them the only signs are localized ten- derness and a slight degree of crepitus ol)tained by direct pressure. The loss of power, not only in greenstick fractures, but even when the bone is broken com- pletely in two, is by no means absolute. It is not uncommon to find that the patient is able to place his hand upon the back of his head, if he is sufficiently resolute to stand the pain. Treatment. — /// Greenstick Fractures. — There is little or no trouble in the case of the greenstick fractures that are so common in children. The deformity must be rectified as far as possible. It rarely happens that the shape of the bone can be exactly restored ; direct pressure is the only means that can be applied, and if the jagged edges of the broken part are so far displaced that they fit against instead of between each other, this is of little service. Generally, however, the angle is merely an exaggeration of the normal curve, and it gradually becomes smoothed down as the child grows older. All that is needed is to confine the arm to the side with a bandage under the clothes, taking care to have the skin tho- ?i,,, roughly dried and dusted to avoid ,^'!:' v excoriations. In every case of frac- / ^a'^ '"■ tured clavicle it is as well to have the ^^^f^^. "■/— , edges of the bandages sewn together ^■^'''"^'"^ h \ \'- \ in two or three vertical lines, to avoid /' // \ H V displacement; strapping should be / \. / | \% si)aringly used in the case of children. / V./ |j t ' Union occurs very soon, and all I ..f ' \ bandages may, as a rule, be left off | 'i./. js at the end often days or a fortnight, |s i'^^A^. ' though it is as well to keep the arm 1^ / !^-^"' ' ' inside the clothes for a few days 'Mi/ longer. yy, --r) In fractures without displace- \ |. - V , , .' jnent nothing more is required than \ ^''<:'' to support the weight of the elbow \ ._ ;; ^,-1 and forearm, and protect the shoulder \ ^ ■*;-•. -^ from any accidental movement. The \ simplest apparatus during the day- \ time is the triangular bandage used \ as a sling. This is made from half \ a square yard (cut diagonally) of \ unbleached calico, or any other ma- \ / terial that is sufficiently strong and \ / unyielding, and is applied so that \ / the two acute angles are tied together \ / round the back of the neck, while \ / the forearm rests in the sling thus '' made. The long side of the triangle ^'^- "^.-Xhe TriangulY Bandage Arranged as a Sling. The o <=' dotted line represents the position before the end is brought corresponds to the hand; the right over the shoulder of the injured side. angle to the elbow, and the layer that comes up in front of the forearm passes over the neck on the injured side. 388 DISEASES AND INJURIES OE SPECIAL STRUCTURES. 'riiis leaves tlie right angle projecting between the arm and the body, and the flap so formed is brought round the elbow and jjinned on to the front layer, so as to inclutle the joint in a kind of cap (Fig. ii8). At night the elbow is secured to the side with a bandage, ami the patient is directed to lie on his back, with only a small j)illow beneath the head. /// Eraitiircs with Displacement. — In adults, if there is the ordinary displace- ment, shortening is the rule, not the excei)tion, no matter what appliance is used. Fortunately it does not interfere with the utility or strength of the arm ; but often it is very unsightly. The method that gives the best result is to keej) the patient permanently on his back, in bed, on a well-made hair mattress, with only a small jmIIow beneath the head ; and where, as in ladies, it is essential to avoid deformity, this is the only plan. Even when the position is too irksome to be kejjt u]) with- out intermission for three weeks, the requisite length of time, it is of great .service if it can be managed for the first i^w days. All that is necessary is a bandage to confine the forearm to the front wall of the thorax, and a cushion to support the elbow. The angle and vertebral border of the scapula are fixed by the pressure of the body, the point of the shoulder is held back, and the weight of the part, instead of causing downward displacement, assists. All the muscles are relaxed ; the amount of shortening is reduced to a minimum, especially if the forearm is l)rought across the chest ; and if the position can only be kejJt up, union is almost perfect. The number of appliances that have been suggested and tried in fractures of the clavicle is sufficient proof that no one of them is satisfactory ; and complicated ones, even when they can be obtained in time, and have not to be made to fit the [)atient, are no whit better than, if they are as good as, the simplest. It is impos- sible to depress the inner fragment if it is tilted upward ; the head may be kept bent to relax the sterno-mastoid, but that is all. Direct pressure only causes slough- ing ; and though, according to Sayre's plan, the clavicular part of the pectoralis major may, when the humerus is drawn l)ehind the trunk, possibly tend in some slight degree to pull it downward, it Ijecomes relaxed again as soon as the arm is flexed in its permanent position. More may be done with the outer fragment. The downward displacement gives no trouble ; all are agreed that the elbow must be raised either by means of a sling or by a bandage carried over the opposite shoulder ; this, however, is the least serious of the three. Rotation for- ward is more difficult, but it may l)e met in various ways. One plan is to pull the whole arm, including the elbow, back h behind the median lateral line of the \ trunk ; if this is done an axillary pad must be used to prevent its being pulled inward as well, and so making the short- ening worse (Fig. 119). Another is to bring the elbow so far forward that the hand rests on the wall of the chest, above " the opposite breast ; and then, by means of a bandage carried under the point of the elbow, attemi)t to force the shoulder back. This method is also of .service in correcting the amount of .shortening, as it tends to some extent to drive the shoulder out a.s well. A third relies on fixing the scajjula against the trunk by firmly strap- ping it down. The shoulder must be held in position, a pad accurately adjusted over the angle and vertebral border, and then fixed by strapping carried obliquely upward from the sternum toward the backbone. Of these three the first is the Fig. 119. — BamLige for Fracture of Clavicle, with Pad Axilla. FRACTURE OF THE CLAVICLE. 389 one that in actual j)ractice succeeds l)e.st ; the second, though it is of assistance in correcting shortening, relies too much on force, and is very uncomfortable; the third answers exceedingly well in the recumbent position, but if a patient is allowed to get about it is not possible to fix the scapula efficiently. Shortening is the most difficult of all ; indeed, if the fracture is oblique, and the patient is not confined to bed, it is almost impossible to counteract the muscles passing from the thorax to the arm, without using an amount of force that would be unreasonable and injurious. It is true that by jjlacing a pad of sufficient size in the axilla and then l)an(!aging the elbow firmly to the side, a great amount of leverage can be obtained, in spite of the shape and of the yielding of the wall of the thorax, but it is at the risk of injury to the important structures running down the inner side of the humerus ; and there is a strong suspicion that many of the instances in which the brachial plexus has suffered have really been due rather to the pad than to the fracture. As a splint a pad is invaluable, but it is of very limited utility as a lever. Further, the elbow, as already mentioned, may be forced up for a short time, so as to press the shoulder out, but it is generally found, after the strapping has been on a {^w hours, either that the pressure is intolerable or that something has yielded a little. The same may be said of Sayre's api^aratus. Fig. :2o. Fig. 121. Sayre's Method for Fracture of the Clavicle. in which a band of strapping round the arm is used as a fulcrum and the elbow as the long arm of a lever to force the shoulder back and out. In short, there is no thoroughly satisfactory method that can be applied to all cases alike ; the best is to place the patient in the recumbent position, so that the muscles are relaxed ; the next, to make use of a moderate-sized axillary pad as a splint, and bring the whole arm a little behind the median line ; if this fails, bringing the elbow forward and raising it forcibly may be tried ; but probably the deformity will persist to a great extent. The axillary pad should be wedge-shaped, about three inches thick at the base in the case of an adult, and should be held, base upward, in the axilla by means of tapes tied over the opposite side of the neck. Then, the fracture having been adjusted as well as possible, and the arm and elbow held in the position it is wished to attain, the bandage should be fastened round the arm, close up to the axilla, and carried behind the back, round the thorax, including the forearm and arm, until the whole is encased in horizontal turns, drawing the elbow well, but not too forcibly, into the side. Finally, a few turns are taken obliquely under the forearm and the point of the elbow, over the opposite shoulder, to prevent dropping of the outer fragment ; and the whole is secured either with starch or by stitching the layers together. Union is usually complete in children in about three weeks, in 390 DISEASES AND INJURIES OF SPECIAL STRUCTURES. adults in four or five ; but the arm should be carried in a sling for a week or so longer. If there is any rigidity about the shoulder-joint afterward, the limb may be worked while the patient is under an aricesthctic . I^Ilis's s])lint consists of a well-padded short crutch, which is pressed up into the axilla by a straj) carried over the o])]JOsite shoulder, and of a band, embracing the arm, passing through two slits in the crutch, and then surrounding the thorax. The head and elbow are sui)ported by a sling in the ordinary way. Sayre makes use of strapping sjjread on moleskin without any axillary pad. Two pieces are required, each three and a half inches wide. The first is sewn loosely in a loop round the humerus (the non-adhesive side next the skin) just below the axilla, and then carried behind the back round the chest until the circle is completed ; this draws the shoulder back and acts as a fulcrum. Then, while an assistant brings the ell)Ow forward and j^ushes it up, a second strip is carried from the opposite shoulder, obli(|uely across the first, under the point of the elbow (which fits into a slit cut to receive it), and under the forearm as it lies upon the chest, up to the point from which it started. The theory is that when the elbow is forced ujjward and forward in this manner, the shoulder, owing to the way it is held, is driven outward and backward, in this way correcting the tendency to displacement inward and forward ; but, though this plan succeeds fairly w-ell in ordinary ca.ses, it is doubtful how far it is due to the leverage (Figs. 1 20, 121, 122). The figure-of-eight bandage is practi- cally abandoned; it is exceedingly un- \ comfortal)le, very insecure, and tends to I depre.ss still fiirther the outer fragment. Pick's four-tailed bandage is very useful in i the case of children. It is made of a ; stout piece of calico, long enough to go '; more than round the body, and (for an \ adult) fourteen inches wide. This is slit up from either end to within six inches of the middle, but one tail on each side is four inches wide and the other ten. An axillary pad is adjusted ; the patient is placed in the recumbent position, with his arm by his side, and the forearm flexed across the chest ; and then the bandage is arranged so that the point of the elbow is opposite the untorn strip in the middle (a vertical slit may be made in it here for the purpose of supporting the joint), and the broad ends surround the arm and the chest. These secure the arm to the side, and then the narrow ones are brought up from under the elbow, and tied over the opposite .shoulder. This bandage has the very great merit of being much less easily disarranged than most of the others (Fig. 123). Compound fractures of the clavicle are nearly always the result of direct violence, and may be either comminuted or complicated by the presence of injuries to other structures near. In one or two ca.ses the fragments have been wired together. Ununited fracture is very unusual, even when the deformity is very great and the part is not kept properly at rest. The loss of power to the arm is by no means so marked as might be expected. Fig. 123.- -Pick's Quadrangular Bandage Arranged as Sling for Arm. FRACTURE OF THE SCAPULA. Fracture of the scapula may involve the body, the acromion, the surgical neck, or the coracoid process. Fracture of the anatomical neck (leaving the cora- coid on the body of the bone and detaching the glenoid fossa only) is doubtful. FRACTURE OF THE SCAPULA. 391 Fig. 124. — Fractures of the Anatomical and Surgical Necks of the Scapula. Sometimes, in dislocalions of the humerus, portions of the margin are chipped off (Fig. 124). Fracfiircs of the /)ot/y ?,cvircc\y c.\ex occnx except from direct violence ; they may be single, stellate, or comminuted, and may traverse the spine or not. The signs are usually distinct, though, owing to the dense fascia, and to the muscles attached to both surfaces of the bone, dis|)lacement is rarely considerable, and it is difficult to obtain distinct crepitus. Pain, swell- ing, and loss of power are always ])resent. A firm pad must be moulded on to the scapula to retain it in position by direct pressure, and the arm fastened to the side with a small pad in the axilla ; but unless there is great com- minution or bruising, in a few days it is sufficient to have the thorax bandaged and to carry the hand or forearm in a sling. Some deformity commonly persists, but there is rarely any perma- nent loss of power. Fracture of the acromion from direct violence is not uncommon, though many of the cases in which it has been found detached post-mortem are really examples of rheumatoid arthritis with sepa- ration at the epi[)hysial line, or of delayed union. It may give way at the tip or close to the spine. The signs are quite definite : the arm hangs help- less by the side, the shoulder is flattened, the line of the acromion interrupted, the outer fragment depressed and freely movable, and the patient is either unable to abduct the arm, or can only do so to a slight extent and with great pain. Crepitus can be obtained by direct manipulation, either on pushing the elbow upward or abducting and rotating the arm. If only the tip is broken all that is necessary is a triangular bandage to raise the elbow ; but for the first few days it is advisable to strap the scapula closely to the thorax and to bandage the arm lightly to the side, so as to prevent accidental movement. Union, if the fracture is near the spine, may take place by bone ; in front of this it is nearly always fibrous, but this does not interfere with the strength or the range of movement of the joint. The coracoid process may be broken off by direct violence or by muscular action, but it is very rare. In the former case the injury, which may be caused either by a bloAv or by crushing, as when a cart-wheel passes over the axilla, is generally very extensive ; in the latter there is scarcely any dis])lacement, owing to the strength of the ligaments connecting the process to the clavicle. Fracture of the neck of the scapuhi is almost equally rare. It can only occur by direct violence. The symptoms at first sight resemble those of dislocation of the arm, but the intense pain, undue mobility, and crepitus render the presence of a fracture certain. Moreover, the displacement returns as soon as reduction has been accomplished, unless means are taken to prevent it. Fracture of the surgical neck of the humerus can be excluded at once by the fact that the head of the bone in the axilla rotates with the shaft ; but unless the coracoid process is movable it is almost impossible to make certain of the exact line of fracture in the scapula, especially as the amount of swelling is, generally speaking, very great, and dislocations are sometimes accom])anied by injury to the glenoid fossa. The treatment is almost the same as in the other fractures of the scapula ; the body of the bone must be fixed as well as possible, the elbow raised to take the weight of the limb off, a small pad placed in the axilla to act as a splint, and the arm band- aged to the side. Passive motion should be commenced early, not later than the third week. Even then it is probable that there will be a considerable degree of stiffness about the shoulder. 392 DISEASES AND INJURIES OF SPECIAL STRUCTURES. FRACTURES OF THE HUMERUS. The Upper Extremity. Varieties. — These may involve the surgical or the anatomical neck ; or the epiphysis may be detached from the shaft ; or the intracapsular portion may be split longitudinally and the head dragged forward so as to give the appearance of a dislocation. Of these, fracture of the surgical neck is by far the most common, especially in the aged, when the medullary canal of the shaft is beginning to enlarge. Separation of the epijjhysis can only take place under twenty ; longitudinal fractures detaching the great tuberosity are not often met with unless there is a dislocation at the same time, while fractures of the anatomical neck are among the rarest known. ( I ) 77/1? Surgical Neck. Causes. — Fractures of the surgical neck of the humerus may be the result either of direct or of indirect violence, of blows upon the shoulder, or of falls upon the outstretched arm ; muscular action by itself is very rarely sufficient. The line of separation lies between the base of the tuberosities and the upper margin of the insertion of the teres major. In general the fracture is transverse, but it may be oblique to a greater or less extent, and impaction may take place, the upper end of the lower fragment being wedged into the cancellous tissue of the tuberosities ( Fig. 125). Displacement. — The 'displacement affects both fragments, but in very different degrees. In many cases there is scarcely any, the fracture is transverse, and the broken ends are kept in the same straight line by the biceps tendon. In others, especially if the direction is at all oblique, it is very con- siderable, and it may be a matter of great difficulty to retain the fragments in position. The upper of the two is abducted by the supra-spinatus and rotated outward by the infra-spinatus and the teres minor. The lower is drawn upward chiefly by the deltoid, and inward by the muscles passing from the thorax to the upper part of the arm, so that it may completely overlap the other and form a projection that stands out under the skin in the front wall of the axilla. Symptoms. — In some instances the amount of shortening is considerable, as much as three-quarters of an inch, though this is unusual. The rounded shape of the shoulder is not lost, but there is a depression some little distance below the acromion ; the axis of the limb is altered ; the elbow points backward and outward, though it may be brought into the side with very little i)ressure ; and there is a certain amount of fullness about the front fold of the axilla. Undue mobility and crepitus are easily made out if the fragments are not impacted ; the glenoid fossa is still filled by the head of the bone, and the upper end of the lower fragment can be 3 fl felt projecting in front. Loss of power is complete, and often the *^ pain is very severe, running down the arm, owing to pressure upon the brachial plexus. c*Jk'iir Many of these symptoms are wanting when the fracture is impacted, but there is great pain, especially at the seat of injury, complete loss of power over the limb, a slight amount of deformity and distinct shortening. Extravasation is extensive, as a rule, and the swelling very distinct, especially on the inner side of the arm. In some cases it may be due to rupture of the circumflex arteries ; in others it is merely the result of bruising and laceration of the muscles. Treatment. — Xo attempt should be made to reduce an impacted fracture \ Fig. 125. — Frac- ture of Neck of Humerus. FRACTURES OF THE HUMERUS. 39: unless the axis of the limb is seriously distorted. It is often difficult to bring the fragments into good position, and always harder to keep them there. All that is needed for such injuries is a pad in the axilla to act as a support, and a bandage round the arm to confine it to the side. In all fractures of the humerus the hand should be carried in a sling, but this should never be allowed to extend untler the elbow. When there is no impaction the uiJjjer fragment is ])ractically out of control. It is so short and so deeply covered that very often it is difficult to be certain how far it is displaced. Nlore may be done with the lower, though sometimes it is impossible to bring this into position and adjust it properly. It may be nece.ssary to place the patient under an anaesthetic and to abduct and raise the arm from the side before the ends can be disengaged. The displacement inward is most easily met by placing a firm pad in the axilla, or, as Erichsen suggests, a piece of leather bent into the shape of a U, one side applied to the thorax and the other to the arm. If this is placed well up in the axilla, and if, at the same time, the elbow is carried slightly forward and fastened to the side of the chest by means of a bandage, the upper end of the lower fragment is carried outward and backward and the broken surfaces can generally be brought into good apposition. Then the hand is arranged in a sling, as already mentioned in the case of impacted fractures, and a cap of gutta-percha, or, what is better, as it is not so hot, of poroplastic felt, adjusted over the shoulder and down the arm, taking care not to bring it so far on to the neck that it becomes displaced by the move- ments of the head, or so far on to the thorax that it loses its grasp on the arm. This is fastened by a bandage carried round the opposite side of the chest. It must be admitted, however, that even when every care is used, union in a faulty position cannot always be avoided. Band- aging the hand and forearm is quite unnecessary (Fig. 126). Union is generally complete in from five to six weeks, but the arm remains stiff and powerless for some time after. Passive motion should be commenced at the third week at the latest ; in many cases it answers well to begin even before this, very quietly and gently, with the object rather of preventing the formation of adhesions by straightening out the folds of the capsule than of breaking them down. If this is not done the joint is sure to become rigid, owing to the mobility of the scapula, and it may be necessary at a later period to place the patient under an anaesthetic and work the part thoroughly. Delayed union and even complete failure occasionally occur. Fig. 126. — Bandage with Shoulder-cap and SUng for Fracture of Surgical Neck of Humerus. Part of sling cut away. (2) Separation of the Upper Epiphysis. This is not an uncommon accident under twenty years of age, and presents practically the same features as fracture of the surgical neck. True crepitus, however, is wanting, even when the line of separation runs between the cartilage and the bone ; only an indistinct soft rubbing can be felt, and the upper end of the lower fragment, when it is made to project beneath the coracoid, is smooth and rounded instead of being sharp and angular. In some instances there is 26 394 DISEASES AND INJURIES OE SPECIAL STRUCTURES. consideral)le difficulty in reduction ; the under surface of the upper fragment is cup-shaj)ed and prolonged downward upon its inner and anterior aspect, and it is said that the edge of the lower fragment may be caught by this. To release it, the arm must be forcil)ly abducted and extended. In other cases it arises from the upper end of the lower fragment being driven through the capsule. Union, especially al)out the time of puberty, is very likely to be osseous, impairing the growth of the limb. This, however, is not invariable, probably because in many of these cases the injury is really a fracture, running through the recently formed bone without involving the cartilage. Comijlete failure has been known, and even suppuration, although the skin was unbroken. In two instances in which union had taken place in so distorted a position that the arm was almost useless, Bruns separated the fragments again, resected part of the diaphysis, and wired them together with a good result. In one or two cases, in which the bones could not be brought into proper apposition, the joint has been laid open from the front, the interposing tissues divided, and the two fragments fixed together by means of a long drill driven through the skin. This was removed on the eighth ^> day, as soon as sufficient lymph had been poured out i';' ;^.:^v^-,;-;^A(ryi: to uiake the ends secure. I ' :■'':' V^^:^'- ■■'■:'"- •' It is possible for the joint to escape without being V ^ ■:,'-•■_,, • opened; the capsule is so firmly attached to the J ''':•,.;:';: - ■.:; epiphysis that it may rematin in connection with it, ..., , : •. \:-- j stripping off the periosteum from the shaft. More • .1 ?:■•;;;■•?{,.../ ' ■■' often it gives way upon the inner side. 1' ■i:s (3) Eracture through the Tuberosities. Longitudinal fractures through the upper end of the humerus are not common. Sometimes, however. 4^ J,^'- ' '-i/£_li the great tuberosity is torn off by the contraction of ^ the muscles when the head of the bone is dislocated ; ^'f;- i27--yert'cai Section through ^nd occasionally the imrt is split by direct violence. Upper Epiphysis of Humerus, show- ■' '■ 1 • 1 1 ing the sh.ipe of the End of the \\ hcn this occurs, the great tul)erosity alone may be Diaphysis. dctachcd ; or the line of separation may run through the head, or even along the bicipital groove, so that most of the articular surface is broken off, and the small tuberosity is left almost by itself on the end of the shaft. Symptoms. — The character of the displacement is the same in all, though it varies in degree. If the tough tendinous periosteum at the insertion of the muscles is not torn, there is exceedingly little; in general it is very considerable. The breadth of the shoulder is the most prominent feature ; this is immensely increased owing to the way in which one fragment is pulled forward and the other backward ; and the axis of the limb is altered so that the elbow points backward and outward. Very little pressure, however, is required to bring it again into its normal position. As a rule there is no shortening, but there may be a great amount of bruising and extravasation, especially in cases in which the injury is caused by direct violence. Loss of power is complete. Crepitus is sometimes difficult to obtain on account of separation of the fragments ; but the most char- acterise! sign is the presence of a bony projection under the coracoid in front, resting on the anterior surface of the glenoid fossa, and under the acromion behind, with a deep furrow in between. The anterior follows the movements of the shaft, and corresponds more or less to the head of the bone ; the posterior is the greater tuberosity drawn upward and backward by the muscles attached to it. The diagnosis of this jjeculiar accident recjuires especial care, as subcoracoid dislocation of the head of the humerus may be associated with it, and if it is not made out, serious deformity is certain to result. Treatment. — If the displacement is only slight, all that is necessary is to FRACTURES OF THE HUMERUS. 395 place a pad in the axilla as a splint, and to support the elbow, either by means of a triangular sling or a four-tailed bandage ; but this is (juite exceptional. In general it is very considerable, and bony union may fail, as it is not at all easy either to bring the fragments together or to maintain them in that position. The simplest plan is to place a pad in the axilla, and try, with the aid of a bandage round the upjier i)art of the humerus, to bring the upi)er end of the lower fragment backward and outward, while an attemjjt is made to press the other forward by strai^jMng a pad firmly on it. If this fails the only alternative is to place the jiatient in bed, with a small pillow under the head, and to keep the arm extended and rotated out so that the hand lies on its dorsum. Even if union is bony it is a long time before full use of the joint is regained ; the fracture often involves part of the articular surface, and lips of callus are thrown out around it ; or the capsule becomes thickened and rigid, so that the range of movement is limited ; or rheumatoid arthritis sets in afterward and leaves the joint permanently cripi>led. (4) Fracture of the Anatomical IVeck. Fracture of the anatomical neck is exceedingly rare and can only be produced by direct violence ; most of the cases have occurred in old people, or at any rate after middle life, probably owing to the changes that take place in the substance of the bone. The line of separation is supposed to follow the anatomical neck of the humerus, but it nearly always lies partly inside, partly outside the capsule. It is very doubtful if such a thing as intracapsular fracture, in the strict sen.se of the term, has been proved. The head of the bone does not undergo necrosis, though union maybe only fibrous or may fail completely; impaction is common, the upper fragment being driven into the substance of the tuberosities ; where this does not take place an amount of nutrition sufficient to maintain life, though it is seldom enough to repair the injury, is kept up by the reflected portion of the capsule on the under surface of the neck. Displacement. — In a i^w extraordinary instances the position of the upper fragment has been found completely reversed, the cartilaginous surface, that is to say, facing the tuberosities. It is very difficult to see how this is produced, but it is almost certain that it must be the result of forces acting subsequently to the fracture, perhaps long after. In other ca.ses it is very slightly displaced, unless there is impaction, when it may be driven so far into the substance of the tuber- osities as to split them in two. The lower fragment is held by the attachment of the capsule and the insertion of the muscles immediately below, so that it is only drawn upward and inward to a very slight extent. Symptoms. — The most prominent symptoms are those due to the contusion. The loss of power is complete ; the shoulder is swollen, tense, and painful ; signs of bruising show themselves very soon, especially along the margins of the deltoid, and the whole of the upper and inner part of the arm may be blackened. If anything, there is a slight amount of shortening, and probably this is greater in impacted fracture ; deformity is very little marked and is easily rectified ; there is no undue mobility ; but when the arm is raised from the side, and the head of the bone is felt in the axilla, a certain amount of irregularity can usually be detected. Crepitus is easily produced, unless there is impaction, by pressing the elbow upward so as to bring the broken surfaces in contact. Kind of Union. — If the fragments are impacted, union, generally speaking, takes place by bone. In other cases it may fail completely, the two surfaces be- coming hard and smooth from constant friction ; or there may be a certain amount of fibrous tissue formed between them ; or the head may be enclosed l)y a growth of bone, like a coronet, around it, so that it becomes quite fixed. In true intra- caj«ular fractures union can hardly take place without impaction. Treatment. — No attempt should be made to reduce impaction ; it is true that the shortening and the deformity are, generally speaking, greater, l)ut they are never serious, and impaction affords the surest promise of bony union. In 396 DISEASES AND INJURIES OF SPECIAL STRUCTURES. other cases all that can be done is to protect the shoulder, and carry the forearm in a sling, with the elbow bandaged to the side, but no axillary pad. Care must be taken not to tear the capsule of the joint any further, as union depends upon this to some extent. It is possible that the head of the bone may remain loose in the cavity of the joint, and give rise to such an amount of inconvenience that its removal may be recjuired ; but such an occurrence is very doubtful. Fracture and Dislocation Combined. Fracture of the surgical neck of the humerus with subcoracoid dislocation occurring at the same time is not so rare an accident as might be imagined. Nearly seventy cases of it have been recorded. In all probability the dislocation occurs first, and the neck of the bone gives way from a continuance of the same force. The injury itself is not an easy one to make out, as all the ordinary signs of dislocation that depend upon the alteration in the axis of the limb are not only wanting, but ])oint directly to fracture. The most characteristic feature is the absence of the head from the glenoid fossa. The patient must be placed under an anaesthetic, and every effort made to reduce the dislocation by squeezing the bone in the direction of the glenoid fossa when all the muscles are relaxed. If this fails it is generally recommended to put the fracture up, and when it is fairly well united to make another attempt ; but at any rate, in the case of a young and healthy patient, to whom it is of some conse- quence to retain full use of the limb, it is questional)le whether it would not be advisable to open up the joint and replace the head of the bone at once. Co7npound Fractures. Compound fractures of the upper extremity of the humerus are not common, except as a result of gunshot injuries or of machinery accidents. The latter gen- erally require amputation as soon as the shock has passed off, but the question must be decided in each case by the condition of the soft parts. Where they are not seriously hurt every attempt must be made to save the limb, even if the bone is extensively splintered. The ends may be removed, the head of the bone excised, or resection of a more or less formal character be performed with excellent results. Six inches of the bone have before now been removed. Where, on the other hand, the soft parts are extensively injured, the skin stripped up, and the muscles badly torn, it is very doubtful, even if there is no comminution, whether any attempt of the kind would succeed in leaving a service- able arm. The artery may be divided and tied at both ends ; and the same may be done with the vein, without amputation being necessary, if the collateral circu- lation has not been injured — practically that is to say, where the fracture is not due to direct violence. The nerves rarely give way unless the arm is almost torn off; if, however, one of them has been divided, the two ends should be carefully sutured tofrether with catfrut. Fracture of the Shaft of the Humerus. These are generally due to direct violence ; sometimes they are caused by falls upon the elbow, and in a it\\ instances they have been known to occur from mus- cular contraction ; but though this is more common here than in any other bone, the total number is not large. Displacement. — The seat of injury is more often below the insertion of the deltoid than above, and the fracture is generally oblique from above downward and outward. In children, however, and in fractures from muscular action, it may be nearly transverse. The lateral displacement is almost entirely dependent on the direction of the fracture, and the action of the muscles. In injuries above the deltoid it is worse than in those below^ ; in the former the muscles that pass FRACTURES OF THE HUMERUS. 397 from the thorax to the arm i)ull the up])er iViii^Miient inward, while the deltoid carries the lower one outward, and raises it at the same time ; in the latter, these muscles antagonize each other to a great extent, so that the jjarts may remain in api)osition. Shortening is rarely considerable, and in transverse fractures, especi- ally if the i)eriosteum is not torn, is absent altogether. Symptoms. — All ordinary symptoms are well marked. The deformity when the arm is hanging by the side may not be conspicuous, but crepitus, undue mobility, ecchymosis, intense pain, and utter helplessness are nearly always present. In general there is no difficulty in feeling the fragments through the skin. The artery rarely suffers, but the musculo-spiral nerve, as might be expected from its peculiar relation to the bone, is often hurt, and still more frequently is injured by being conn)res.sed in the callus that is thrown out. Treatment. — Fractures of the upper part of the shaft are treated in the same way as those of the surgical neck ; only a short inside splint, coming down to the internal condyle, is better than an axillary pad ; and the shoulder cap should be continued down the limb to the elbow, and be made to fit accurately round at least two-thirds of the arm. When they occur lower down, various appliances may be used. Four short, well-padded, wooden splints may be adjusted round the limb, the inner one reaching from the axilla to the inner condyle, the outer from the acromion to the external, and the anterior resting on the bend of the elbow. When these are secured by webbing-straps and buckles, or even with sticking-plaster, movement is hardly possible. Instead of the three outer ones, Gooch's splint may be employed. This consists of narrow strips of wood fastened parallel to each other, on one surface of a piece of wash-leather or mole- skin, after the fashion of some kinds of dinner mats, so that it can easily be rolled round a limb. In several instances I have used the ornamental flower-pot holders that are made of diagonal interlacing bars, and can be opened or closed to any requisite width (Fig. 128). A layer of cotton-wool or of lint must be placed round the arm first, and care must be taken to cut away suf- ficient material to accommodate the elbow^ and the axilla ; but when this is done they can be fixed with the greatest ease, and they are sufficiently elastic to fit without being unpleasantly rigid. Poroplastic felt may.be used in the same way. Plaster-of- Paris is rather heavy. With all of these the hand must be carried in a sling, and the elbow allowed to drop, and of course the condition of the circulation in the hand and fingers must be carefully watched. Sometimes there is a considerable amount of shortening in oblique fractures. This can only be prevented by confining the patient to bed ; hanging weights upon the elbow is useless so long as he is allowed to move about. The arm must be laid upon an inside splint, a stirrup fixed above the elbow^ and a weight carried from it by means of a cord running over a pulley placed at a convenient angle by the side of the bed. Where the upper fragment is much displaced or where, from the age of the patient or other causes, it is not considered advisable to carry a bandage round the thorax, Middledorpf s triangle is the best contrivance. This consists of a light, well-padded triangular framework ; one side runs down from the axilla to the hip, a second from the axilla to the elbow, and a third joins the lower ends of the other two. The object is to secure the elbow and shoulder, and at the same time keep the arm fixed in abduction. Fig. 128. — Splint and Sling for Fracture of the Sh;ift of the Humerus. Part of sling cut away. 398 DISEASES AND INJURIES OF SPECIAI STRUCTURES. Union generally takes place in five or six weeks, but total failure and false joint are more common in the shaft of this hone than in any other. It has nothing to do with the j)Osition or direction of the nutrient artery, nor is it in any way the result of separation of the fragments for want of support at the elbow joint. It has been assigned, with more probability, to the fact that neither the shoulder nor the elbow joint is properly fixed, so that more movement tiikes jjlace at the seat of injury than is advisable ; but it is very doubtful whether the means adopted to obviate this do not do more harm than good. Angular splints, for example, as Hamilton pointed out, soon make the elbow stiff, so that if the forearm drops at all, or if any attempt at mo\ement is made, the fracture yields, and not the joint. Certainly, in many instances of ununited fracture, the elbow joint is stiff. Fur- ther, if an inside angular splint is api)lied to the arm, and then the hand placed in a sling, the elbow becomes abducted at once, and this movement takes place more easily at the seat of fracture than it does at the shoulder. Probably the real cause, in the majority of instances, is the interposition of some foreign substance — generally speaking, muscle ; and its "frequency may be explained by the very exten- sive surface of the shaft that affords attachment to the brachialis anticus and triceps. If the direction of the fracture is in the least oblicjue, either fragment may be easily driven so far into the soft parts that it is almost impossible to disengage it. In one or two instances the musculo-spiral nerve has been found between the fragments. The treatment dei)ends upon what can be made out with regard to the posi- tion of the fragments ; if they are in apposition with each other, any of the methods already mentioned, in speaking of delayed union, may be adopted ; but if it is practically certain that there is some intervening substance, union is impos- sible until this is removed. It is essential, before attempting any operation of this kind, to encourage the circulation through the limb by galvanism, friction, and whatever kind of movement is possible. When an arm has been confined in splints, or carried in a sling for many months together, the nutrition becomes so much impaired that, not unfrequently, even such a proceeding as wiring the frag- ments is entirely unattended by the formation of callus. Frj^cture oy the Lower End of the Humerus. A certain amount of confusion has arisen with regard to these from the variety of names employed. This may be avoided by making use of the term epicondyle for that part of the bone (internal or external) which lies outside the cajjsule and gives attachment to the muscles, reserving the word condyle to include part of the joint. The line of fracture may either lie wholly outside the capsule of the joint or may traverse this in part. 1. In the former class are included transverse fracture above the olecranon fossa (supra-condyloid) : separation of the internal epicondyle, and separation of the corresponding epiphysis by itself. The external epicondyle does not project sufficiently. 2. In the latter are T-sha]jed fracture; .separation of either condyle, the line passing from above the corresponding epicondyle oblicpiely into the centre of the joint, and detaching either the ca])itellum or the trochlea ; and separation of the lower epiphysis. It is true that, owing to the firmness with which the capsule of the joint is fastened to the margin of the epii^hysial cartilage, it is possible to detach this from the shaft by stripping up the periosteum without opening the synovial cavity ; but it is very unlikely that this really happens in c^ses of fracture. Separation of the epiphysis for the internal epicondyle may take place by itself without involving the joint, but if the whole ma.ss is detached, or if the three outer ones together are separated, there is nearly certain to be some rent in the synovial membrane. The line of attachment of the fibrous capsule surrounds the coronoid depres- FRACTURES OF THE HUMERUS. 399 sion on the front of the l)one, and on either side encloses the trochlear and cai)itellar surfaces, skirting the cartilage of the latter very closely. IJehind it includes the whole of the olecranon fossa, but not that part of the bone that lies above and behind the radial surface ; this is altogether uncovered. The line of junction between the epiphysis and the shaft separates off both epicondyles and the whole of the cartilaginous surface, running transversely across the centre of the bone and turning upward at either end, so that, as the external epicondyle is never detached by itself, separation of the internal is the only form of injury that can take place without throwing an immense strain upon the capsule, a strain so great that practically it always gives way. The relative situation of the olecranon and the two epicondyles, as compared with those on the opposite arm, is of the highest importance in the diagnosis of injuries in the neighborhood of the elbow joint. Measurements should be taken in all positions of the limb, and the transverse diameter, from the tip of one epicondyle to the tip of the other, should not be neglected. Fractures of the lower end of the humerus are more common in children than in adults ; they are often complicated with dislocations ; and if the diagnosis is not made at once they are always attended with such a degree of swelling that it can hardly be -made at all. Impairment of mobility is a very common result, especially when the joint is involved ; the fragments are exceedingly difficult to retain in position ; a large amount of callus is often thrown out by the extra- articular part, so that the fossje are filled up and the bones lock too soon, and the capsule is very likely to become thickened and rigid from the development of extra-articular adhesions. In children an accident to the elbow is not an uncom- mon precursor of tubercular mischief. I . Fractures Extcrtial to the Joint. Transverse fracture above the condyles : supra-condyloid. In some cases this involves the reflection of the synovial membrane in the olecranon fossa ; usually it is situated a little above. It is generally produced by falls upon the elbow, the tip of the olecranon, perhaps, acting like the apex of a wedge, split- ting the bone across ; but it may be caused by direct violence, or by the cross-breaking strain in over-extension of the elbow joint in place of dislocation. The line of separation is fairly trans- verse from side to side, but very often is oblique from above downward and forw^ard, and this determines the displacement. The deformity is almost the same as that of dislocation of both bones of the forearm backward, but it is not at the same spot. The elbow joint is flexed and the hand generally pronated ; the olecranon projects behind with a great depres- sion above, in which the tendon of the triceps stands out distinctly ; in front there is a prominence due to the lower end of the upper fragment ; but as soon as the injury is examined with the hand it is found that the relation of the olecranon to the two condyles is unaltered, and that the projection in front is not the articular surface of the humerus, but is on a distinctly higher level. In addition to this the length of the humerus is altered ; crepitus is present ; there is undue mobility, instead of the joint being fixed ; and, what is most important of all, if the deformity is rectified, it returns as soon as the arm is released. In cases in which the amount Fig. i2g. — Fracture of the Lower End of the Humerus. 400 DISEASES AND INJURIES OF SPECIAL STRUCTURES, of swelling is so great as to obscure all the bony prominences, this test may be relied on absolutely ; the only other injury in which it is present is dislocation backward combined with fracture of the coronoid J ^^..i process, and this is distinguished by the fact that Vil^ ' f the condyles of the humerus still retain their rela- i tion to the shaft. 1 \\hen the line of fracture runs in the opposite \ direction across the bone, the symptoms are not so / ^• characteristic, as there is no projection of the ole- / t, cranon ; but all the ordinary signs of fracture — " shortening, crepitus, undue mobility, and pain — are i well marked. Treatment. — Reduction is easily effected, ^ '. but when the fracture is oblique there is some diffi- culty in maintaining the length of the limb, owing ^ ■ to the strength of the muscles. Swelling is often . very considerable if the fracture is not put up at t^/ f . ;w'"' "^"^s- ^^ ™^y "ot be so bad as when the injury ^""—^ ''■ ..T traverses at the joint, but, if it is at all serious, the - / patient should be confined to bed, and the limb y' fastened lightly to an inside angular splint. Cold \ — . applications are generally recommended, and they Fig 130— Common Form of Maiposi- are of great usc at first ; the vessels become con- tion after Fracture of Lower End of . • . i*" _ j ^u • • n ^i. Humerus. strictcd undcr their influence, the extravasation ceases, the exudation of lymph is limited, and the swelling of the joint is checked ; but, after the first few hours, gentle compression, if it can be managed with safety, is much more effectual. It requires, it must be confessed, the utmost care ; a thick layer of cotton-wool must be used, the fingers must be constantly watched to see that the circulation is being carried on properly ; the pulse at the radial must be felt from time to time, and the bandages must be put on after the limb is in position (most of the disastrous cases of gangrene have been caused by the dressing being applied to the limb when it was extended, so that as soon as it was flexed the bandage cut deeply into the fold of the joint) ; but if it is properly carried out there is nothing that succeeds so rapidly or so surely in removing the swelling and preparing the limb for a more permanent apparatus. It is of great importance to limit the amount of exudation poured out around the end of the bone ; sometimes, especially when the fracture involves the joint, it is so excessive that the lower part of the humerus appears to be converted into an almost shapeless block, and movement is checked in all directions. The most convenient form of splint is rectangular, made of some plastic material, arranged along the posterior asi)ect of the arm and the under surface of the forearm from the axilla to the wrist. With this there should be a short anterior one down the arm, thickly padded opposite the bend of the elbow, so as to correct as far as jiossible the tendency to forward displacement of the upi)er fragment. The hand must be carried in a sling. In some few cases an anterior angular one appears to answer better, but the ordinary metal or wooden inside splint, with a joint at the bend, is of little use unle.ss the patient is confined to bed. Passive motion should be commenced not later than the end of the second week, but extraordinary precautions must be taken. There is danger on both sides ; if the elbow is allowed to become stiff, non-union may occur, though it is not so frecjuent as higher up in the shaft ; if, on the other hand, the seat of injury is not securely held, the soft callus yields, and is liable to become broken up and absorbed. If the fracture is low down, extension is often limited, owing to the way in which the olecranon fossa becomes filled up, but this is not nearly so bad as in T-shaped fractures ; and even in the worst cases great improvement takes place in the course of a year or two. FRACTURES OF THE HUMERUS. 4ci Separation of the Internal Kpiiondylc. — This occurs more fre(niently than is generally suspected, but from its being associated cither with extensive bruising, or with dislocation, the symjjtonis to which it gives rise are often overlooked. It may be produced by direct violence (a fall or a blow on the inner side of the elbow- joint), in which case there is not much separation of the fragments, or by dis- location of the bones of the forearm outward, when it may be dragged a consider- able distance. Sometimes it is wrenched off by muscular action alone. The symptoms and importance of this accident depend upon the way in which it is caused. So long as the line of fracture lies entirely outside the capsule, as it does in the majority of instances, it is of little consequence. Movement in the direction of fle.xion and e.xtension is free and almost painless until the extremes are reached and the tension falls upon the fibres of the internal lateral ligament. Pronation is very painful. Sometimes an interval can be i'elt in following down the line of the internal condyle ; and occasionally the detached portion can be plainly made out and moved freely from side to side. Crepitus can only be obtained when the degree of separation is slight. When, on the other hand, the violence is direct, the swelling may be so great as to obscure the outline of the bones ; and, not improbably, in many of these cases the fracture extends further outward into the substance of the bone, so that the injury approximates in character to the separation of the internal condyle. In most cases it is sufficient if the forearm is carried in a sling, with the elbow at a right angle. Union is only fibrous if the epicondyle has been dragged down to any extent by the traction of the muscles, but this interferes very little with the strength of the arm. When the cause is direct violence, a large amount of callus is sometimes thrown out, probably because the splintering extends further than is apparent ; and there may be some impairment of movement at the elbow joint, even when there was no evidence of its having been involved. I have known one instance in which, for a long time after, there was persistent pain in the course of the ulnar nerve. Separation of the epiphysis for the internal epicondyle may take place up to the age of eighteen or nineteen. The symptoms are practically the same. 2. Fractures that hivolve the Joint. ~^ -shaped Fracture. — In this there is a transverse fracture passing across the lower extremity of the humerus, and a vertical split running down from it into the centre of the joint, separating the two condyles. It is always the result of direct violence ; the apex of the olecranon and the ridge that traverses the greater sigmoid cavity from before backward are driven violently against the lower end of the humerus, and split the bone like a wedge. I have known the T incomplete, and only the vertical portion of the fracture produced in this way. The symptoms are the same as those of the supra-condyloid fracture, of which it seems a more severe form ; but the swelling is much greater ; the condyles can be moved independently of each other and of the lower end of the shaft ; the dis- placement is more serious, and is even harder to rectify ; and perfect freedom of movement is rarely restored. In many of these cases, owing to the great rapidity with which the swelling sets in, and the enormous size the joint assumes, all that can be done is to lay the arm on a pillow, or to fasten it lightly on an inside splint, and try to limit the amount of exudation by means of cold and pressure. The joint must be kept at a right angle, or even a little less, so that in case ankylosis does take place, the arm may be in the most useful position. With the elbow fixed at this angle the hand can be placed behind the head, and brought sufficiently near for the patient to feed himself; if it is more open the joint is almost useless. The earlier the fracture is set, the better the prospect of good adjustment. The olecranon must be dislodged from between the fragments, and these must be brought close together and into the same straight line with the shaft. A great deal 402 DISEASES AND INJURIES OF SPECIAL STRUCTURES. may be done by careful readjustment up to the end of the first week ; and some improvement may be effected for a few days longer ; but, as a rule, at the end of a fortnight the fragments are too firmly fixed to allow anything further. Passive movement must be commenced as soon as possible, the joint being thoroughly, but quietly, flexed and extended once a day, while the fragments are held in position as firmly as they can be. Hamilton states that it should be commenced by the seventh day. Fracture of the Internal or External Condyle. — In this the line of separation nms from above the corresponding ej)icondyle through the articular surface of the humerus into the middle of the joint. The internal can only be detached by direct violence : the external may be separated either in this way, or by a fall upon the hand (Fig- 131)- The symptoms are very much the same as those of the T-shaped fracture, but less severe, as there is scarcely more than half the injury. The displacement varies very much : if the trochlear surface is left intact, it is very slight ; if, on the other hand, the articulation for the ulna is separated from the shaft, it may be sufficient to suggest back- ward dislocation of both bones. Treatment must be carried out on the same principle, and early ]>a.ssive motion must be insisted ujjon. When the internal condyle is broken off, leaving merely the capitellum, the limb may be kept in a position of extension with advantage, at least for the first fortnight, and then gradually flexed. Care must be taken to preserve the outward angle that the r F forearm makes with the arm. riG.131. — rracture • y > of the Internal Separation of the Lower Epiphysis. — In infants this is not H°u"merus.° ' ^ uncommou ; the whole of the cartilaginous mass at the lower end of the humerus is detached from the shaft, without of neces- sity the joint being opened, though it probably is, in nearly every case. In children it is equally frequent ; but the line of separation rarely corresponds exactly, for its whole length, to that of the epiphysis; and the internal con- dyle is seldom separated with the rest. The outer part is the one that suffers, as a rule; it consists of three osseous nuclei, that which represents the capitellum being much the largest and forming a considerable share of the trochlea ; the line of fracture runs from above the external epicondyle into the centre of the joint, to one side or other of the trochlear surface ; if the latter is included, the lower fragment is carried backward with the bones, so that it.closely resembles a dislocation. The most frequent cause is violent abduction or adduction of the forearm coml)ined with hyper- extension. The symptoms are nearly the same as those of the supracondyloid and condyloid fractures, and, as a rule, the same treatment is required. Only where the line is immediately above the joint, and it is difficult to retain the fragments in position, it is recommended to put up the injured limb in a position of com])lete flexion, care of course being taken not to interfere with the circulation. In addition to these, other forms of fracture are occasionally met with which do not admit of classification. Sometimes the lower end of the humerus is completely comminuted ; or dislocation of the radius, or ulna, or both together, occurs at the same time ; or the injury is complicated by fracture of the bones of the forearm. Compound Fractures into the Elboiu-foint. — These are not uncommon, and frequently the ulna or the radius is involved, as well as the humerus. The treat- M Fig. 132 — Vertical Section through the Lower End of Humerus at fifteen years of age. Showing the Relative Size and Position of the Epiphyses. FRACTURE OF THE RADIUS. 403 nient, as in the case of compound fractures into other joints, must he guided l)y the age and constitution of the patient, and by the extent of injury to the soft parts and the bones res])ectively ; but this is modified to a certain extent as regards the elbow by the excellent results that are obtained by excision. If there is but little comminutit)n, and the wound is small and clean cut, the part should be thoroughly cleansed with corrosive sublimate, the wound sealed With a dressing of wood-wool or some similar absorbent material, and the limb arranged upon an angular splint, and slung with a counterpoise from a pole over the bed, as in an excision. But if the bone is extensively injured or the skin much bruised, so that the amount of movement in the joint afterward is a matter of some doubt, it is better to excise the part at once. Amputation is only required when the soft tissues are destroyed to such an extent that there is no prospect of the limb recovering. FRACTURE OF THE RADIUS. This may involve the head, the neck, the shaft above the insertion of the pro- nator radii teres, or the lower extremity. When the shaft is broken the ulna, generally speaking, gives way, too. Fractures of the head dixe very rare, but occasionally they are produced either by direct violence crushing the external condyle or by falls upon the hand. They have been found in several of the instances in which the coronoid process was broken. The line of fracture is usually longitudinal, splitting off more or less of ..._^- --- ''!S3^v. the circumference of the bone. v ,\ Fracture of the neck of the bone is \ >■ still more uncommon, though it is an injury \.^-. that is often suspected during life. It may / V V occur in children or in adults, probabl\- /- - •■ from direct violence, though one or two [ __ . _ / instances are recorded in which it has been -^ <. ^'-^- •— ,, . / due to falls upon the hand. The head of - •^'-^' the bone is unduly movable and does not , %' rotate with the shaft ; pronation and supi- nation are impossible, and when the hand '. ^^ -^^r-stsy' is moved in either direction there is intense \^ pain at the seat of injury ; a slight amount Vi of crepitus is usually present. I have met *• - „ , ->*5k-s^js^-> - with one instance in which the upper epi- "^ > '^^^S*^/ physis Avas separated, the external condyle .' y^ of the humerus being considerably crushed yy. at the same time. The only treatment that !\ - , can be adopted is to retain the elbow joint \ ^^ ' f in a light form of rectangular splint with a v v^^ ^i^' ) firm pad over the front of the forearm, and Ki'-*^ ^F" ^ . . . ^ i r » < to commence passive motion as m fractures of the lower extremity of the humerus. If, owing to the contraction of the biceps, the 1 displacement cannot be rectified in any 'I other way, the arm must be put up fully -'^ flexed; but it must be recollected, when |. , . passive motion is begun, that the muscle is S-i,:„,-^ very likely to have become rigidly contracted Fig. 133.— Separation of Upper Epiphysis of Radius r „ 1 1 . rj^i ■.■ r ii with Crushing of Capiteliar Surface and External from prolonged rest. 1 he position of the Epicondyie. posterior interosseous nerve in relation to the bone must not be forgotten in connection with this fracture. Fractures of the shaft of the radius alone are due either to falls upon the hand or blows upon the arm, and may take place either above or below the insertion 404 DISEASES AND INJURIES OE SPECIAL sfRUCTURES. of the pronator radii teres. In tlie former case the ui>per fragment is acted on by the supinator brevis and the biceps, the lower by the jjronators, so that the relative position of the radius and ulna is not the same above and below the seat of injury. In the latter the upper fragment, owing to the attxichment of the l^ronator teres, is not much disi^laced ; but the lower is tilted inward toward the ulna, ])artly by the supinator longus, partly by the pronator quadratus. So long as the ulna is intact the amount of deformity is very slight. The other signs are well marked : there is intense pain over the seat of injury ; pro- nation and supination are imjiossible ; when the hand is grasped and made to rotate, the upper end of the radius does not move with it, and crepitus can be felt at once. Fractures of the upper part of the bone should, if possible, be jnit up in a position of complete supination. The upper fragment is already in that position, and if the lower is partly pronated it is clear that a certain amount of supination must be lost, and though this can be supplemented to a great extent by rotation at the shoulder-joint, especially after long practice, the movement at the elbow Fig 134. — Section through the Lower End of the Radius, the Carpus, and Metacarpus, to show the Position in a Fall upon the Hand and the Influence of the Inferior Radio-carpal Ligament. If the force were continued, the hard, compact anterior surface of the radius would be driven into the cancellous tissue of the lower fragment. is exceedingly awkward. It seldom happens, however, that patients will endure it ; if they are confined to bed the arm may be laid on its back and completely extended ; if not, all that can be done is to fit a posterior rectangular splint down the arm and forearm and to arrange a sling so that the hand, resting on its dorsum, is as much in front of the median lateral line of the body as the elbow is behind. When the seat of injury is below the insertion of the i)ronator teres, the danger is that the upper end of the lower fragment may be drawn inward and at length unite with the ulna, when, of cour.se, both pronation and su])i nation are lost. To prevent this, straight back and front splints must be u.sed, wider than the limb, so as to take off all lateral pre.ssure, and well padded, esjiecially down the centre, so that the muscles may be squeezed as far as may be into the inter- osseous space ; and the limb should be put up midway between pronation and supination, that is to say, with thumb uppermost and the dorsum of the hand looking forward. The sling should only take the forearm, so that the hand may hang down in a position of adduction. FRACTURE OF THE RADIUS. 405 Fracture of the Lower End of the Radius. — With the exception of the clavicle this bone is broken more fre(iiiently than any other. The fracture is usually transverse from side to side, though in the vertical direction it may incline from above downward and forward, and it nearly always lies within an inch of the carpal surface. The size of the lower fragment, however, varies considerably ; it may be merely a plate of bone carrying the articular cartilage. The cause is almost always indirect violence, a fall upon the hand. If the palm is toward the ground, the displacement is dorsal (Colics' fracture), and it may be impacted, or non-impacted, or comminuted ; if, as occasionally happens, the hand is doubled imderneath so that the back is downward, the lower fragment is forced in the opposite direction. Colics' Fracture. — For many reasons this is of special interest ; it is exceed- ingly common ; it is much more often met with in women past middle life than in men ; it is distinguished l)y dis|)lacement of a very striking character ; and it often leaves behind it unsightly deformity and a very serious degree of stiffness. The structure of the lower end of the radius favors its occurrence. The compact tissue of the shaft is firm and strong, but over the articular end it is scarcely thicker than paper, and one part passes very abruptly into the other. In men of good muscular development the bony ridges in the back and at the sides strengthen it sufficiently ; but in women these are almost wanting and the whole bone is more smooth and rounded. As age advances the medullary canal enlarges and encroaches upon the centre of the articular end, the cancellous tissue grows more open, and the trabeculae becomes thinner and fewer in number. The immediate cause is a fall upon the hand, but not, as usually described, outstretched. This may dislocate the elbow or the shoulder, or it may break the surgical neck of the humerus, but it can hardly cause a transverse fracture through the radius. The hand is really almost under the body, the radius is much more vertical than horizontal, the wrist is violently over-extended, the lower fragment is fixed by the inferior radio-carpal ligament, and the cross-breaking strain snaps the bone in two. In men it occurs most frequently in falls from some considerable height, when they pitch ujjon their hands, or in accidents on the ice from the feet suddenly slipping up. (I have known, on a frosty morning when the roads were very slippery, seven patients, one after the other, come to the hospital with this form of fracture.) In women it comes from slighter falls, for not only is the bone relatively much weaker in proportion to their weight, but, partly from their mode of dress, partly from their inability to save themselves, they come down upon their hand with much greater force. If the violence is only moderate in degree, the bone is merely broken across ; if it is more severe there is impaction (in at least two-fifths of the cases and probably many more) ; the compact tissue of the dorsal surface of the upper fragment is driven into the cancellous tissue of the lower, without the periosteum on the back being torn ; if the violence is greater still, there is comminution, the impaction being carried so far that the lower fragment is split into pieces. Displacemc?it. — The d i s- placement is threefold ; the upper fragment is held fixed by the pronators, the lower is carried bodily toward the dorsal surface, so that it no longer lies in the same plane ; it is rotated round a transverse axis so that its artic- Fig. 13;.— Section through Forearm showing Displacement in Colles* ular surface, instead of looking Fracture. almost directly forward, looks forward and upward, and the outer side is, as a rule, displaced much more than the inner, partly because the latter is held by the triangular fibro-cartilage. 4o6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. partly because in falling upon the hand the radial side of the carpus receives the brunt of the shock. The original displacement is due, there can be little doubt, to the crushing force ; but CoUes himself attached much importance to the contraction of the extensor muscles of the thumi), which pass over the posterior surface of the radius in sheaths firmly connected to the bone. Symptoms. — If the bone is merely broken across, the deformity is not very marked, but if there is im- jjaction or comminution, it is most conspicuous. Looked at from the radial side the back of the hand appears strangely long, the natural de- pression of the wrist seems to Fig. i36.-Outiine of Hand in coiies' Fracture. havc disappeared, and in its place there is another an inch and a half or two inches higher up. Opposite this, on the flexor surfaca, the tendons are rai.sed and thrust prominently toward the skin, while the wrist itself is unusually arched. Seen from above it is still more striking; the hand is dis- placed toward the radial side and abducted, the ulna stands out as if it were coming through, the fingers are flexed, pronation and supination are impossible, and the patient carefully supports the injured wrist in the palm of the other hand. Swelling sets in very soon. The flexor tendons are always hurt by lieing strained over the end of the bone, and their synovial sheath becomes filled with fluid at once ; but this rather serves to exaggerate the deformity than to conceal it. The margin of the ulna can be traced down without any difficulty ; and by firm pres- sure on the outer border of the radius it is nearly always possible to make out the line of separation ; but crepitus and undue mobility are rarely very distinct unless there is comminution. Sprains of the flexor tendons of the wrist are sometimes mistaken for Colles' fracture; they are caused in the same way, and it is difficult to prove that the bone has escaped unhurt and that the tendons by themselves have been sufficiently strong to stand the strain. The reduction of the deformity is often a matter of the greatest difficulty. Colles states, it is true, that a moderate degree of extension is sufficient to restore the limb to its natural shape, and that it slips back again at once ; but this only occurs when there is comminution. Gordon, who denies impaction, and who describes the broken surface of the upper fragment as convex from within out- ward, and also from before backward, believes that the difficulty is entirely due to the rotation of the lower fragment ; if the upper one is fixed, the lower pressed forward, and the hand flexed to an angle of 45°, the concavity of the radius is restored at once. If there is no impaction, the obstacle must of course be due to locking of the fragments or muscular spasm ; but there can be no question that it is present in a very large number of instances (jjrobably the majority) ; and that the difficulty arises partly from this, partly from the small size of the lower fragment, which makes direct extension almost impossible. Direct manipulation of the fragments while extension is being made from the hand is very often successful. If this fails, adduction may be tried at the same time, the lower end of the ulna being used as the fixed jjoint, and the forearm being held in a position of sujiination with the elbow flexed ; but care must be taken not to put too much strain upon the ligaments. If this does not succeed, another trial may be made at the end of a week, when the fragments have become softened to a certain extent ; but it is not likely to be successful, and it is advis- able to caution the patient from the first that there will probably be a certain amount of permanent deformity. Treatment. — This depends upon the success with which reduction is accom- plished. If the fragments cannot be separated, all that is required (so far as the FRACTURE OF THE RADIUS. 407 fracture is concerned) is a simple wristlet, made of some light material, to j^rotect the part from further injury. Union in these cases is very rapid, but it must not be forgotten that the flexor tendons are generally hurt at the same time, and that, unless steps are taken to prevent it, stiffness of the wrist and rigidity of the fingers are almost certain to follow. If, on the other hand, the fracture is transverse without impaction, or if it is comminuted, and the deformity has really been reduced, the broken surfaces can be kejit in contact with the simplest of contrivances. lOither Carr's or Gordon's splint answers p'erfectly ; l)ut eipially good results may be obtained by fixing the forearm midway between pronation and supination, in two straight wooden ones, reaching from the ell)ow to the bases of the metacarpal bones. After a week or ten days they may be replaced by a well-devised poroplastic gauntlet, including the thumb and the flexor surface of the forearm. Adduction is of no use unless there is comminution ; but then, in some instances it is of great ser\ice. It is managed most easily by means of a pistol- shajjed splint, arranged either on the dorsal or the palmar surface, with a short one on the opposite side for counter-pressure. The pads should be arranged as they are in Gordon's. Fig. 137. — Gordon's Splint Applied. Gordon's splint consists of a dorsal and a palmar portion ; the former is much the longer and is bent down at its lower extremity so as to maintain the wrist-joint in a position of semiflexion ; the latter is very short, and is either carved or padded so as to fit into the concavity of the radius. If it is padded the edge of the splint projects like a flange so as to avoid lateral pressure. It should be kept well up on the forearm, not allowed to encroach upon the wrist. Carr's is simpler. The flexor splint is made of wood and is about eleven inches long and two wide ; across the end of this is a round bar placed obliquely, so that when the fingers are flexed over it the hand is slightly adducted. It should be stoutly padded opposite the upper fragment on the radial side. A dorsal splint may be used with it, but in many cases it is not necessary. Stiffness. — It is always necessary to warn patients that CoUes' fracture is liable to be followed by stiffness, afiecting both the fingers and the wrist, especially if there is any tendency to gout or rheumatism. It is due, in many cases, to strain of the flexor tendons ; but it is made tenfold worse by rigid confinement, and it is by no means unlikely that, in certain circumstances, this is .suf- - ficient of itself. So far as the fingers are concerned, it can gen- erally be avoided ; they should never be bandaged ; one great merit of Carr's splint is the free- dom of movement it gives them ; and passive motion must be com- menced and thoroughly carried out from the first day. With the Fig. iss.-Carr'sSpiim. wrist it is more difficult, but on several occasions I have . begun gentle manipulation on the fourth or fifth day with an excellent result. Pressure should be carefully applied along the forearm 4o8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. if there is much effusion into the sheath of the tendons ; and as soon as the fracture is fairly firm, massage, counter-irritants, and steaming must be com- menced ; but not uncommonly it is necessary to place the i>atient under an anaesthetic, and work every joint thoroughly, before there is much improvement. If there is comminution of the lower fragment, or if the impaction is not reduced and the plane of the articular surface restored, some limitation of movement usually persists. Fracture of the lower end of the radius with palmar displacement is very rare, and does not present any special features. Separation of the lower epiphysis may occur; and, if union takes place by bone, the growth of the ulna may lead to serious distortion of the hand. Compound and even comminuted fractures of the lower end of the radius may be produced by direct violence, without of necessity the joint being involved. In one case under my care, in which a man's wrist was pinned against the ground by the sharp edge of a beer-cask, though the bone was broken to pieces, the joint and both the arteries escaped unhurt. FRACTURES OF THE ULNA. These may involve the olecranon, the coronoid process, or the shaft. Fractures of the Olecranon. — This process is frequently broken, especially in adults, in falls upon the point of the elbow ; and it has been separated by muscu- lar action. As a rule it gives way at its narrowest part, laying open the joint, but occasionally the tip only is detached, and then it is jjossible for the synovial membrane to escape. Stellate fractures are sometimes met with. The amount of separation depends upon the extent to which the aponeurosis of the triceps and the fibres of the capsule at the side give way. If they are torn the upper fragment is raised by muscular contraction and the distention of the joint cavity until there is a wide gap between them. More rarely the broken sur- faces remain in contact, and crepitus can be obtained. Loss of extension is com- plete, manipulation and i)ressure are exceedingly painful, and the amount of swelling is generally very great. Treatment. — If the bruising is severe, the arm should be laid upon a pillow for the first i^tw days, in a position of easy extension, and cold and pressure ap- plied until the swelling is in some measure reduced. In most instances all that is necessary is a light wooden splint running down the front of the limb, sufficiently long to hold both arm and forearm firmly. It should be thickly padded opposite the joint, as absolute extension is uncomfortable, and has a tendency to tilt the surfaces. Sometimes the fragments can be brought closer together by a figure-of- eight bandage, or by loops of strapping, so arranged as to pull the upper one downward ; but in many instances this seriously increases the swelling of the limb. It is more satisfactory to bandage the part carefiiUy and evenly with abundance of wool around the joint, so as to insure early absori)tion of the fluid and tho- rough relaxation of the muscles. This jiosition should be maintained for three weeks, and then the arm may be gradually bent, until in about ten days the forearm rests easily in a sling. If there is much separation, union is nearly sure to be fibrous ; but so long as it is fairly close and strong it does not interfere with the use of the limb. Stellate fractures unite by bone. Flexion from the first has been recommended by some, on the ground that if ankylosis were to occur the arm would be in a more convenient position ; but there is scarcely any reason to fear this (Fig. 139). If union fails, or is so weak that there is no power of extension, the frag- ments must be drilled and wired together. I have seen one instance in which the use of the triceps was lost, owing to the upper portion becoming united to the humerus. Compound fracture is not uncommon. If it is merely transverse, the frag- ments should be fastened together at once ; if there is comminution, every effort T'RACTURES OF THE ULNA. 409 must be made to save the part; l)ut if there is any fear of supimration, it is better to jierform excision. Fracture of t]u- coronoid process is a very rare form of acci- dent, and is nearly always associated with backward dislocation of the bones of the forearm. It may be produced l)y direct violence crushing the bone, or by falls upon the hand when the elbow is extended ; the shock must be transmitted from the radius to the ulna, and from this to the trochlear surface of the humerus. The tip also may be detached by violent abduction, or adduction, of the forearm. The brachialis anticus is attached to its anterior surface, near the base, so that fracture from muscular action alone can hardly take place, and separation of the tip from this cause is im])ossible. I'he most important symptom is the disi)lacement l)ackward of the bones of the forearm, when the elbow joint is extended, returning as .soon as the reducing force is relaxed. In addition there is intense pain on pressure, increased by attempts at flexion, and, unless it is merely the tip, there is a considerable amount of swelling. It is recommended to keep the elbow joint flexed at a little le.ss than a right angle, secured by plaster or a fixed bandage, and Fig. 139— Fracture commence passive motion at the end of a week. If the frag- Fibrouru"n°ion.""' ments are at all separated, union is sure to be ligamentous. Fracture of tlie shaft of the ulna by itself is usually the result of direct vio- lence, and, because of the exposed situation of the bone, is often compound. It may give way at any part, but owing to its comparative weakness it is more com- mon below the middle. The line of separation is usually distinct, unless the amount of bruising is too great, and the movements of the arm are restricted and very painful. The displacement is not conspicuous, unless the radius is broken or dislocated at the same time. If there is any tendency for the ends to be displaced outward toward the radius, the fracture should be put up as if both bones were broken. In other cases a shield of gutta-percha, long enough to grasp the whole of the forearm and the ulnar side of the hand, is quite sufficient. As the hand, when placed in a sling, rests upon the ulnar border, care must be taken that the fragments are not dis- placed by direct pressure. Fracture of the styloid process of the ulna is not uncommon when the lower end of the radius is broken and the hand much abducted. Union is usually fibrous. Fracture of the radius and ulna together, in the middle of the forearm, may occur from direct violence, or from a fall upon the hand. In children the fracture is often partial or greenstick ; and the only prominent sign is an angular deform- ity, generally an exaggeration of the normal curve. When the separation is com- plete, crepitus and undue mobility are present. Pain, swelling, and loss of power occur in all alike. Greenstick fractures must be straightened as far as possible ; sometimes this cannot be done without making them complete; but if there is only a small angle, not sufficient to interfere with pronation and supination, it disappears to a great extent as the child grows older. When the injury is above the level of the pronator radii teres, the forearm should be put up in the position of complete supination, as already described in speaking of fracture of the shaft of the radius alone. When it is lower down, two straight splints should be used, wider than the limb and thoroughly well padded, especially down the centre, so as to avoid as far as possible any risk of cross union ; and the fracture should be set with the limb midway between pronation and supination, that is, with the thumb upward and the dorsum of the hand forward. Passive motion should be commenced in about three weeks, as there is some risk of the interosseous membrane becoming thick- ened in the region of the fracture and losing its flexibility. No bandage should 27 41 o niSEASES AND INJURIES OF SPECIAL STRUCTURES. ever be ajiplied under the splints, and care must be taken to examine the fracture every day for at least the first week. It is in this form of injury that gangrene is especially common, to some extent, as already mentioned, from flexion of the elbow, but also because both radial and ulnar arteries are easily compressed against the bones for a considerable portion of their course. Fractures of the Carpus and Mf:tacarpus. Fracture of the carpus is not common, owing to the mobility and protected position of the bones, and to the way in which the pressure is distributed among them. They may give way, however, from direct violence. Exact diagnosis, unless the injury is compound, can rarely be obtained, especially as the amount of bruising is always extensive. As a rule it is sufificient to carry the hand in a sling, and for the first few days to protect the part from careless movements by means of a light palmar splint of gutta-percha, recollecting that the natural position for the joint is one of slight extension. Unless there is comminution or fear of suppura- tion, passive motion should be commenced as early as possible, so as to avoid permanent rigidity. The victacaj-pal bones are often broken from direct blows, as in fighting, the first, from its exposed situation, giving way the most frefjuently, the third the least. The dis[)lacement is nearly always toward the dorsum of the hand, an exaggeration of the natural curve, so that the head is turned to the palm. If seen at once, it can easily be rectified by direct manipulation ; but often the patient does not apply for some days, considering it a mere bruise. The plan recommended by Astley Cooper, of placing a ball in the palm of the hand, and extending the finger over it, answers very well, and maintains thoroughly the natural curve ; but, as a rule, a simple gutta-percha splint, well moulded, is quite sufficient and is much less cumbersome. The metacarpal bone of the thumb is liable to a peculiar form of fracture which can easily be mistaken for dislocation, as it does not involve the dorsal surface of the bone. The palmar half of the ba.se is broken off; the length of the bone is unaltered, but the security of the articulation with the trapezium is lost, and the bone keeps constantly slipping back. Crepitus can be felt by pressing the detached fragment from the palm outward toward the rest of the bone. Union is generally attended with some impairment of movement. Simple fracture of the phalanges is very common, and may be treated either with a light pasteboard splint or a gutta-percha trough, keeping the finger nearly extended. Compound fractures extending into the wrist joint are very serious ; the bones are generally crushed, the joints torn open, and often the soft parts extensively injured as well. The question of amputation must be decided by the last-men- tioned consideration ; I have on several occasions treated fractures of this descrip- tion, it which it was necessary to remove fragments of bone from both rows of the carpus, with corrosive sublimate baths for an hour each day, not only without suppuration, but with an excellent result so far as movement was concerned. If inflammation and suppuration once set in, the whole carpus is almost sure to become involved, the bones undergo necrosis, and the pus is very likely to spread from the articulations, either into the synovial sheaths of the tendons, or into the deeper planes of cellular tissue, until the whole limb is implicated. If this sub- sides, the hand and wrist are almost useless ; more often than not amputation is required to prevent more serious consequences. Compound fractures of the hand, if they are at all extensive, if for example the palm or several fingers are badly crushed, should be treated in the same way. It is often impossible to tell at the first how much of the bruised and damaged tissue will live, and every fragment is of importance. The sloughs, it is true, are somewhat slow in separating, but, owing to the amount of the antiseptic dead FRACTURE OF THE PELVIS. 411 tissues absorb, putrefaction does not take i)lace ; there is no fear of cellulitis or other inflammatory comi)lications ; granulations gradually spring up, and the whole of the tissue that is not too much damaged by the accident is preserved. FRACTURE OF THE PELVIS. The innominate bone may be broken by direct violence or by muscular action ; or the pelvic girdle may be squeezed until it gives way under the pressure. In this case the position and direction of the fracture are often definite ; under other circumstances they are very variable. Fractures of the False Pelvis. Portions of the crest of the ilium are occasionally broken off by direct blows ; in a few rare instances the anterior superior spine has been detached by muscular action ; and the same thing has been known to occur in the case of the epiphysis that forms the crest ; but unless there is great comminution, injuries of the false pelvis are rarely attended by serious consequences ; the shock may be severe ; the ordinary signs of fracture are well marked ; but the viscera very seldom suffer ; and repair takes place readily, though there is often a certain amount of difficulty about retaining the fragments in proper position. Fracture of the Acetabulum. This may be produced in two ways : in the first, and the most serious, the head of the femur is driven inward with such violence that it splits the cavity into pieces ; in the second a portion of the lip only is detached. The former of these never occurs except as the result of extreme violence applied to the great trochanter ; the bone is very much comminuted fthe three portions that form the acetabulum being driven asunder), the shock extreme, and the danger of injury to the viscera very great. The position the limb assumes closely resembles that of fracture of the neck of the femur, but the trochanter is more sunken. The amount of mobility varies a good deal ; in many instances it is unusually free, probably owing to the small relative size of the neck compared with the head ; crepitus is generally distinct, and manipulation exceedingly painful. If there is any doubt, an attempt may be made to feel the head of the bone through the rectum or vagina. The accident frequently proves fatal from shock or from injury to the viscera ; if the patient rallies sufficiently, an attempt must be made to extract the bone, but it is not very likely to succeed ; if it does, the limb must be put up as in fracture through the base of the neck. Movement is sure to be much impaired. Fracture of the lip of the acetabulum is more common. It is caused by the sudden impact of the head of the femur against the upper and back part of the cup, and may be produced by fdlls upon the feet. In one instance, however, under my own observation, it was clearly shown that the upper part of the body struck the ground first, so that in all probability it was produced in the same way as the fracture that is met with at the base of the skull from the sudden shock of the atlas coming upon the occipital condyles with the weight of the body behind it. The position the limb assumes is almost identical with that of dislocation backward ; reduction is easy, but as soon as the hand is removed the head of the bone slips back. Crepitus can generally be felt if deep-seated pressure is applied above and behind the great trochanter while extension is being made. This injury must be treated in the same way as fracture through the base of the neck of the femur. The patient is to be kept in bed with a long splint and weight-extension, pro- 412 DISEASES AND INJURIES OF SPECIAL STRUCTURES. portionate to the strength of the muscles, for at least three weeks. After this a permanent appliance is to be worn for six weeks, or two months more ; the foot must be slung, and no weight allowed to rest uj^on the limb until at least this length of time has elapsed, though j)assive motion may be commenced much earlier. In most cases there is a certain amount of shortening afterward, but the use of the limb is not imiraired. Fr.vcture of the Sacrum and Coccyx. The sacnon is occasionally, but very rarely, broken by direct violence. The lower portion suffers more fretpiently than the rest, owing partly to its weaker construction. If the fracture is compound, as it often is, it must not be forgotten that the spinal canal runs down the middle of the bone, and that meningitis may occur. When there is great comminution, the structures on the anterior surface, in particular the nerves as they issue from the foramina, may be involved as well. The coccyx, on the other hand, is frequently injured by falls in a sitting position upon something hard, or by kicks. Sometimes it is broken right across and displaced, so that crepitus can be distinctly felt when it is grasped between two fingers, one in the rectum, the other on the skin, and moved backward and for- ward ; more often it is only bent or partially broken. Perhaps, sometimes, the injury is really a dislocation. The most ])rominent symptom is the pain caused when any of the muscles attached to the bone are called upon to act ; sitting, stooping, walking, coughing, and especially defecation are attended with much suffering. The displacement is easily reduced, but is very liable to return. The only treatment is to keep the patient in the recumbent position for a few days until the pain has to a certain measure subsided, and to keep the motions relaxed so as to avoid, as far as possible, any undue strain upon the sphincter or the levator ani. Injuries of the coccyx are very frequently followed by persistent pain, and great tenderness of skin over the region supplied by the lower sacral nerves. This is especially the case in women, though it is not coniined to them. Sometimes it can be traced to gouty or rheumatic inflammation of the fibrous tissue surround- ing the bone, and it may be relieved by iodide of potash, and by counter- irritants ; but in many instances it is rather a sign of uterine derangement, and nearly always it becomes worse at each menstrual period. In the worst cases it is necessary to provide the sufferer with a circular cushion, so that the tuberosities of the ischium may sustain the whole weight, and the coccyx lie, as it were, buried. Subcutaneous section of the tissues around the bone and excision of the bone itself have been performed, when the distress was very great, but not always with success. Fracture.s Throuc.h the Pelvic Girdle. When the pelvis is crushed it gives way at the weakest spot, rather than at the , sides of the circle ; the line of fracture nearly always ])asses across the bone at the inner margin of the obturator foramen, and then if the force continues, at or near the sacro-iliac synchondrosis on the opposite side. Sometimes, when the force comes from in front, the fracture is almost symmetrical, the whole of the body of the pubes being separated from the rest, and both the articulations opened up behind. In a few cases the displacement is perceptible at once ; more often the existence of a fracture is only suspected from the extreme shock, the intense pain at certain points, greatly aggravated by any attempts to separate or bring together the crests of the ilium, and the injury to the neighboring viscera. The urethra suffers most often ; it may give way either on the superficial or the deep FRACTURES OF THE FEMUR. 413 surface of the triangular ligament ; in the former case the urine is extrava- sated into the scrotum, in the latter into the deep cellular tissue of the i)elvis. The bladder, however, may be ruptured, the rectum, or even the contents of the abdomen se- verely injured, and the large vessels torn across. The injury, even when it is not complicated in any way, is always serious ; and as the soft parts and the viscera are generally torn, crushed, or wounded by splinters, the prognosis in accidents of this kind is most unfavorable. So far as the fracture itself is con- cerned, very little is required ; the part must be kept at ])erfect rest and over-examination care- fully avoided, but the condition of the viscera must be ascertained with the least possible delay. Fig. 140.— Fracture of Pelvis. FRACTURES OF THE FEMUR. I. The Upper Extremity. These were divided by Sir Astley Cooper into (i) fractures of the neck entirely within the capsule, (2) fractures at the base of the neck where it joins the trochan- ters, external to the capsule, and (3) fractures through the trochanter major, to which may be added (4) separation of the epiphyses. As, however, wholly extra- capsular fracture of the neck of the femur is an anatomical impossibility, so far, at least, as the front of the bone is concerned ; and as this does not take into considera- tion the question of impaction (on which repair depends to a very great extent), it seems better to divide them into — (i) Impacted fracture. (2) Non-impacted fracture, of which there are tw^o varieties : — {a) Intra-articular, wholly within the joint ; and (J)) Through the line of attachment of the capsule, at the base of the neck, partly within, partly without. (3) Fracture through the trochanter. (4) Separation of epiphyses. It is true that a certain number of cases cannot be grouped under any one of these, but it holds good for the vast majority. They are to be regarded as types of common occurrence, presenting perfectly definite symptoms, and requiring entirely different methods of treatment. It is as well to leave impacted fractures until the other forms have been con- sidered. Jtitra-articular Fracture. This is peculiar for several reasons : it is very rare under fifty years of age, very common afterward ; it is produced by exceedingly slight degrees of violence ; it is more common in women than in men ; and unless it is impacted, or the frag- ments are in some way held together, bony union never takes place. The line of separation lies wholly within the capsule, immediately below the head. If the force acts vertically the fracture is stated to be generally oblique ; if from in front, trans- verse. Occasionally the under surface only gives way, the tissue at the upper part of the neck being bent rather than broken. When it is impacted the compact tissue on the under surface of the neck is driven into the cancellous substance of the head. 414 DISEASES AND INJURIES OE SPECIAL STRUCTURES. 'I'his may be explained in great measure by the structure of the part and by the changes the bone undergoes as age advances. The angle which the neck of the femur forms with the shaft is commonly stated to be about 128° in the adult, and to diminish gradually in old age; in women it is less than in men, and certainly the smaller it becomes and the more nearly it approaches a right angle, the more likely it is to give way. It is not true, however, that this change is invariably associated with age. In many old people the angle of the femur is quite unaltered ; and, on the other hand, in ex- amining the bodies of well-developed adults without a sign of rheumatoid arthritis, I have on several occasions found the top of the trochanter higher than the head, and this rotated so far that a flattened facet was develojied on the front surface, corresi>onding to the tendon of the ilio-psoas. The changes in the substance of the bone are more constant, but even they are proi)ortionate rather to the amount of disuse than to the years of the jjatient. The cavity of the shaft extends upward with the cancellous tissue of the neck ; the trabeculge are thinner and softer, the bone itself is infiltrated with fat, and the compact layers on the exterior waste, until, in extreme cases, they are almost translucent. When this is far advanced it is scarcely surprising that a very slight strain is sufficient to break it across. The causes are always of the most trivial description. Sometimes it is a sudden vertical shock, as in slipping from off a curb-stone ; in other cases it is a twist, as when in walking the inner side , of the great toe catches against a fold of the carpet ; the ilio-femoral band acts as the fulcrum of a lever ; the leg is the long arm, the neck the short one ; the head of the bone cannot move, the liga- ment is much too strong to yield ; so if the force is severe and sudden enough the short arm must break across at its weakest spot. Even turning round in bed will sometimes do it. In a third set the bone is broken by a fall upon the trochanter, and then there is often impaction ; the thinnest part of the neck gives way, and a continuance of the force drives the compact tissue upward and inward into the cancellous substance of the head. Signs. — No attempt should ever be made to elicit crepitus, and manipulation of all kinds should be avoided as much as possil)le. The fragments at first are close together, and the only hope in obtaining union lies in keeping them there; any movement that would cause crepitus is sure to separate them. Displacement. — The direction is nearly always the same, but the extent is very variable. The neck of the femur is invested, especially on its under surface, by dense bands of fibrous tissue, which pass upward from the line of attachment of the capsule to the margin of the head. These are the reflected fibres which form a kind of periosteum for the neck and convey to the head its most important vessels. In intra-articular fracture they rarely give way at the time of the accident, and partly from this, partly because the capsule is not torn, much separation of the fragments is unusual. The muscles that pass from the trunk to the thigh pull the femur upward and inward toward the middle line, so that the trochanter sinks in and the limb is slightly shortened, but the amount of this rarely exceeds three-quarters of an inch. After two or three days, however, when, owing to the exudation that takes place, all the fibrous tissue is infiltrated and soft- ened, it often increases to an inch and a half, or even two inches, unless care is taken to prevent it. As accuracy in measurement is very essential, various methods have been devised for estimating the amount of alteration. Which- ever plan is adopted, care must be taken that the position of the two Fig. 141.— Bryant's Triangle. C B, test-line for fracture or 1 :,,-,K< ;« olicnlntpl v <:vmmptrirnl • the shortening of the neck of the thigh-bone. iimus IS aijsoiuteiy Symmetrical , inc FRACTURES OF THE FEMUR, 4'5 least deviation is sufficient to vitiate the result comi)letely. A roui^^h guess may be made by comparing the position of the two malleoli, having first made sure that the body is perfectly straight, and that the pelvis is not tilted. Measure- ment, either by means of tape, or better, with a sliding graduated rod, from the anterior superior spine of each side to the internal malleolus, is more accurate ; but neither of these methods can i)rove where the shortening is. To effect this three different plans have been recommended : Nelaton's line, Bryant's triangle (Fig. 141), and Morris' bi-trochanteric measurement. Nelaton's test consists in stretching a taj)e from the anterior su[)erior spine of the ilium to the most prominent part of the tuberosity of the ischium. In the healthy adult the top of the trochanter never comes above this ; if it does, the neck of the bone must have been shortened either by disease (rheumatoid arthritis or rickets) or by fracture. Bryant's triangle is made up of the perpendicular line Fig. 142. — Intra-articular Fracture of Neck of Left Femur. No uuiou has taken place; the neck has been absorbed ; and the under part of the head glides up and down a polished surface corresponding to the anterior inter- trochanteric line. Fig. 143. — Vertical Section through Upper End of Right Femur, from the same patient, showing the changes undergone in extreme atrophy. from the anterior superior spine (when the patient is lying down) ; the line from the same point to the great trochanter ; and a third drawn from this at right angles to the vertical one. The difference in the length of this third line on the two sides gives the amount of shortening. Morris' bi-trochanteric measurement compares the distance on each side from the median line to the top of the great trochanter. It indicates the inward displacement of the trochanter, and can only be taken satisfactorily by having a rod, graduated on each side from the middle, with two pointers sliding on it, so that when it is held over the body they may come into contact with the top of the great trochanter. The appearance of the limb is very characteristic. It lies on its outer side, completely everted from the hip to the foot, with the knee slightly flexed ; there may be a slight swelling in front over the hip-joint, due to the rotation of the lower fragment ; the trochanter is sunken inward and drawn nearer the anterior spine, and there is from half an inch to an inch of shortening. There is no 41 6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. superficial bruising or contusion ; the trochanter is not thickened, and though it is painful when pressed upon, the pain is not like that of fracture through the base of the neck. The most tender spot is generally on the inner side of the thigh, about the insertion of the ilio-psoas or a little lower down. In some rare ca.ses the patient is able to raise the heel from the bed, ])robably because the reflected fibres are intact or the fragments interlocked ; more often the knee can be Hexed a little, Init any attempt to lift the leg fails completely. In a few exceptional cases there has been inversion of the foot. The eversion is due mainly to the weight of the limb ; at least there is no doubt this is sufficient to cause it, though possibly the contraction of the ilio-psoas may a.ssist (the short muscles attached to the great trochanter when the neck is broken would scarcely have any rotatory power) ; inversion, when it is present, must be produced by the direction of the violence that caused the fracture, and is probably kept up by the accidental locking of the fragments. In most cases the fascia lata on the outer side of the thigh, extending from the crest of the ilium to the head of the tibia, is distinctly relaxed, both above the trochanter and again above the knee joint. Manipulation should be avoided as much as possible, but when it is really necessary for the diagnosis extension readily restores the limb to its proper length, and often, at the same time, gives rise to the sensation of crepitus, especially if the limb is rotated inward at the same time. Further, if the trochanter is grasped while this is being done, it clearly does not move through the same range as the other. Movement in all directions is abnormally free and very painful. The constitutional disturbance in these cases is always slight at first ; there is no fever and but little shock, but very often the patient never really rallies, the circulation remains feeble, the heart's action never recovers, the mind begins to wander, and congestion of the lungs, retention of urine and cystitis, or bed-sores, make their appearance in spite of every care. The prognosis, therefore, is always .serious, especially in the aged. Repair. — Union by bone probably never occurs unless the fracture is impacted. The broken surfaces are not in contact. Even if the action of the mu.scles and the weight of the part could be set aside, the distention of the capsule, partly from hemorrhage, partly from exudation, would be enough. Further, the head is often rotated in its socket, so that it no longer faces the broken surface of the neck; and as its blood-supply is cut off, no callus is ever found on the upper fragment. As Astley Cooper pointed out, most of the vessels that supply this part of the bone enter the neck on its under surface, and, of course, are torn ; recently, too, it has been shown that the artery running in the ligamentum teres does not enter the bone at all. The blood-vessels in the neck probably dilate, because, in a large proportion of cases, this part of the bone is completely absorbed. The main bond of union is the capsule, which becomes enormously thick. Sometimes there is a certain amount of fil)rous tissue formed between the fragments, passing from the under surface of the neck, and also from its cancellated structure, to the head ; but in many there is no union at all, the surfaces become hard and polished, the neck disapjjears, and the head of the bone rests on the lesser trochanter, or spurs are thrown out round the base of the neck to catch the rim of the acetabulum. Many patients after accidents of this kind remain almost bedridden, or can only get about with assistance ; others, especially if they are not corpulent, can lay aside their crutches after a time and walk with a stick — a few can dispense even with this; but, in sj^ite of a high heel to compensate for the shortening, a certain amount of lameness is always left. Treatment. — This must be guided entirely by the condition of the patient. Many old people never really lie down at all, and to keej) them on their back by means of a long splint would inevitably bring on congestion of the lungs. Astley Cooper recommended that they should be i)roi)]ied up in bed, with the limb supported by pillows in the most comfortable position, for ten days or a fortnight, until the ])ain in some measure had subsided ; then they should sit up every day in a high chair, so as to avoid flexion of the limb, and begin to use crutches as FRACTURES OF TJIF FEMUR. 417 soon as possible, bearing a little more weight upon the foot each day, until the capsule had become sufficiently strengthened. In the meantime water-cushions must be used freely so as to avoid the occurrence of bed-sores ; the'most scrupulous cleanliness must be observed, especially as urinary trouble, i)artly from age, partly from the confinement in bed, is very common ; and the skin must be sponged with spirit every day to harden it. .As soon as the patient begins to sit up,- the limb nuist be enclosed in a shield made of leather or felt, large enough to grasp the pelvis and the thigh, running completely round the body and two-thirds round the limb, as low as the knee. This should be made with straps and buckles, so that, while it is able to hold the part firmly and give it sufficient support to protect it from injury, it may also be removed every few days for the purpose of attending to the skin. In younger patients, especially when the amount of .separation is not great, an attempt may be made to ])rocure union between the fragments, though it is very unlikely that it will be osseous. A long splint must be applied to the outer side of the limb from the axilla to below the foot, as in fractures of the shaft, and a moderate weight attached to the leg, counter-extension being made by raising the foot of the bed. Particular care must be taken to correct the eversion ; it is not sufficient for the foot to be merely straight, the great toe must be a little inverted, or when the bandages are removed it will be found that the correction is not sufficient. If possible, this must be kept up for six weeks, though if the patient's health begins to fail, or if, in spite of water-cushions, there is any fear of bed-sores, it is possible to do with a fortnight less ; then the limb may be secured either in a Thomas's hip-s]jlint or in a leather shield, and the patient allowed up on crutches, the foot being slung and not allowed to touch the ground for six weeks or two months more. Unless rheumatoid arthritis sets in, there is very little fear of the hip joint becoming unduly stiff. In one or two instances the hip joint has been laid open from in front and the fragments wired together. The operation was successful and apparently osseous union followed ; but cases in w^hich such a proceeding could be recom- mended must be very rare. Fracture through the Base of the Neck. This stands out in clear contrast to the former. The line of separation fol- lows the intertrochanteric line in front; behind it is a little internal to it, so that the fracture is partly within, partly without the capsule ; the whole of the neck is detached and the trochanter often comminuted. It may occur at any time, but is most common in adult life, and in men, because it is never caused but by an ex- treme degree of violence applied directly to the hip. A moderate amount of force breaks the bone across, drives one fragment into another, and leaves it impacted there ; when it is more severe the wedge -shape neck splits the trochanter into pieces and frees itself again. There is a great deal of "-■<;.5vv^'3>^' '<^ bruising all round the hip ; the trochanter ■ 1 J 1 r^ ^1 r «. Fig. 144. — Horizontal Section through Neck and is Widened, and often the fragments are Trochanterof Femur, to ilU.strate the method of Ciuite loose; crepitus is always present; production of fracture through the base of the ' . . ' ' ^ ' . ' neck. 1 he anterior layer of compact tissue pain is very great; usually the shock is bends when the posterior is driven into the ^- r ,. 1 . r-. 1 fVi trochanter, and then breaks. Probably partial severe, sometimes even latai , ana tne fractures are of common occurrence. amount of shortening at the first is rarely under an inch and a half, and may be as much as three. Eversion is present in the vast majority, but occasionally inversion occurs, as it does in the intra- articular form. Eigelow has shown, in reference to these injuries, the way in which the 4i8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. fracture occurs. If a horizontal section is made through the neck and head of the femur, the anterior layer of compact tissue is seen to be ecjually strong throughout, perhaps rather stronger in the middle than elsewhere, owing to the section passing through the tubercle ; the posterior, on the other hand, ends abruptly in the cancellatous tissue of the trochanter. In a fall upon the hip this part gives way first; the anterior layer splits more or le.ss vertically, .so that the shaft is everted upon the neck ; and if the force continues the jjosterior compact layer is driven further and further into the trochanter until it sfjlits into fragments. The difference in the mode of repair is equally striking. Union by bone is almost invariable, and the amount of callus thrown out is often greatly in excess of what is needed. In these cases, therefore, every effort must be made to restore the length of the limb and the position of the fragments as thoroughly as possible. Very often it is of great advantage to give the patient an anaesthetic ; the manipulation is painless ; the broken surfaces can be adjusted more accurately ; the mu.scles are relaxed so that th« limb can be extended to its full length at once ; and when consciousness returns, owing to the compression and extension to which they are subjected, there is not the same amount of spasmodic contrac- tion. The most efficient method is by means of a long splint and a weight, the amount employed being regulated in each case by the condition of the mu.scles and the degree of shortening. If it is attached to the limb alone, and there is no friction against the bed-clothes, eight or ten pounds are usually sufficient, though in exceptional cases much more may be required. The rapidity with Avhich re- pair takes place depends upon the age of the patient and on the bruising and comminution to which the parts have been subjected. Generally the patient may be allowed to get about at the end of four weeks with a Thomas's hip-splint, or a leather .shield, or a firm spica (made extra strong in front and on the outer side), but no weight can be allowed upon the limb for at least six weeks or two months more. Union rarely fails, but there is nearly always a certain degree of lameness and shortening afterward. Impacted Fracture of the Upper End of the Femur. This, again, is entirely different. There are two varieties, corresponding to the two described already, but they can rarely be distinguished from each other ; and, as they require precisely the same treatment, it is doubtful if there is much advantage in attempting to do .so. In the one the line of separation follows the ba.se of the neck, and this is forced into the substance of the trochanter until it is fixed there (Fig. 145) ; in the other the fracture is immediately below the cartilage, and the under surface of the neck is driven into the cancellous tissue of the head (Fig. 146). The former is not confined to any age and sometimes may be diagnosed from the condition of the trochanter; the latter (the intra-articular form) rarely occurs except in old people, but it is .seldom possible to distinguish one from the other. The important feature is the existence of impaction. The cause is always direct violence, a fall or a blow upon the hip. The symp- toms are almost the .same as those described already, but they are not nearly so marked. The shortening is rarely more than half, or at the most three-quarters of an inch ; and so long as the impaction continues it does not vary. There may be in- version in this as in the other fractures, but it is very rare ; the limb is either straight or everted, and it is not possible to rotate it inward, as it is when the bone is not impacted. Sometimes the patient can lift the limb from the bed ; walking, even, is possible ; and Astley Cooper mentions the case of a man who- went about for four days and pa.ssed inspection before the impaction gave way. Crepitus and undue mobility of course are wanting; while the amount of pain and the severity of the shock naturally vary with the nature of the accident. The condition of the fascia lata on the outer side of the thigh, whether it is relaxed or not, is in many cases the only sign by which it is possible to distinguish between impacted fracture of the neck of the femur and a severe contusion of the hij) FRACTURES OF THE FEMUR. 419 in an old or rheumatic patient. Sometimes even this fails, and then the diagnosis can only be made by the length of time that it takes for the liml) to recover. The important point in these fractures is the presence of impaction. If this can be ])reserved, repair by bone is fairly certain, with the minimum of deformity; if it is broken down, in the one case there will be only ligamentous union, perhaps none at all ; in the other the deformity and shortening will almost certainly be increased, and the period of confinement much lengthened. The limb must be handled with the utmost care, and any manipulation that is not absolutely neces- sary strictly avoided. For security's sake it should be bandaged to a long splint, or, if there is any fear of congestion of the lungs, fixed between sand-bags with a weight of two or three pounds attached, not for the purpose of keeping up exten- sion, but merely to prevent spasmodic contraction. In three or four weeks' time a Thomas's sjilint may be applied, or the limb encased in a shield or a spica, and the patient allowed to get about on crutches with the foot suspended in a sling. A shorter time than this is rarely advisable ; and if the injury is very severe, or the patient corpulent, it may be extended with advantage. The accident is a serious 'vm Fig. 145. — Impacted Fracture through Base of Neck of Femur. .,=^r^r:^ 4^ Fig. 146.— Impacted Intra-articular Fracture of Neck of Femur. one, the weight and the leverage of the limb are very great, and it is rarely worth w'hile running any risk. The shortening is easily compensated for, but if much eversion of the limb is left the position of the foot is very awkward. Fracture Through the Trochanter. Two forms of this have been described, but they are both rare. The first is merely a variety of the fracture through the base of the neck without impaction, the line of separation running obliquely through the trochanter a little further outward, so that one half remains attached to the head and neck, the other to the shaft. The symptoms depend upon the amount of displacement, which, unless the fragments become locked in some way, is generally very great. In one case the injury closely simulated dislocation on to the sciatic notch, but the presence of crepitus and undue mobility, the results of measurement in the flexed position of the limb, and the absence of the hollow in Scarpa's triangle, are sufficiently characteristic to prevent serious difficulty. In the other variety the trochanter is detached from the rest of the bone 420 DISEASES AND INJURIES OF SPECIAL STRUCTURES. by direct violence. Several instances are on record, but as the patients were young, in all probability they were examples of separation of the epiphysis (Fig. 147). Tlie swelling and ecchymosis may be so great as to render diagnosis difficult ; jjassive movement of the joint is unimpaired, though very painfid ; crepitus ( an rarely be felt, owing to the way in which the troclianter is pulled upward by the glutei and the short rotators, and the length of the limb is unaltered. In one case the broken surfaces were held together by the fascia, which was not torn. Union, unless this is pre- served, is almost sure to be fibrous, and for some time at least there is considerable loss of power over the Fig. 147— Separation of Great ''mb. Trochanter of Femur. Sejjaration oi the epiphysis forming the head of the femur may occur, but it ha.s not been proved. The symptoms would be the same as those of the intra-articular variety. Diagnosis. — The diagnosis of fracture of the neck of the femur must be made from sciatic dislocation, impaction of the head of the bone into the floor of the acetabulum, fracture of the lip of the acetabulum, and contusion, especially in cases of rheumatoid arthritis. If there is the least doubt, the examination should be completed under an anesthetic ; to say nothing of the pain, it is almost impos- sible to manipulate the thigh of a muscular adult satisfactorily unless the muscles are relaxed. 1. Sciatic Dislocation. — The difficulty is due to the fact that in this form of injury the limb is often almost straight, and retains (especially at first) a very un- usual degree of mobility ; and also that the head of the bone can rarely be felt. Unless, however, the patient is very stout, an emj^ty space can always be made out in Scarpa's triangle ; the femoral vessels can be felt to dip down suddenly ; abduc- tion of the limb when it is flexed at a right angle is impossible, and the measure- ment of the length of the thigh, when the hip is in this position, shows very considerable shortening. 2. Impaction into the Floor of the Acetabulitni. — This is a very rare accident, but on several occasions the mistake has occurred. The injury is produced in the same way ; the violence is extreme and the amount of bruising sufficient to conceal everything. Movement may be very free, probably owing to the extent to which the bone gives way. The chief distinction is the extreme inward disi)lacement of the trochanter ; in addition there may be signs of injury to the innominate bone ; and it may be possible to feel the head of the femur through the rectum or vagina. 3. Fracture of the Lip of the Acetabulum. — When the upper and back i)art is chipped off, the head of the bone slips out of the cavity and rests on the dorsum, almost in the jjosition of a dislocation. In one case under my care the displace- ment was exactly that of a sciatic dislocation, and was reduced as such, but it immediately returned, and when the limb was manipulated the head of the bone could be easily felt above and behind the trochanter. 4. Severe Contusions. — In these the difficulty is very much greater, and if the limb is shortened and everted from old rheumatoid arthritis ; if (as is often the case) the trochanter is thickened, and, owing to the disappearance of the articular cartilage, there is a certain amount of crepitus on movement, it may be impossible to feel certain until a sufficient length of time has elapsed for the muscles to re- cover. The limb lies perfectly helpless and everted ; the muscles cannot act, o\ving to the way in which they have been bruised, and it is im])ossible to say whether the whole of the shock has been expended on the soft tissues, or if the bone has suffered too. Not imjjrobably in many of these cases the neck is splintered on its anterior surface, though it may not actually be broken across. The history is of little service, sui)posing it could be relied upon ; the existence of rheumatoid arthritis would not in any way preclude fracture. The only distinguishing sign is the condition of the fascia lata on the outer side of the thigh ; if the shortening is FRACTURES OF THE FEMUR. 421 gradual (as from disease) this is tense ; if siuiden, it must be relaxed ; Init it must be admitted that it is not always jjossible, even when the two sides are compared, to make certain of the difference. At a later jieriod the diagnosis of contusion without fracture is occasionally called in (juestion, owing to a peculiar alteration that takes place in the substance of the bone. It sometin-.es happens tliat, within a twelvemonth of an accident of this kind, the neck of the femur almost disappears, the limb becomes everted and shortened an inch or even an inch and a half, the muscles waste, the movements are crippled, and the appearance is almost identical with that left after fracture of the neck. This is known as interstitial absorption of the neck of the femur. In many of its features it closely resembles rheumatoid arthritis, and it is well known that this sometimes attacks a single joint, almost to the exclusion of the rest, especially after injury ; but these changes are not unfrequently met with in young adults, who, at the time at least, show no other sign of this disease ; and an altera- tion of a somewhat similar character is found occasionally in connection with other bones, the humerus, for example, after fracture. All that can be said is that injuries of this description are sometimes followed by ])rofound alterations in the nutrition of the part. Fractures of the Shaft of the Femur. These may be caused by direct or indirect violence, or l)y muscular action, and may affect any part of the bone from the lesser trochanter to the base of the condyles. In infants and children they are transverse and usually subperiosteal ; in adults they are more frequently oblique, sometimes even spiral. Compound and comminuted fractures are not uncommon, but impaction is rare, except at the lower extremity. Displacement. — The relative position of the two fragments is dependent mainly upon the direction of the fracture. When it is transverse and the perios- teum is not torn, there is merely a certain amount of angular bending ; in all other cases the lower part of the limb rolls outward, from its weight, /intil it lies com- pletely upon its outer side, and is pulled upward toward the u-unk by the con- traction of the muscles. There may be as much as three or even four inches shorten- ing in a muscular adult. The position of the upper fragment is not constant ; it is generally rotated outward to a certain extent, especially if the fracture is high up, by the muscles attached to the great trochanter, but never so far as the lower one, and it is usually flexed and tilted upward, partly by the action of the ilio-psoas, partly by the pressure of the lower fragment against its under surface. When the fracture is immediately below the lesser trochanter I have known it tilted to such an extent that the broken surface projected underneath the skin upon the front of the thigh. Symptoms. — The ordinary signs of fracture are well marked ; the limb is shortened, everted, and absolutely helpless ; undue mobility and crepitus are always present, and there is always extreme pain about the seat of injury. Ecchymosis, however, owing to the deep situation of the bone, often does not show itself for some considerable time, in many cases not at all. Sometimes it is difficult to make certain of the exact position and direction of the broken ends, especially if they are very oblique or driven deeply into the substance of the surrounding muscles, and it is never easy to appreciate the amount of comminution. The soft tissues rarely suffer to any serious extent in simple fractures, except when the injury is low down in the thigh ; in those that are compound by direct violence, on the other hand, they are often hopelessly disorganized. Union is generally sufficiently firm at the end of three weeks to allow the patient to get about on crutches with some fixed apparatus, but no weight must be placed upon the foot for at least ten weeks from the date of the accident, and in many instances, when the patient is corpulent or the fracture oblique, this time may be extended with advantage. Except in transverse fractures, shortening to 42 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. ii>.\ o o the extent of half an inc h is so common, in spite of every precaution, that it must be regarded as the rule : sometimes it is even worse than this, without its being possible to say that the case has been treated badly. Delayed union is not uncom- mon, and false ;oint may occur, especially when the fragments are oblique or are driven into the muscles around. Treatment. — The simplest and most useful method for all ordinary cases is a combination of Liston's (Fig. 148) or Desault's (Fig. 149) long splint, with ex- tension by means of a weight attached to the limb. Counter-extension is made, not with a perineal band, which is very apt to gall the patient, and in women is peculiarly objectionable, but by raising the foot of the bed, .so that the body lies on an inclined plane [and itself constitutes the counter extending force.] The splint must be sufficiently long to reach from the axilla to below the foot, the outer malleolus fitting into the hollow made to receive it, and sufficiently broad to be really on a level with the thigh ; in cases in which the hips are prominent, the padding must be especially thick or the patient cannot lie straight, and there should always be a cross-bar screwed to the under surface at the lower end, to serve the double purpose of raising the heel well off the bed and of preventing any rotation of the limb. A flannel bandage is first placed round the foot and the lower part of the calf; and then a piece of strapping two inches and a half wide, and twice the length of the distance from just above the patient's knee to six inches below the sole, is fastened to the limb, so that the two ends lie one on each side, and the loop projects below the foot. If the strips are arranged ob- liquely, the outer end winding round the limb toward the posterior surface, and the inner to the anterior, the ex- tension helps as soon as the weight is on, to correct the eversion of the limb. Transverse strips are then placed round the limb to hold this in position, the centre of each corresponding to the posterior surface of the leg and the ends crossing obliquely in front, until the whole is covered in from the middle of the calf to the condyles of the femur. The loop is held open with a wooden stirrup, which is per- forated in the centre to allow of a cord being passed through and is wide enough to jirevent any pressure upon the malleoli, and the weight suspended from the other end of the cord by means of a pulley at the foot of the bed. The amount depends upon the degree of shortening and the strength of the muscles, but eight or ten pounds are usually sufficient (Fig. 150). If the patient is under an anaesthetic the splint may be bandaged on at FRACTURES OF THE FEMUR. 423 once ; in other cases it is sometimes advantageous to wait until the next day, when the fragments have resumed their normal situation ; the part in the meantime is kept steady by means of sand-bags. The long splint is fastened to the outer side of the limb, from the foot to above the knee, beginning with figure-of-eight turns, wide enough to pass through the notches at the lower end of the splint and to come well above the ankle ; if any pressure falls upon the back of the heel, a sore is sure to form. In fractures near the middle of the shaft it is advisable to place a splint behind the limb to maintain the natural arch of the bone ; the inner and anterior surfaces may be covered with felt or with Gooch's splint, cut to fit the part, and fastened on with straps and buckles Fig. 150.— Mode of Applying Stirrup for Weight-Extension. (Fig. 151). In Other cases it is sufficient to carry the bandage up from the knee over the seat of fracture. In bandaging a fractured femur the turns should be carried from the outer side over the front of the limb down the inner one, as this is of considerable help in correcting the eversion. Finally the splint must be secured round the waist, either by means of a broad bandage, or a belt provided with straps and buckles, and bandages starched. Liston's splint is made of wood four inches wide, and half an inch thick, long enough to reach from the axilla to six inches below the foot. The upper end is perforated for the attachment of a perineal band ; the lower notched, so as to afford a better grip for the bandage. Desault's differs in having a foot-piece to fit Fig. 151.— Liston's Splint Applied with Gooch's round Seat of Fracture. on the outer side, in being hollowed out, and in being much wider at the upper end than at the lower. At the end of a fortnight or three weeks, according to the age of the patient and the direction of the fracture, this maybe replaced, either by a fixed apparatus of gum and chalk, a starched bandage with longitudinal strips of torn pasteboard, or, better still, by a Thomas's knee splint. This consists of a well-padded circle, fitted obliquely round the thigh as high up as it will go, two straight rods coming down from this, one on each side of the limb, and a small patten at the bottom, below the foot, to connect them together. If the stirrup has been well applied the long splint can be removed, a Thomas' splint fitted on, the weight cut off, and the cord fastened to the patten at the bottom without disturbing the limb in the least 4 24 DISEASES AND INJURIES OF SPECIAL STRUCTURES. (Fig. 152). In most instances it is advantageous to replace the cord by an elastic band, so as still to keep up a certain degree of extension, or the sides of the splint may be made so that the length can be altered at will. Anterior and jxjsterior wooden or felt splints are necessary to protect the seat of injury, and the leg and thigh must be firmly bandaged to the side rods. As soon as this is secure the patient may l)e allowed to get about on crutches, with a patten under the oppo- site foot ; but, though the whole of the weight would be transmitted directly from the fjelvis to the ground, it is not advisable to let him rest upon the splint i^atten for some weeks longer : the leg should hang from the hip-joint as a mere appendage. In some cases Thomas's splint is used from the first, but it is difficult to obtain the requisite amount of e.xtension without galling the patient ; after being kept steadily on the stretch for two or three weeks, the tendency to contract on the part of the muscles is very much diminished. In fractures below the trochanters another plan must be adopted. Extension in a straight line does not in any way correct the deformity, and as it is impossible to influence the upper fragment materially, the lower must be adjusted to it. This is accomplished either by laying the patient upon the injured side, and flexing the thigh upon the abdomen as recommended by Pott, or by making use of a double- inclined plane. The latter is the more comfortable ; the patient can be propped up in bed so as to relax the ilio-psoas still more, and there is less risk of bed-sores. A Maclntyre splint answers better still, and is less cumbersome. Whichever plan is adopted, extension is made from the lower half of the thigh by means of a stirrup and a weight suspended over a pulley at a convenient angle (Fig. 154;. In cases in which there is a wound on the posterior surface, or the hip or knee is ankylosed in an awkward position, an anterior splint, either Hodgen's or Nathan Smith's, may be used. The former of these consists of two parallel metal rods, long enough to reach from the groin to below the foot, held apart from each other by cross-bars. The limb is suspended from between these by cotton sacking, or broad strips of flannel, so that it rests and makes a bed for itself Fig. 152 — Thomas' Brace Splint with Stirrup- Extension. The anterior and posterior splints on the thigh and the bandaging are not repre- sented. Fig. 153. — Badly United Fracture of Femur. FRACTURES OF THE FEMUR. 425 in a kind of trough (Fig. 155). Tlie foot is fixed by a stirrup to the cross-bar at the end, and the whole is slung from a pole over the bed at such an angle that a certain amount of extension is kejjt up, the weight of the body acting as a counter-extending force. The knee joint nuist be kept nearly straight. Nathan Smith's is either formed of a similar framework with the rods closer together, or ^^c Fig. 134- — Maclntyre Splint with Weight-extension from the Knee in Fracture of the Femur below the Trochanter. of a single flat median bar. The limb is bandaged directly to its under surface, so that it must be bent to fit accurately, and then it is suspended in the same way. When properly adjusted these splints are exceedingly comfortable, but they are very difficult to arrange (suspending hooks should be made so that they can be fixed at any point) ; they do not secure the same degree of immobility, or maintain extension so well, and it is very difiicult to prevent eversion with them. Transverse fractures of the shaft in children may be treated in various ways. In very young infants, where the thick periosteum is probably intact all round, it is sufficient in many cases merely to lay the child upon a pillow on its injured side, with the hip and knee flexed. As a rule thev lie re- Fig. 155. — Dr. J. T. Hodgen's Suspension Splint, as used at Guy's. Fig. 156. — Plaster Bandages and Verti- cal Extension for Fracture of Femur in an infant. markably quiet, and though the bone may not be perfectly straight, the angle is so slight, and the subsequent changes so rapid and extensive, that in a year or two it is scarcely perceptible. Union is fairly firm in ten days or a fortnight. In those a little older, vertical suspension of both legs is more satisfactory ; a miniature stirrup is fastened on to each in the ordinary way ; the cords are 28 426 DISEASES AND INJURIES OF SPECIAL STRUCTURES. passed over two pulleys attached to a cradle or a horizontal bar over the child's body, and a weight is suspended from each just sufficient to keep the leg straight in a vertical position. A starclied l)an(lage is then placed round the thigh. The child soon becomes accustomed to the constraint, and the bandages remain dry and clean to the last. Bryant's splint, which is made of two long ones, one on either side of the body, connected together by an arch over the trunk, and a bar below the feet, is especially useful in the case of older children. Extension can be applied by a weight to the injured leg ; it is impossible for the child to twist its body round, and the limbs are kept exactly parallel. Fractures of the Lower Extre.mitv of the Femur. These may be classifietJ in the same way as fractures of the lower extremity of the humerus. The bone may be broken across altogether above tlie knee-joint. —->^ F1G.157. — Shaft and Epiphysis of Femur Sepa- rated by maceration. The epiphysis had been split in two about a year before the limb was removed, and union across the epiphysial line was osseous. Fig. 158. — Fracture of Lower End of Femur with Displacement of Upper Fragment Backward. About a year after the accident the projecting end wore a hole in the popliteal artery and gave rise to an arterial haema- toma. supracondyloid ; in addition to this the lower extremity may be split vertically in two, by the wedge-like action of the patella, T-shaped ; one or other condyle may be detached ; or the epiphysis may be separated. Imi)acted fractures are not uncommon, the lower end of the upper fragment being driven into the cancellous tissue of the other with sufficient force to become fixed in it, but not sufficient to break it into pieces. The lower end of the femur may be split vertically by the impact of the patella, without any transverse separation (Fig. 157). Supra-cotidyloid and T -shaped. These mav be produced by direct or indirect violence ; in the latter case the bone gives way at the junction of the compact tissue of the shaft with the ex- panded lower extremity; impaction is not unusual; and, if the force is very FRACTURES OF THE FEMUR. 427 severe, the lower fragment is split into two (or even more pieces), the fracture assmiies a T-shape, ami the knee joint is opened up. In the supra-condyloid form there is peculiar danger from the position of the popliteal vessels. The fracture is generally oblique from above downward and forward ; the gastroc- nemius, pulling on the lower fragment, causes it to rotate; the fractured surface is directed backward, the normal anterior one upward ; and if any extension is made upon the leg the vessels are almost certain to be compressed, perhaps even torn. The same thing occurs when the displacement is in the opposite direction, if the lower end of the upper fragment comes in contact with the artery (Fig. 158). The synovial membrane of the knee joint may be torn under the quadri- ceps tendon so as to communicate with the fracture, even when there is no vertical fissure running down. Signs. — Shortening, deformity, pain, and swelling are so conspicuous that, even if the fragments are impacted, there is little difficulty in the diagnosis. If they remain loose, crepitus and undue mobility are present as well. When the knee joint is involved the synovial cavity becomes distended with blood ; if the condyles are separated, they can be made to work backward and forward upon each other by pressing on them alternately ; and there is an increase in the transverse measurement of the part. When the popliteal artery is torn, or w^ounded, an immense sw-elling forms with great rapidity in the popliteal space, filling it up completely, and the limb becomes cold and pulseless ; if it is merely pressed upon, the temperature of the limb falls more gradually, but in spite of the collateral circulation the same result generally ensues. Treatment. — This depends to a great extent upon the direction of the fracture and the amount of injury done to the knee joint. Shortening is very common, unless the fracture is transverse, and nearly always there is some impairment of movement, partly owing to the difficulty of restoring exactly the outline of the articular surfaces, partly from the formation of adhesions. The condition of the posterior tibial artery requires even more than ordinary atten- tion. Liston's long splint and weight extension from the leg may be used, if the upper fragment has a tendency to back\vard displacement : in all other cases either the limb must be placed on a double inclined plane (or a Mclntyre splint), or the tendo-Achillis must be divided. The latter is preferable, as, owing to the small size of the lower fragment of bone, it is almost impossible to make satisfactory extension from it with the knee flexed. If the knee joint is involved, the distention of the synovial sac must be reduced as soon as possible by cold, pressure, and even aspiration, though this should only be resorted to when the case is really urgent. Then the fragments must be replaced by man- ipulation, and fixed by pressure, taking care to cover them with a thick even layer of cotton-wool. Passive motion of the joint should be commenced not later than the end of the fourth w^eek. If the popliteal artery is wounded, an attempt may be made to secure the two ends by ligature ; but very often the vein is injured as well, or the fracture communicates with the joint, and either gangrene sets in or the knee is disorganized to such an extent that the limb has to be amputated. Separation of a Condyle. It occasionally happens as a result of direct violence, or even it is said from forcible rotation, that one of the condyles is detached from the rest of the bone without the shaft being broken across. The symptoms depend upon the amount of comminution ; the joint becomes distended with blood, generally at once, but in one case under my care this was not. marked in degree for several hours ; the length of the limb is not altered ; pain on pressure is very great ; and crepitus and undue mobility are usually distinct. A fixed bandage, with a thick layer of cotton- wool over the joint, should be applied as soon as the fragments can be manipulated into position ; but as absorption proceeds it will probably require to be replaced in 428 DISEASES AND INJURIES OF SPECIAL STRUCTURES, Ihe course of a few days. Passive motion should be commenced not later than the third week. Separation of the loivcr epiphysis is not an uncommon form of accident ; it can only occur under twenty years of age, and is rarely met with over sixteen. Generally speaking it is produced by indirect violence, forcible wrenching or twisting, but it may be caused by direct. The knee joint is almost certain to be involved, though it is anatomically po.ssible to separate the epiphysis without open- ing the synovial membrane. The symj^toms are almost the same as those of the supra-condyloid variety, from which it can only be distinguished by the age of the patient, the absence of true crepitus, and the position of the adductor tubercle. The displacement and the treatment are the same, though owing to the concave shape of the upper surface of the epiphysis there is not the same tendency to backward rotation of the lower fragment. Compound Fractures of the Femur. These may occur either from direct or indirect violence. The latter are not common, partly because the bone is situated at such a depth, partly because it is so impossible for a patient with a broken thigh to try to stand ; most of them occur at or near the lower third, and frequently they involve the knee joint. When they are due to direct violence, the injury to the soft parts is generally so extreme that there can be little hope of saving the limb, especially as the skin is not unfrequently destroyed far above the point at which the bone is crushed. The only question is when amputation should be performed. In the case of the upper part of the femur, this operation, when primary, affords so little hope, that, unless in exceptional instances, it is practically abandoned ; hemorrhage must be checked, not merely that from the main artery, which seldom bleeds, but the capil- larv oozing, for this, though almost imperceptible at any given moment, is very serious from its persistence ; putrefaction must be prevented, especially in the region of the bone, where it is exceedingly prone to occur ; and every effort must be made to restore the patient's temperature and tide him over the shock. When reaction has fully set in, the mangled part may be removed and the stump trimmed without so much risk. If the injury involves the lower half, amputation may be performed as soon as the patient is in a fit state to bear it ; but, unless it is done immediately after the accident, so that the operation is really primary, it is better to treat the case in the same way as a fracture of the upper half, and wait till the second or even the third day. In fractures that are compound by indirect violence the prospect is much better, and even when the knee joint is involved the limb can usually be saved. The treatment must be guided by the age and constitution of the patient and by the nature of the injury. A mere puncture may be dusted over w'ith iodoform and sealed beneath an absorbent dressing, the wound and the bone, if it pro- truded, having first been thoroughly cleansed with corrosive sublimate or some other antiseptic. A larger opening should be carefully exi)lored with the finger, washed out to its utmost recesses, and either drained with counter-openings or left gaping to a certain extent. If the bone is comminuted, any loose s{)linters may be removed, and if the fragments are much displaced they may be sutured together, but this is rarely possible in the case of the femur without enlarging the opening very considerably. Wound of the femoral artery does not of itself require amputation in a case of compound fracture ; injury to the vein appears to be more serious. The same line of treatment must be pursued when the fracture extends into the knee joint, but it must not be forgotten that, though the opening on the sur- face may be small, the real size of the wound is equal to that of the synovial membrane. Every effort must be made to prevent inflammation ; the part itself must be thoroughly cleansed ; the wound, if more than a puncture, washed out FRACTURES OF THE PATELLA. 429 from the bottom with an antiseptic and drained ; the limb placed upon a Mac- Intyre splint ; cold and gentle pressure applied to the joint ; and an ice-bag laid upon the femoral artery if there is the least sign of heat in the limb. If, in spite of these precautions, the joint swells up and becomes tense, and if the skin over it becomes red and (L'dematous, and the patient's temperature begins to rise, free incision should be made on each side into the joint and thorough drainage carried out. Even then the articulation may recover, though suppuration, with destruction of the cartilages and ankylosis, is a more probable result ; and secondary amputa- tion may be required to prevent the patient sinking from exhaustion. l-KACTLRES OF THE PATELLA. These are nearly always the result of muscular action ; occasionally produced by direct violence. In the for- mer case the line of separation is always transverse, though it may run across any part of the bone ; the fascia is torn to a greater or less extent ; the amount of sepa- ration is generally considerable ; and union by bone is the exception, not the rule. In the latter the fracture may be stellate, verti- cal, transverse, or comminuted ; the fascia covering it and attached to the sides is not torn ; the amount of separation between the fragments is not exceptional, and union nearly always takes place (Figs. 159 and 160). Fig. 159. Transverse and Stellate Fractures of by bone Fracture by Muscular Action. I'he frequency with which this takes place is accounted for by the anatomical relation of the part. When the knee is flexed, the lower half of the patella rests uijon the prominent portion of the condyles of the femur, the upper is entirely unsupported, and the plane of the Fig. 161. — Section through Knee after Fracture of Patella, showing Displacement. Fig. 162. -Knee in a case of Fractured Patella. bone is almost at right angles to the direction of the quadriceps. If this muscle suddenly contracts, the whole of the strain falls upon one spot, and the bone gives way just as when a stick is snapped across the knee. The patient is 430 DISEASES AND INJURIES OF SPECIAL STRUCTURES, conscious of something breaking before he falls, and it sometimes happens that, in the desperate effort to save himself, the other patella snajw across as well. I liave known this occur to a man in the first stride of a race. Displacement. — The amount is very variable, and depends ui)on the lacer- ation of the fascia; if this does not give way there is no separation. At the first instant it is caused by muscular contraction, and it is often made worse by attemj^t- ing to stand or walk. Afterward the broken surfaces are forced asunder by the effusion into the joint, and the separation is kept up by clotting of the blood in between, or by tilting of the fragments owing to the insertion of the tendon into the edge of the anterior surface of the bone ; or by shreds of fascia and some- times even the skin being driven down into the gap. In old cases the upper fragment is often practically immovable, either because it is fi.xed to the femur or because the muscular substance of the quadriceps has undergone degeneration. The outer edge of the patella is longer than the inner, so that when the two fragments are brought together they do not meet on the inner side, and in cases of fibrous union the inner part is usually longer than the outer (Fig. 162). Symptoms. — There is rarely any difficulty in the diagnosis, though occa- sionall} when there is a thickening in the bursa over the bone, or extravasation of blood into the periosteum, a deceptive transverse depression may be felt. As a rule there is wide separation, the fragments are distinct and can be moved from side to side, or one can be tilted by direct pressure without the other ; swelling sets in at once and assumes the shape of the synovial membrane of the joint ; crepitus, of course, is not present unless the upper fragment can l)e pressed down ■'tA -^ S^--^^ ^ Fig, 163. — Osseous Union of Transverse Frac- ture of Patella. From a subject in the dis- secting room. There was no scar visible on the skin. Fig. 164. — Fibrous Union of the Corresponding Bone on the Opposite Side. and brought into contact with the lower ; the loss of power over the quadriceps is complete in proportion to the separation of the fragments and the tearing of the fascia ; in a very few instances the patient has been able to raise and extend the limb. Prognosis. — Union may take place by bone, though this is rare, or by fibrous tissue, the broken surfaces being united directly to each other face to face ; or there is no true union at all, but merely a thickened layer of fascia passing over the anterior surface of the fragments from one to the other. In no case does the quadriceps, especially that part of the vastus internus just above the knee joint, completely recover. If there is good fibrous union, with not more than half an inch interval, the use and the strength of the limb are scarcely impaired ; when the fascia is the only uniting medium, though the interval may be small at first, it is sure to elongate, until it may be as much as five and even six inches (Figs. 163 and 164). Flexion is permanently impaired in many cases ; in a few the knee remains quite stiff, and occasionally the upper fragment becomes attached to the femur. As vertical fractures almost invariably unite by bone, and as in some few cases the amount of callus thrown out is so great as to interfere with the gliding of the patella on the femur, it is clear that the failure of union is due mainly to the fragments not being in contact — they are kept apart either by the effusion, or by being tilted, or by the fascia being pressed down between them and entangled by the broken surfaces ; and the amount of callus formed is not sufficient to FRACTURES OF THE PATELLA. 431 bridge the interval ; none is thrown out by the articular surface, and very little by the cutaneous. Treatment. — Where the effusion is only slight, and the fascia at the sides of the jxxtella is not torn, there is little difficulty in maintaining the fragments in contact, esjiecially if they are of equal size. The knee must be kei)t straight on an inclined plane, the hip slightly bent, and the whole limb encased in a starch bandage,'carried in figure-of-eight turns over the knee right up to the groin. A short back splint or a firm pad in the popliteal space is advisable to make it more secure. The effusion rapidly becomes absorbed, the fragments are drawn together by the bandage, the amount of tilting is very slight, and the even pressure round the quadricei)s checks any tendency to spasmodic contraction. No lateral move- ment of any kind should be allowed for at least six weeks, even to test the degree of union ; little bony spicules are occasionally found shooting through the lymph from one fractured surface to the other, and all of these should be broken off at once. In the majority of instances, however, something more than this is required. Every effort must be made to get rid of the effusion as soon as possible ; not only does it force the two fragments apart, but it stretches the membrane, and makes it thick and stiff, so that it interferes with the freedom of movement afterward. Cold is of great service at first, but it can only check exudation, not assist absorp- tion ; pressure properly applied over a thick layer of cotton-wool is much more Fig. 165. — Transverse Fracture of Patella Treated by Extension from a Poroplastic Shield. effectual ; but if at the end of three days there is much left, the joint should be aspirated. It is true that, unless proper precautions are taken, this proceeding is attended with a certain amount of risk ; and that sometimes it is impossible, owing to the density of the coagula, to empty the articulation completely ; but many of the cases obstinately resist for such a length of time that nothing else is of any avail. The opening, which is best made above and to the inner side of the patella, should be valvular, and if a cannula is used it should be cleaned well first by boil- ing it in a solution of caustic potash. Sometimes after this is done the fragments come into apposition almost of themselves ; more often something further is required to bring them together. The simplest apparatus is a back splint, rather wider than the limb, and hollowed out to fit the knee. Two hooks are screwed into each side about eight inches apart, one above the joint, the other below ; and two elastic bands are fastened to these, so as to loop over the limb in a figure-of-eight. The lower one passes above the patella, and tends to draw the upper fragment down ; the u])per one, crossing this, catches the ligamentum patellae and forms a fixed point. The skin, which is very freely movable over the knee, should be stretched a^svay from the seat of fracture as far as possible before this is applied, or it may be forced down between the broken surfaces. The chief disadvantage is the liability to tilting of the fragments. A better plan is to mould a piece of thin poroplastic felt or thick moleskin over the front of the thigh, cutting it out so as to fit round the upper margin of 432 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the patella, ami leavin^^ on either side a looj^ or a i)rojertioii to which an elastic band can be attached. The limb should be fixed in a Maclntyre or a 'I'homas's knee-splint, and the elastic bands drawn down, one on each side, and secured to the foot-piece. At the same time a stri}j of bandage or plaster must be carried over the ui)per fragment to ])revent it rising. At the end of a fortnight or three weeks the whole limb maybe incased in a fixed apparatus and the patient allowed to get about on crutches (Fig. 165). If due precautions are taken, Malgaigne's hooks may be used with a fair de- gree of safety (Fig. 166) ; and, so far as mechanical reasons are concerned, nothing can answer better, especially if the instrument is divided longitudinally, so that there are two halves, right and left, which can be screwed up separately. The limb must be secured to a back splint, so as to keep it at i)erfect rest in complete extension ; the fragments must be brought down to their definite position ; and a minute puncture made with a sharp-pointed scalpel at the spot the hooks are intended to penetrate. The two upper should be carried right down to the bone, and, as suggested by Treves, may be made use of to evacuate the fluid from the joint ; the lower do not in- volve the synovial membrane. Then the hooks are inserted, the lower ones being fixed first, and screwed up until everything is in position. If there is any tendency on the part of the upper frag- ment to ride forward, it may be checked by carrying a tape round the limb and the splint, and tightening it up as required. The Fig 166 1-*^^'^ ^^ ^'^"-y ^^iftl'it' i''ot sufficient to recpiire an anaesthetic ; the Malgaigne's Hooks, fragments Can be adjusted perfectly ; and if the little wounds are dusted over with iodoform and kei)t dry and quiet, there is little risk of inflammation.* In former days there is no doubt this was not an unfre- quent consequence. The hooks may be kept in for six or eight weeks without any ill consequence ; but there is no advantage in retaining them for more than three ; at the end of that time the limb is generally sufficiently secure to be enclosed in a fixed apparatus. The plan of fixing the hooks into crescents of felt or moleskin strapping, fastened to the skin above and below, does not present any advantage over other methods. Many other plans have been devised for bringing the fragments together by means of pins or hooks fixed in the bones. Transverse channels have been drilled through the two fragments from side to side, and wires or pins passed through. Longitudinal ones have been tried, without any incision other than that required to admit the point of the drill. Pins have been driven into the ligamentum patellae and the tendon of the quadriceps, so as to obtain some fixed point. They have all succeeded, but they are none of them devoid of risk. Laying open the knee joint, and converting a simple fracture into a compound one, has been strongly recommended, even in recent cases ; and it is worthy of consideration in exceptional instances in which it is impossible, in spite of every endeavor, to bring the two fragments face to face. The risk, however, even with the strictest antiseptic precautions, is much too great ; especially as in young and healthy subjects, firm fibrous union, leaving a strong and useful limb, may be reasonably counted upon without. A vertical incision, two inches in length, is made over the anterior .surface of the bone with its centre opposite the line of fracture. The joint is opened freely ; all blood-clots turned out ; and then two holes are drilled obliquely, from the cutaneous to the fractured surface, so as not to involve the cartilage. A stout silver wire is inserted through these ; a drainage- tube passed through the deepest part of the joint upon the outer side; the frag- ments brought together ; the wire twisted up and the ends cut ofl" and hammered down. Others recommend a transverse incision above or below the line of frac- * The hooks as originally devised by Malgaigne were very sharply curved so that the points should not penetrate the joints. FRACTURES OF THE PATELLA. 433 ture, on the ground that if suppuration occurs in the skin wound the deep one is less liable to be infected. It is true that bony union has taken place in the major- ity of cases operated on ; but suppuration has occurred in several, in spite of anti- septic precautions; ankylosis of a greater or less degree has followed in many; and in one or two the bond of union has broken down again and further opera- tion has been required. The only other plan that requires special mention is that first devised by Kocher. It consists in passing a stout silver wire completely round the patella. A needle in a handle (such as is used for sewing up a lacerated perineum, only longer, stouter, and with a wider curve) is passed through the ligamentum patellre, through the tendon of the quadriceps and out through the skin. It is then threaded and drawn back again ; the broken fragments are brought together ; the wire twisted up, over something to protect the skin ; and the openings dusted over with iodoform. The limb is then jjlaced upon a back splint, and carefully bandaged, for three weeks. At the end of that time the wire is cut, drawn out of the wound, and the little ulcers that are left dusted over again with iodoform until they are healed. I have known this employed in a large number of cases without untoward result of any kind ; and the union was always exceedingly close, though I am bound to confess it was not possible to prove in the majority that it was osseous. The after-treatment of a case of fractured patella rer[uires just as much care. It is not uncommon to find that the distance between the fragments, even though it is scarcely half-an-inch at the first, in a few months grows larger and larger, until it may be as much as five or even six inches. In the majority no doubt this is due to the fact that there is no true union at all ; but in very many it is the result of allowing the joint to bend too soon and throwing an undue strain upon newly-formed fibrous tissue. In all cases of transverse fracture the limb should be thoroughly encased, without being touched, for at least six or preferably eight weeks ; and then an apparatus must be worn, so that there can be no attempt at flexion for at least as many months. The best are made of leather, laced up at the sides, with an opening in front for the patella, and a steel rod behind, so that bending is impossible ; but a very serviceable splint may be made from poroplastic felt, or even from gum and chalk. At first it should be left off at night only, and then by degrees more and more, until at the end of a twelvemonth it may be dispensed with altogether. For a time, of course, the joint is stiff, and the quadriceps wasted, but (with the exception, as already mentioned, of a portion of the vastus internus) this soon passes off ; and if there is good fibrous union it does not stretch, no matter what strain falls upon it. Massage, hot douching, galvanism, and gentle passive motion may be used to expedite matters, but as a rule (unless the patient is gouty or rheumatic), the stiffness disappears at length of its own accord (Fig. 167). Imperfect Repair. — The question of operation in these cases rests upon entirely different grounds ; union by ordinary methods has been tried and failed ; and it depends upon the degree of utility the limb possesses, upon the strength and occupation of the patient, whether he shorUd be recommended to get about with the support afforded by a knee-cap, or whether an attempt should be made to ob- tain firmer union. The operation itself is carried out in exactly the same way : the tissue between the broken surface must be removed thoroughly, and either the fragments drilled together or a wire passed round them after Kocher's plan ; which- ever is adopted it is essential that the apposition should be accurate. If an opera- FlG. 167. — Apparatus for Fibrous Union of Patella. 434 DISEASES AND INJURIES OF SPECIAL STRUCTURES. tion of this kind is attempted, it is advisable not to wait too long ; when the quadriceps has once undergone degeneration, it is almost impossible to bring the upi>er fragment down sufficiently ; tlie adhesions between it and the femur may be torn, the tendon divided, and even V-shaped incisions made in the muscular substance above it, without its being i)ossil)le to bring it close enough to ensure good union. Refracture occasionally takes place, the fd^rous band tearing across, or the bone giving way at a fresh ijlace. If it is simple, it may be treated in the ordinary manner, and it is surprising how far recovery can take place, and how useful the limb can prove ; if compound, the fragments had better be wired together at once. In one or two instances, in which the interval was too great, resection of the knee joint was performed in the hope of giving firmer support. Fractures rv Direct Violence. In these the fascia attached to the bone is seldom torn, and the degree of separation is slight, even when the joint is fdled with blood. The treatment is the same as for transverse fracture without displacement ; but, a.s union is nearly always osseous, passive flexion of the limb may be commenced much sooner. Co.MPOuxD Fractures. When the accident is the result of direct violence the injury is rarely confined to the patella : generally the other bones are involved as well, and often the soft parts are extensively destroyed. In former days amputation was regarded as inevi- table for such injury as this ; at present, if the part can be thoroughly cleansed and thoroughly drained, a successful result may be hoped for, even when such an amount of bone is removed that practically it becomes a primary resection. If, however, the skin is extensively damaged, or if the i)opliteal artery or vein has been torn or punctured, there is no alternative. Fractures by muscular action are occasionally compound, especially when the bone gives way for the second time. In one case under my care the skin was torn across from one side of the joint to the other ; but though the patient (who was a coalheaver) was not brought to the hospital for some hours after the accident, union took place by the first intention, without the least fever. If it is feasible the frag- ments should be wired together at once ; if it cannot be done the joint may be re- sected ; but probably a better limb would be left by drawing the fragmentsasclo.se together as jiossible and making the ]atient wear a support for the rest of his life. FRACTURES OF THE LEC. Both bones may be broken ; or the tibia or the fibula may give way by itself. If the violence is indirect, the tibia generally breaks across at the junction of the lower with the middle third (the weakest part), and the line of separation runs from above downward and forward ; the fibula usually gives way higher up. If direct it depends upon the nature and locality of the injury. In either case com])ound fracture is very common, owing to the thinness of the covering over a great portion of the tibia ; and all kinds of comjilications are frecpiently present. The bone may be comminuted, even when the force is indirect ; the neighboring joints may be involved, though the seat of injury is a long way off. owing to the way in which fi.ssures run obliquely, or even spirally, in the thickness of the bone ; the veins and arteries may be compres.sed, punctured, or torn comjjletely in two ; the muscles extensively lacerated ; the nerves stretched across sharp-edged fragments ; and the skin, even when it does not give way, stripped up to such an extent from the deep fascia, that it seems to float \\\>ox\ a kind of water-bed, and is in imminent danger of gangrene. FRACTURES OF THE LEG. 435 Fractures of the Tiisia and Fiiui.a. This is the most common form, whether the accident is the result of direct or indirect violence. In the former case the fractures may be transverse and on the sanie level ; or they may be comminuted to any degree ; in the latter they are usually more or less oblique (esjjecially if there is much twisting of the limb), and the broken ends are sharply pointed. In falls upon the feet, i>articularly when the force is very considerable, and combined with rotation, as in jumping from a carriage in motion, the bones are frequently broken in more places than one. The displacement is usually distinct at the first glance, though sometimes, when the fracture is exactly transverse, and through the upper part of the leg, or when the surfaces are much serrated, the broken ends retain their normal position. The causes of the deformity are the continuance of the force after the bones have given way, the weight of the part and the spasmodic contraction of the muscles ; its i)ersistence (unless there is inqjaction) is due entirely to the two last, and especially the muscles. The direction depends upon the obliquity. If it runs from above, downward and forward, the lower end of the upper fragment projects beneath the skin, being driven to the front by the pressure of the other ; if it has the opposite direction, the lower of the two is the more prominent. The fibula has very little influence. Signs. — These are usually definite, though a few cases are on record in which a person with both bones broken has been able to stand, and even walk. Crepi- tus, undue mobility, and deformity are almost invariable ; pain is intense, and increased by the slightest pressure ; and loss of power is practically complete. The greatest care must be taken in manipulation to prevent the skin giving way ; and, for the same reason, the limb must always be made secure at once. It should be a rule to examine the condition of the arteries, particularly the posterior tibial, in all fractures. Treatment. — Fractures of both bones may be divided roughly into three classes. (d) If the limb is so badly crushed that it is doubtful whether it can live, it is better to arrange it as comfortably as possible between sand-bags, or to tie it up in a pillow, so as to make it secure against any incautious movement, and raise it well, in the hope that the circulation may recover. {b) If the fracture is transverse, or nearly so, and if, as usually happens in these cases, the surrounding structures have almost escaped, there is no reason why the limb should not be put up at once in some form of immovable apparatus. This holds good with even greater force when only one bone is broken and the other is left as a splint. {c) If the fracture isvery oblique, particularly if it is of that variety which is sometimes called pen-nib, from the way in which the point of one of the fragments projects beneath the skin, or if the bone is extensively comminuted, or the soft parts much injured, and the swelling already serious, it is safer to postpone this for ten days or a fortnight, and to make use of ordinary splints, until the tendency on the part of the muscles to cause displacement has in some measure disappeared, and the swelling and tension are beginning to subside ; with such an injury there can be no object in getting the patient out of bed. • The variety of splints that have been devised for fractures of this kind is almost endless. The great object is to secure muscular relaxation ; the fragments should fall of themselves into their natural position ; force must be avoided as much as possible, though in a few cases continuous extension answers where nothing else will. One of the simplest and most efficient appliances consists of a back and two side splints swung from a cradle. The former is made of metal, sufficiently strong to retain its shape, but capable of being bent, and should reach half-way up the thigh to form a sole-piece for the foot. At the heel there is a large perforation to avoid pressure, and two cross-bars to sling it by are soldered to the under surface. It should be fitted accurately into all the curves 436 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the opi^osite limb before being padded, and esjiecial rare must be taken to make the bend corresi)ond with the position of the knee; extra pads to exert special pressure on certain ))oints should be used as little as possible. If the sole- piece is at right angles to the leg for with advantage a little less), and if the knee is sufficiently flexed (as much as 60° if necessary) the broken fragments fall into their natural jx)sition of themselves. Division of the tendo-Achillis. though jjer- fectly safe, is very rarely required, and continuous extension is seldom of service, except in those rare instances in which, owing to the direction of the fracture and spasmodic contraction of the quadriceps, the lower end of the upper fragment is tilted forward. The secret is to keep the knee well bent, the foot at right angles, and the inner side of the great toe, the inner malleolus, and the inner border of the patella in the same line. Strapping may be used to secure the foot, but ban- dages only should be allowed above the seat of injury, and for the sake of neat- ness they are to be starched. The side splints are simply straight jMeces of deal, well padded, sutificiently long to reach from the condyles of the femur to the foot and sufficiently broad to project well above the level of the limb. Webbing straps and buckles are used to hold them together, and the whole is suspended by leather bands from a cradle sufficiently large to allow it to swing freely. No moderate movement of the patient can have any influence upon the fragments ; but he should not be allowed to lie upon the injured side, for fear of the upper part of the limb becoming rotated while the lower is held fixed. Another plan is to lay the limb upon its outer side, on a well-padded wooden spMnt, with the hip and knee flexed, and the foot kept at a right angle by means of a sole-piece. The splint should be hollowed to fit the limb, sufficiently long to reach up to the knee, with a prolongation along the side of the foot, and the sole- piece screwed to it at a right angle. Opposite the malleolus there should be a perferation to avoid pressure. The patient is placed upon the injured side ; the fragments manipulated into position, and the limb secured by bandages. Care must be taken to keep the heel well down, and the foot at a right angle, for fear of the ankle becoming rigid. If there is any tendency to lateral projection, a short inside splint may be added with advantage. In some instances the limb may be suspended from an anterior sjjlint, either Hodgen's (Fig. 155) or Nathan Smith's, as already described, the angle and the point of suspension being altered to fit the case ; it is easy to make extension, and the limb, when it is once adjusted, is exceedingly comfortable, but it is very difficult to prevent the foot from pointing, and they certainly do not secure the same degree of immobility as the others. Probably the majority of the fractures that admit of being treated in this way might as well be put up at once in one of the many forms of immovable apparatus. At the end of ten days or a fortnight, according to the condition of the frac- ture, the splints may be removed and some form of immovable appliance substi- tuted, such as an ordinary plaster-of-Paris or gum and chalk bandage. Care must be taken first to get rid of all (edema by means of elevation and pressure. The following plan, for the details of which I am indebted to Mr. E. N. Xason, is in common use at the London Hospital. Equal parts (by weight) of finely powdered prepared chalk and common gum acacia are taken ; the latter is made into mucil- age, somewhat stronger than the B. P. strength, and is then thoroughly mixed with the chalk, until the whole is about the consistence of cream ; this is strained through coarse muslin in order to get rid of the lumps. The leg is then thoroughly oiled, and a common cotton stocking, with the point of the toe cut off and large enough to fit easily, is put on, outside inward, a piece of stout tape being arranged along the front of the leg beneath it. A second stocking, slightly larger than the first, is put on over this, the leg is supported in position, taking care that the foot is at a right angle, and the mixture of gum and chalk is thoroughly rubbed in. A third stocking of the same size as the second one is now drawn over the other two, right side outward, and more of the mixture rubbed in until no more can be ab- sorbed, and the ribs of the stocking show up clearly. The whole is then suspended FRACTURES OF THE LEG. 437 by tlic tape, which lies beneath all the stockings, shing from a cradle and left to dry. This takes eighteen hours, unless (juickened by placing the patient near the fire, or putting hot-water bottles on either side, the limb, of course, being kept outside the bed-clothes. If silicate of potash is used instead of gum, a somewhat better splint results. The solution (which can l)e obtained in gallon jars; is mi.xed with the chalk in the same way, but not so much chalk is recjuired, and it only takes si.\ hours to dry. When the splint is firm, it is cut down the middle line in front, along the tape, trimmed up, and the edges bound with strapping to prevent fraying. Eyelet holes are then punched on each side, and eyelets put in and clamped with the instruments commonly used l)y shoemakers. The leg is enveloped in a domett or soft flannel bandage, the splint put on and laced up the front as tightly as may be reepiired. For lightness combined with strength these splints can hardly be surpassed ; the fit is perfect, and at the same time they are sufficiently elastic to be taken on and off if required without injury. The plan of suspending the limb by the tape is not only of assistance in dividing the splint, but helps materially to keep the foot at a right angle ; unless this position is obtained the splint must be condemned at once. Many cases of fracture, especially if only one bone is broken, as already men- FiG. 168. — Stocking Splint. tioned, may be put up immediately ; but either the splint must be made in two halves or it must be cut down the centre, and laced or fastened up again in some other way, so that in case of swelling the seat of injury is accessible at once. As a matter of precaution the limb should be raised for forty-eight hours after the splint is applied, and the circulation in the toes must be constantly examined. .'Absence of pain is not by any means incompatible with gangrene. Poroplastic felt splints (which may be obtained in sizes shaped already to some extent at most instrument maker.s) answer admirably. They should be fitted roughly to the other leg so as to make sure that the length and breadth are correct, and softened with heated air or water, and then moulded to the fractured limb while it is held in position. They become dry and firm in a few minutes, and then they can be removed, lined with wash-leather, and either fitted with eye- let holes and laces, or fastened on directly with webbing straps and buckles. Plaster-of- Paris is more extensively used for this purpose, especially since what is called the Bavarian splint became known ; before this, bandages of crinoline muslin, into which the dry plaster had been rubbed, were w^ound round and round the limb until the requisite degree of strength was obtained ; and if it was desired to loosen or remove this, it had to be cut, and probably was spoiled. The plaster must be the finest, such as modelers use, and freshly prepared, or, if there is the 438 DISEASES AND INJURIES OF SPECIAL STRUCTURES. least doubt, baked ; the setting may be quickened by the addition of a small quan- tity of alum to the water. Two pieces of coarse house-flannel are taken, long enough to reach from the })Oijliteal space to the balls of the toes and three inches wider than the circumference of the limb ; these are sewn together down the middle line for the length of the leg ; below this (for the length of the foot) they are cut in two. A very good idea of the shape and size required may be obtained by taking a stocking, cutting the toes off, slitting it down the middle line in front for the whole length, and down the middle line of the sole behind ; but the flannel must be three inches wider. The leg is ' - then placed upon the flannel so 1 A " ~ ' that the seam runs down the back ( "^\ ^"^ ends at the point of the heel ; I ^^ and the inner layers are folded \ over and fastened together down ^- _ --.; the front. The end portions are Fig. i69.-Bavanan spi.nu "sed to cover in the foot, which must be kept exactly at a right angle. The leg is then placed upon one side, and held accurately in position ; a layer of plaster the consistence of cream is spread over the inner layer, from the fold in front to the seam behind, and the outer one pressed down upon this before it has set (Fig. 169). As soon as it is firm the leg is turned over and the process repeated on the other side. Finally, the fastening down the front is undone, and two side splints, fitting accurately to the leg and foot, fall apart from the limb, bending at the hinge formed by the stitching behind. The edges are finished off afterward, the inner layer being fastened down to the outer on the surface of the splint. Modifications of this, introduced by Croft and Gamgee, are simpler of execu- tion, as the side splints are separate throughout. For the former, four pieces of house-flannel are taken, the size and shape of the patient's stocking when flattened out ; two of these (one for each side of the limb) are dipped in warm water, to go next the skin ; the two others, the outer ones, are thoroughly soaked in plaster the consistence of cream. A bed is then prepared for the leg, consisting first of a layer of stout muslin cut so as to act after the fashion of a many-tailed bandage ; then one of the pieces that have been dipped in plaster, and a second simply wetted. On this the leg is placed, the surgeon making extension and adjusting the fragments as far as possible ; then the other pieces are laid upon the ujiper surface, and the muslin is brought up and fastened over the limb so as to press the layers of flannel against it. In this way two strong plaster moulds are made, one for each side, fitting the leg accurately ; and as soon as the plaster sets they can be separated by simply cutting the muslin. In Gamgee's method the principle is the .same, but instead of house-flannel, absorbent cotton-wool is used, one layer next the skin, the other dipped in plaster cream, moulded on the outside of this. Fr.\cture of the Tibi.\. The shaft rarely gives way by itself except as the result of direct violence ; the internal malleolus, however, may be wrenched off; the tubercle torn away by sudden contraction of the quadriceps ; and the spine, and even the head of the bone, split in two by the tension of the crucial ligaments in violent twists of the knee. Asa rule there is no difiiculty in the diagnosis; but if the line of separa- tion is exactly transverse, especially in the upper part of the bone, and if there is much ecchymosis, so that it is not possible to feel the edge of the crest, it may be necessary to wait for some days, treating the case as a fracture in the meantime. FRACTURES OF THE LEG. 439 The deformity so long as the fibula is intact cannot be serious, though there is sometimes a certain amount of rotation at the lower articulation. Union takes place readily ; but in a few cases, in which the patient, in spite of the pain, has continued to use the limb, a false joint has formed, the fibula becoming bowed and greatly strengthened, so as to take more than its share of the weight. In all cases of fracture near the upper extremity of the tibia the condition of the knee-joint must be carefully examined, as it is not uncommon for fissures in the bone to run ui)ward as well as downward in the shaft. Fracture of the Fibula, on the other hand, is of very common occurrence. It may be due to direct or indirect violence ; in the former case the situation of the fracture depends upon the locality of the force ; in the latter, when the foot is twisted round between the malleoli, it generally takes place at the weakest spot, two to four inches above the anlvle-joint ; sometimes, however, it is higher up, under cover of the muscles, and occasionally in both places at the same time. In many instances the diagnosis is very difficult ; and it is not improbable that fracture is present, without being detected, in a large number of sprains. A slight degree of mobility and crepitus can generally be made out by pressing alternately with the thumbs side by side over the seat of injury, or by forcibly twisting the foot; deformity is exceptional in uncomplicated fractures. In other cases the only sign is the loss of spring when the bones are squeezed together ; the fibula yields and gives instead of recoiling ; or ecchymosis makes its appearance days after the accident ; or there is one spot at a distance from the apparent seat of injury, very tender on pressure ; and it is of unusual significance if this spot remains constant when the bones are squeezed together higher up or lower down. Fractures of the head and neck of the fibula are far from common ; but they sometimes occur from .direct violence, or from muscular action, the tendon of the biceps and the external ligament combined tearing the upper part off from the rest. In many of these cases the peroneal nerve is injured too. Complications. — Pott' s Fracture. — Fracture extending into the ankle joint may be caused in various ways. The most common is violent eversion of the foot ; the astragalus is twisted round in its socket ; the external malleolus is forced outward until the fibula gives way and breaks inward toward the tibia ; and the in- ternal lateral ligament is stretched until it either tears across itself, or drags off part of the internal malleolus (Fig. 170). If the force continues after the bone is broken, or if the patient tries to walk, the foot is displaced to such a degree that a kind of dislocation (Pott's fracture) is produced. In very severe cases the interosseous ligament between the tibia and fibula is torn as well, or a portion of the tibia is split off (Fig. 172); in the worst of all the displacement is carried so far that the whole of the foot and the external malleolus are dis- placed to the outer side of the leg (Dupuytren's fracture). Forced inversion causes an injury of a similar character ; only the strain falls upon the external lateral ligament, and the lower end of the fibula is pulled in- ward until the bone breaks at its weakest spot (Fig. 171). If the force is not exhausted, the internal malleolus or the lower end of the tibia gives way as well. In other cases a fissure, starting from an oblique fracture of the tibia, runs down in the substance of the bone until it traverses the ankle joint ; or the tibia and fibula are separated from each other and the astragalus driven up between them ; or both malleoli are broken off so that the foot can be moved freely in all directions upon the leg. These complications, however, are much more rare. As a rule the diagnosis does not present any difficulty ; the character of the displace- ment and the shape of the swelling (for the synovial sac becomes distended with blood at once) can be recognized immediately ; but in every case of fracture of the fibula by indirect violence, if there is the least tenderness on pressure over the internal malleolus, the patient should be warned that the joint is very likely to 440 DISEASES AND INJURIES OF SPECIAL STRUCTURES. be stiff and weak for a considerable time after the accident. Most of these frac- tures can be put up at once, either in the Bavarian splint or in some modification of it ; the foot falls into its natural position as soon as the muscles are relaxed, liut every now and then cases are met with in which the deformity obstinately re- turns, and one or two are recorded in which, in spite of division of the tendo- Achillis, it could not be reduced at all, probably from splintering of the bones and inability to disengage the fragments. For such as these, either an outside splint with a foot-piece, as already described, or Dupuytren's (Fig. 173), answers better. The latter consists of a straight piece of wood about four inches broad, and suf- ficiently long to reach from below the foot to above the knee. The ]jadding is doubled opposite the malleolus and does not extend below it. The splint is first w Fig. 170. — Eversion of Foot, forcing Fibula inward, and throwing strain on internal Lateral Ligament. A > P-. ^' \ \-:- -t=^5:>^ Fig. 171. — Inversion of Foot, forcing Fibula out- ward. bandaged to the inner side of the leg (the knee being well flexed) and then the foot is drawn over the projecting pad and secured to the lower part by a figure-of-eight, no turn of which mast be allowed to come above the ankle. A foot-piece corresponding to the sole may be added with advantage. In all these fractures the greatest care is necessary to prevent any drooping of the toes or carrying backward of the foot ; if the distance between the malleoli is altered in the least, whether it is increased or diminished, lameness and serious disability are sure to follow. Passive motion should be commenced in three weeks, and to allow of this it is essential that the apparatus used should either be laced up or so arranged that it may readily be taken off and on. Stiffness, cedema, and a sense of weakness about the joint are very common after-troubles, and must be met by massage, galvanism, friction, and shampooing. FRACTURES OF THE LEG. 441 If the internal lateral ligament has given way and the weight of the body is allowed to fall too soon \.\\)0\\ the injured jmrt, an obstinate form of flat-foot may result. Separation of Epiphyses. — This is more common at the ankle than at the knee ; in the latter situation it has been produced by forcibly attem])ting to straighten a case of genu valgum ; and when the cartilage has been softened by neighboring inflammation partial displacement is not rare. The lower epiphysis of the tibia is sometimes separated in a violent strain of the ankle joint, and this may be followed by impaired growth. When this occurs, the axis of the bone appears to be altered ; the internal malleolus remains small ; the fibula becomes much stronger, so as to support some of the weight of the leg, and is bowed outward ; and the external malleolus grows so much longer and larger than the other that the sole of the foot is turned inward. Wounds of Arteries. — The anterior and ^ ,,,,,., ^ ., . , . , ..... Fig. 172. — Old United Fracture through lower posterior tibial arteries may be injured in endofTlbia, with separation of the two bones, simple as well as compound fractures ; and [|jfjt"'"°'"°"' L'g-'^ent having remained the former may be torn as it passes between the bones, even when the seat of injury is some distance off. If the skin is unbroken and the soft parts are not too much crushed, hemorrhage from the anterior tibial can generally be checked by pressure ; either the blood is absorbed and the artery closed, or a traumatic aneurysm forms, to be dealt wnth later on. When the upper part of the posterior is torn this rarely happens ; as a rule, the swelling is so great that the collateral circulation is cut off, and the foot soon becomes cold and gangrenous ; or it may hang in the balance for a day or two, and then require amputation. In one or two cases, however, in which the foot retained its warmth, ligature of the femoral has been successful, and compression might very reasonably be tried. In compound fractures, either both ends must Fig. 173. — Dupuytren's Splint. be tied (and, owing to the extent of the injury and the retraction of the vessels, this operation is very often impo.ssible), or the limb must be amputated. Wound of the posterior tibial at its lower part is an exception ; in one instance, in which the ends could not be found, I .succeeded in saving the limb by applying pressure at the expense of a small superficial slough. Compound Fractures of the Leg. Owing to the superficial position of the bones these are very common. Many, fortunately, are slight, the skin being merely punctured from beneath by one of the pointed ends, through carelessness in carrying the patient, or from his attempt- ing to stand. These should be sealed at once and covered with iodoform, the bone, if it is still projecting, being first thoroughly cleansed with corrosive 29 442 DISEASES AND INJURIES OF SPECIAL STRUCTURES. sublimate or some otiier antiseptic. Sometimes it is necessary to enlarge the wound a little or cut off a protruding spike. At the opjiosite extreme are those injuries caused by direct violence, where the bone is so crushed and the soft tissues so disorganized that it is clearly hope- less to try to save the limb. Between these two every grade is met with, and the question of treatment must be decided in each case, first by the age and constitution of the patient (especially the condition of his arteries and kidneys), and then by the amount of injury done to the limb and the complications that are pre.sent. The arteries must be examined first ; if they can be felt pulsating, and if the skin is not stripjied up too far, an attempt may generally be made to save the limb. The wound must be explored with the finger, enlarged if need be, and thoroughly washed out with an antiseptic. Loose splinters must be removed, and if the ends of the bone are bared of their periosteum, or so jagged that they cannot fit, they may be resected and sutured together. Then dependent openings must be made for drainage, all oozing stopped, the wound dressed with some absorbent material so that no fluid can collect, and the limb arranged upon an interrupted splint with l)ads covered with oiled silk. If no pulse can be felt in the foot below, the line of treatment must be determined by the warmth of the skin and the amount of sensibility it retains. Next to the arteries, the condition of the skin is perhaps the most important; if Fig. 174. — Compound and Comminuted Fracture of the Leg. it is destroyed over a large area, or if it is stripped up so that it is in danger of sloughing, the chance of saving the limb is immensely diminished ; and even if this is accomplished it often hai)ijens that such an obstinate degree of oedema and ulceration persists that the limb is not only useless, but a constant source of danger and annoyance. [It is in such cases that the use of hot water made antiseptic shows its highest value. The limb should be enveloped in a sheet wrung out from a hot antiseptic solution, and changed as often as necessary. By enveloping the wet sheet in a rubber cloth the heat will be retained for a longer period.] Everything depends upon the next few days. Sometimes, in spite of every care, the foot becomes colder and colder, the skin more dusky, and the sensibility less. Too much has been tried, and local traumatic gangrene is setting in. The only hope then lies in immediate amputation ; the part cannot be kept aseptic ; the sloughing is sure to spread, and it will not stop at the seat of injury. If the patient is young and healthy, there is a fair amount of hoi)e still, provided the operation is done at once ; if old or broken-down, so that the gangrene is rather the result of impaired vitality than of extensive injury, the prognosis is as bad as it can be. Sometimes, on the other hand, acute inflammation sets in and rapidly be- comes diffuse ; the temperature rises, the skin becomes hot and burning, and in- tense fever, with perhaps delirium, follows. The leg is red, glazed, and immensely FRACTURES OF THE LEG. 443 swollen; the discharge from the wound is offensive, and soon becomes profuse; the swelling rapidly extends up the thigh, especially on its inner side, and the neighboring lymphatic glands become enlarged. The extravasated blood has de- composed ; the poison is pent up, unable to escape, and may infect every tissue in the leg — skin, cellular tissue, periosteum, medulla, lymphatics, and even, per- haps, the veins. The issue depends upon which is the stronger, the irritant or the ti.ssues ; if the former, hopeless gangrene sets in and the patient is almost cer- tain to die from acute septicaemia. If the latter, a wall of vascular lymph is grad- ually formed, and the poison shut off. Even then the course is not always straight. Cellulitis, recjuiring incisions to be made all over the leg, may set in, leaving the limb almost useless ; necrosis, sometimes involving a large portion of the bone, is almost invariable ; phlebitis and pyaemia may occur at any time ; the inflammation may involve the neighboring joints, either by direct extension, or by spreading along the lymphatics into the synovial cavity ; and the patient, if he survives the immediate dangers of septicaemia and pyaemia, may sink later on, from exhaustion. Amputation, so long as the fever continues high, is i)ractically hopeless ; when the temperature begins to drop of a morning a favorable moment can sometimes be seized ; until this occurs, all that can be done is to meet the symptoms as they arise. Fractures of the Bones of the Foot. The posterior extremity of the os calcis is sometimes torn off with the tendo- Achillis by violence ; and occasionally the body of the bone is crushed to pieces by falling or jumping down upon the heel. The astragalus may be broken in the same way and at the same time ; or the neck may be twisted off in violent wrenches of the foot. Very often the bone is partially displaced. The existence of the fracture can generally be made out without difificulty, but it rarely happens that an exact diagnosis as to its seat and direction is practicable. The fragments should, in all cases, be manipulated as much as possible into position while the patient is under an anaesthetic, and then fixed with a plaster bandage. Passive motion should not be delayed for more than ten days or a fortnight, for fear of permanent stiff- ness of the ankle. Compound (open) fractures of the bones of the foot are common, but no definite rules can be laid down as to their treatment. In any operation the tread of the sole .should be interfered with as little as possible ; and it must always be remembered that stability is the first consideration. [The hot antiseptic pack should generally be applied for the first twenty-four hours, preliminary to applying the immovable plaster.] 444 DISEASES AND INJURIES OF SPECIAL STRUCTURES. SECTION III.— DISEASES OF BONE. ATROPHY. Ill old age the bones undergo a natural process of wasting, the central canal enlarges and encroaches on the cancellous tissue at either end, the compact portion of the shaft becomes thinner and thinner, until in some cases it is scarcely capable of sustaining the weight of the i)art, and the medulla is replaced by fat. The same thing may oc- cur from prolonged disuse, as, for examjjje, in cases of old joint-disease (Fig. 175), and must be remembered in the reduction of old dislocations. (Gradual absorption of bone, as of other tissues, Ls caused l)y constant pressure. An aneurysm, for ex- ample, may perforate the sternum or eat away the bodies of the vertebrae until the strength of the spinal column is seriously impaired. The blood-vessels are compressed, the bone wastes away, and though the compact layer is to a great extent retained, the cancel- lous tissue is more or less exposed. Arrest of growth is not uncommon as a conse- of quence of rickets, hereditary syphilis, and other affec- tions of the growing portion of the bone during child- Not only is the length of the bone less than natural, but sometimes, The Fig. 175. — .Atrophy of Bone section through lower femur. vertical end hood. as in the case o-f the pelvis, there is an arrest of development as well same thing may occur from injury. HYPERTROPHY. True hypertrophy may be congenital, the bones becoming involved together with, and in the same proportion as, the other tissues of the part ; or it may arise from over-use, as a measure of compensation ; the fibula, for example, being immensely strengthened, without undergoing any material change of proportion, in cases of partial or complete loss of the tibia. Chronic inflammation not unfrequently gives rise to great alterations in size ; but in this case the structural details of the bone undergo modification at the same time. In hereditary syphilis, for example, and in osteitis deformans, the bones often increase in length as well as in circumference, but on section the normal proportion of compact and cancellous tissue is not preserved. Increase of length from chronic inflammation, affecting the epiphysial line during the growing period, is still more common. INFLAMMATION. The changes that take place in inflammation of bone are similar to those that occur in inflammation of other tissues ; the aj)parent difference is due to the presence of a solid framework which i)lays an entirely passive and secondary part. In compact bone the active vascular tissues lie partly on the exterior (the soft layer of the periosteum), partly in the central canal (the medulla), and to a much INFLAMMATION OF BONF. 445 smaller extent in the substance of the bone itself, in the Haversian canals, and the lacunai. Intlammation may commence in any one of these, as periostitis, osteo- luyclitis, or osteitis, and althougii it never remains confined to one, but very soon involves tlie whole, it is often so much more marked in one than in the other that they may well be described as separate affections. In cancellous bone, on the other hand, interstitial osteomyelitis or osteitis is practically the only form ; there is no central canal, the medulla is distributed evenly through the whole, and although there is a periosteum, the layer of com- pact tissue which it sup])orts is so thin that, even if an affection begins distinctly in one part, the rest of the bone becomes involved almost at once. Pathology. — The pathological changes are the same as in the other tissues of the l)ody ; hyper;-emia, dilatation of the blood-vessels, and increased rajjidity of the flow, followed at a later period by stasis, if the attack is sufficiently acute. Lymph pours out through the walls of the vessels, the tissues become engorged and swollen (so far as they can, for therein lies the difference), the matrix becomes softened (if there is time), new blood-vessels are formed, the amount of exudation continues to increase, and at length periosteum and medulla are replaced by layers of soft, exceedingly vascular lymph or granulation-tissue, as deep and as thick as space will allow. The subsequent course depends upon whether the inflammation is acute or chronic, and whether the portion of bone involved is compact or cancellous. I. Acute Inflammation. When connective tissue is inflamed, the intercellular substance rapidly be- comes softened (unless it is a sheet of very dense fascia), the vessels can expand and enlarge in all directions, and there is scarcely any limit to the amount of lymph that can be poured out. This is not the case in bone, especially when it is compact. It is true that as soon as inflammation commences the osseous frame- work begins to change in a similar way ; it gradually becomes softened and eroded on its surface (whether under the periosteum, round the medulla, or in the Hav- ersian canals), and special multi nuclear cells to which this function is assigned (osteoclasts) are found in all these places, lying in little recesses (Howship's lacunse) which they have eaten out for themselves ; but, while fibrous tissue can soften and yield at once, it takes time in the case of bone, and consequently, if the attack is acute, either stasis occurs, without the possibility of any collateral circulation, or the blood-vessels become strangled in their own canals by the exudation around them. In other words, as in carbuncle at the back of the neck, if inflammation is acute, the circulation is stopped, the tissues perish, and gangrene (necrosis) occurs. In compact bone this is the rule. Acute inflammation, if it is not followed by immediate resolution, ends in necrosis. If the periosteal surface is involved {acute periostitis), the sequestrum, as it is called, is superficial; if the medulla {acute osteomyelitis), it is central and tubular in shape, formed from the layers that immediately line the canal ; if both together, the whole shaft perishes {total necrosis') . In cancellous bone, where the spaces are larger and wdder, necrosis is more rare ; the vessels have more room, dilatation and exudation are possible, and there is less solid bone to be absorbed ; but if the inflammation is so intense as to cause thrombosis or stasis over any extent, the result is the same, and as a matter of fact small rounded sequestra of cancellous bone are not uncommon in the centre of suppurating foci. When a sequestrum is formed, the dead portion acts as a constant irritant until it is separated and thrown off by a process of rarefying osteitis ; so that an acute attack of inflammation causing necrosis must be followed by a chronic one. 446 DISEASES AND INJURIES OF SPECIAI STRUCTURES. 2. Chronic Ini'lammaiion — Rakki'vinc; Dsif.itis. When the exciting cause is not an acute one the bony trabecule have tim^ to soften ; the amount of exudation increases, more vessels are formed, the spaces enlarge, the solid walls that surrounded them are removed little by little, and the affected portion of bone becomes oi)en and jjorous. Compact tissue becomes cancellous, cancellous tissue so soft that it can be cut with a knife. If this commences on the outside the periosteum becomes softer, thicker, and more vascular, the tough fibrous layer is lifted up from the bone beneath by masses of newly-formed lym|jh (forming, if the bone lies immediately under the skin, what is commonly called a /iO(/i') ; and if it is torn off, it leaves a surface that is not white and smooth, but rough, uneven, covered with little bony spicules, and dotted all over with minute openings (Fig. 176). If the medulla is involved first, the changes are essentially the same ; the old spaces are enlarged, new ones are formed by the disappearance of the partitions, and the medullary canal is filled with soft masses of vascular granulation-tissue. The simplest type of chronic inflammation is seen in the process by which a necrosed portion is separated from the rest. The living bone all around becomes more vascular, the Haversian canals expand and become filled with lym]jh, the solid matrix next to the sequestrum is absorbed and replaced by granulation -tissue, and by degrees a line of demartation cuts it out. The necrosed part is detached by the irritation it causes, at the expense of the living bone around it, and lies in a cavity, the walls of which are formed everywhere of granulation-tissue, springing from rarefied bone. In the majority of instances su])i)uration occurs, but it is not an essential part of the process. The subsequent changes depend partly upon the intensity and persistence of the cause, partly upon the strength of constitution of the patient. (a) Resolution. — When the irritant is but slight and transient, resolution soon begins: the vascularity diminishes, some of the lymph becomes absorljed, the rest is organized, and in a short time the natural condition of the part is perfectly re- stored. The changes that take place after a simple fracture are a very good illustration. ij)) Persistence {Caries sicca or fitngosd). — In other ca.ses the process continues without altering in character until the whole of the bony framework is absorbed ; nothing but a mass of soft granulation-tissue is left. The whole body of a vertebra may be removed in this way so as to cause angular curvature of the spine, and the phalanges of a finger may simply disappear until the nail rests upon the head of the metacarpal. Extreme forms of this kind appear usually to be associated with tubercle, but there is no caseation. Deatl bone may be aljsorbed as well as living ; a sequestnuii, so long as it is surrounded by living granulation-tissue (not by pus), gradually diminishes in size, being eroded and eaten into from the surface in the same way as an ivory peg. {c) Organization {Osteosclerosis). — In some diseases, rheumatism for examj^le, and not unfrequently syphilis, the vascular granulation-tissue becomes organized and converted into bone. This is especially prone to happen at a little distance from a focus of suppuration, and not uncommonly extends all round and enclo.ses it (Fig. 178). When it occurs in the substance of a bone, the trabeculne, instead of softening and disa])pearing, become hardened and thickened ; the cells that lie upon their surface are incorporated with them ; the spaces left between filled with soft granulation-tissue, become smaller and smaller ; the Haversian canals are narrowed ; and at length the affected portion of the bone is converted into a dense, Fig. 176. — Chronic Infliunmation of Hone. The Tibia and Fibula from an old ampu- tation, showing excessive vascularity with great production of new bone. RAREFYING OSTEITIS. 447 hard, and heavy mass, like ivory. If the medulla is involved, the canal simply disappears ; it is completely filled in ; if the periosteum, the changes are essen- tially the same ; layer after layer of lymph is thrown out upon the surface and con- verted into bone, until the natural exterior of the shaft is coated over with a ring of newly- formed osseous tissue, and the thickness of the wall is doubled or trebled (Fig. 179). The so-called expansion of bone over cen- tral sequestra or sarcomata is produced in a similar way : as the interior becomes hol- lowed out and weakened, the periosteum on the outside maintains the strength of the part by the new bone it forms, until perhaps the whole of the original shaft disappears, and a new shell with a much larger cavity is de- veloped in its place (Fig- 188). For the most part this change is to lie regarded as reparative in character, but sometimes it leads to consequences which, instead of being beneficial, make matters worse. One has been mentioned already : a suppurative focus in the cancellous end of a long bone may be completely locked in ; layer after layer of dense osseous tissue is formed around it until escape is impossible ; but unhappily, this process is rarely uniform ; the periosteal surface becomes thickened (Fig. 178), but not the articular, so that if a joint is near and suppuration continues, the pus is almost certain to work its way into the cavity and lead to destructive arthritis. In other cases the Haversian spaces and the medullary canal become so constricted that the amount of blood going to the part is scarcely sufficient to maintain its life, and the least irritant causes necrosis. Sometimes apparently none is required. Paget has described a form of quiet necrosis in which there is no suppuration, or exceedingly little ; the sclerosis simply con- tinues until the vascular canals are obliterated and the central portion of the affected area dies. The sequestrum formed in this way may take years before it is completely detached. Meanwhile it acts as a continual irritant, the bone around is kept in a state of chronic inflammation, and either rarefying osteitis sets in, and the strength of the part is so much impaired that spontaneous fracture takes place, or it becomes denser and harder, and layer after layer of new bone is laid down, until at length the circumference is doubled. In either case, the diagnosis from malignant disease is exceedingly difficult, and not infrequently the actual condition has only been recognized after amputation. Syphilitic inflammation of bone, especially the inherited form that occurs at puberty, is often followed by an extreme degree of sclerosis. The whole of the shaft, generally of the tibia, becomes enlarged and condensed ; superficial sequestra form, probably from gummatous infiltration of the periosteum ; and owing to the extreme density of the bone beneath, it may be years before they are loose enough to be removed. The same thing is not uncommon after acute necrosis of the lower end of the femur ; the sequestrum, especially when the posterior surface is involved, may remain adherent for the rest of life. Closely allied to this are the changes in shape and size, as well as in density. Fig. 177. — Suppurative Periostitis and Osteomyelitis of Tibia; the sequestrum, which is locked in, in- volved the whole thickness of the bone. Owing to the constant irritation near the epiphysial line the upper end of the tibia has grown obliquely. 448 DISEASES AND INJURIES OF SPECIAL STRUCTURES. which are sometimes met with in achilts. In most instances (osteitis deformans, for example) they are the result of some general disorder of nutrition, antl the whole skeleton is affected more or less; but occasionally alterations of a similar descrip- tion — elongation, curving, irregularity of the surface, disaijpcarance of the medullary canal, and condensation — are produced l)y jjurely local irritants. In children, before the epiphyses have united, the growth of the bone in length, as well as the shape, may be very seriously affected by premature conden- sation. Ossification sets in, the epiphysis is joined to the shaft before full size is reached, and development is stopped. In other cases, exactly the opposite result follows; owing to the greatly increased vascularity of the part unnatural growth takes i^lace and the bone becomes very much elongated. This may occur on one side of the bone only, so that the axis of the limb is seriously distorted (Fig. 177); or in one of a i)air and not in the other, in the tibia, for example, and not in the fibula, so that the neighboring joint is rendered almost useless. 3. Caries. Of this there are two varieties : {a) simple or non-specific, in which pyogenic organisms only are present ; and (//) specific, in which the destruction is due to tubercular, syphilitic, or lejirosy germs, with or without the others. In the first variety the granulation -tissue breaks down into pus directly ; in the second fatty degeneration and caseation set in first, and suppuration is a complication. In both the trabeculns that are not absorbed are deprived of their nutrition and perish ; and small fragments of dead bone drop off into the fluid that surrounds them. When the inflammation is acute, the sequestra may be of some size {caries necroticd) ; ordinarily they are very minute. Caries may occur either on the surface of compact bone or in cancellous tissue. The former is most often met with in connection with syphilis. A gummatous deposit forms in or under the periosteum, softens and breaks down, leaving a foul- looking ulcer, the floor of which is formed of roughened bone, soft, and, as pyogenic germs are always present in sloughing gummata, covered over with pus. Under- neath, if this is scraped away, there is a border of rarefying osteitis ; and as a rule, further off, one of sclerosis, the difference depending upon the diminishing in- tensity of the irritant. In cancellous tissue it is much more common. The carpus and tarsus, the bodies of the vertebrre and the articular ends of the long bones, are the favorite places. It begins as rarefying osteitis ; the Haversian canals become dilated ; the trabeculte are absorbed, all the spaces enlarge, and very soon the affected part is converted into granulation-tissue with only a {q.\\ bony spicules left. If the cause is a transient one, resolution or organization follows, and the damage is repaired. If, on the other hand, living organisms are present, and they continue to grow, the newly-formed lymph is killed, the solid tissues break down and become liquid, the trabecule that are not absorbed die and drop off as a minute sequestra ; and in a little while a cavity is formed, filled with fluid debris, and surrounded by a wall of softened, congested bone. {a) Simple Caries. — In a chronic abscess of the cancellous end of one of the long bones, such as is sometimes caused by injury (Fig. 178), all these changes may be found existing together, side by side. In the centre is a sequestrum ; thrombosis occurred in some of the vessels at the time of the accident, the collateral circulation could not I)e established, and necrosis resulted. Around this is a cavity filled with pus, a few (but only a few) germs having reached it through the blood. The bone which originally occupied this space has been absorbed ; the inflamma- tion was not sufficiently severe to kill the part en masse as it did in the centre ; there was time for rarefying osteitis to set in ; the bony trabecules were removed ; the granulation-tissue that replaced them melted away into pus, and an abscess- cavity resulted. The wall of the abscess is lined with a so-called pyogenic membrane — in CARIES. 449 other \vorcls, vascular lymph or granulation-tissue, which has caused the removal of every particle of bone, and has been able to resist the action of the i)yogenic organisms. Around this is a circle of rarefying osteitis, gradually becoming less and less characteristic as the distance in- creases. Close to the cavity there is only a bony spicule left here and there ; it is nearly all soft tissue, continuous with that lining the abscess and furnishing by its death the pus that fdls it. Further away the proportion is reversed ; and at length, quite on the out- side, where the effect of the irritant is scarcely felt, organization has taken place, the bone is hard and dense (sclerosed), and new layers are thrown out under the periosteum. These changes are the result of two forces : one is the destructive action of the irritant, aided by the pyogenic organisms ; the other is the effort of the tissues to repair and limit the damage. The same may be seen when caries affects the surface of a bone, provided the patient is otherwise healthy ; in the centre, where the irritant is most active, the destruction is complete ; around the margins of the ulcer (for such it really is) and deep down under its floor there is a deposit of new and dense bone. (a) Specific Caries. — This is nearly al- ways due either to tubercle or syphilis ; the other infective organisms are more rare, and the effects they i)roduce not characteristic. Tubercular caries is especially distinctive the rest by the entire absence of repair. So long as the tubercle is spreading, the inflammation is never confined, either by sclerosis or a deposit of new bone. The W'hole structure is light and porous ; there is no evidence of organization, no thickening under the periosteum or sclerosis in the cancellous spaces. The centre is filled with caseous debris or a thin oily fluid mixed with minute sequestra ; around this is a layer of granulation-tissue studded with miliary tubercles, which constantly spread wider and wider, while they decay and caseate in the centre. If the nutrition of the bone imi)roves, or that of the bacilli deteriorates, so that the former gains the upper hand and the inflammation ceases to be tubercular, encapsulation and sclerosis occur, as when the cause was traumatic. If, on the other hand, the bone-corpuscles are badly nourished or in a state of fatty degen- eration (which is said to be common in tuberculous subjects) there is nothing to oppose the spread of the disease, and it continues until the whole is reduced to a periosteal shell, filled with caseous debris. There is no suppuration unless the pyogenic germs enter as well as the tubercle bacilli, and in sufficient number ; if once they do, the destruction becomes infinitely more rapid. Syphilitic caries presents no special features. It may occur by itself and cause the most extensive destruction (Fig. 185), but suppuration is usually associated with it. Causes. — Inflammation may be caused either by organized or unorganized irritants: the latter may be mechanical (tension or the presence of a foreign body), or chemical (mercury or phosphorus) ; the mode of action of the former is uncer- tain and perhaps not always the same. I. Mechaiiical Injury. — In wounds and fractures the bones, like other ti.ssues, become inflamed if the parts are not kept at rest, if there is any tension or if there Fig. 178. — Diagrammatic representation of an Ab- scess in the Cancellous End of the Tibia, showing a central sequestrum lying in an abscess-cavity with vascular bone around, and further away sclerosis and a deposit of new bone. It is marked out at once from all 45 o DISEASES AND INJURIES OF SPECIAL STRUCTURES. is a foreign body present, such as a sequestrum, and sclerosis or rarefying osteitis sets in, but not suppuration. 2. Chemical Poisons. — Some of these, b'ke mercury and phosphorus, are in- troduced directly from the exterior. Others, as in the case of ^out and rheimia- tism, are in all probability the product of some perversion of nutrition. Whether certain other affections of bone, which are not so distinctly inflammatory in their character (such as osteitis deformans, rickets, and osteomalacia) are also due to chemical changes in the blood, is perhaps open to argument ; but at least no clear line can be drawn between them. 3. Infectious Organisms. — {a) Non-specific. — Inflammation of the most intense character may occur after amputations or comjjound fractures, especially if the medullary canal has been laid open ; or by infection from the blood (acute suppurative periostitis, osteomyelitis, and epiphysitis), the germ entering either through some cutaneous boil, or, if the skin is unbroken, through the alimentary or respiratory tracts, and finding a suitable nidus for its development in the bone. It is not uncommon after the acute exanthemata, especially typhoid fever. As in all forms of inflammation of bone in which necrosis or suppuration occurs, the attack does not cease when the primary cause has spent its energy ; the sequestrum remains behind as a foreign body and acts as a constant irritant, keep- ing up chronic inflammation, until it is detached and the loss repaired. (J>) Specific. — Periostitis and interstitial osteomyelitis are exceedingly common in syphilis, both in the acquired and the hereditary form. The inflammation may be acute, occurring early in the course of the disea.se, affecting the periosteum chiefly and ending for the most part in resolution, or chronic, involving the bone as well, and often complicated by suppuration. Sclerosis and hyperostosis are more common in the hereditary form. Tubercle usually affects young subjects, and nearly always cancellous bones, though it may occur upon the cranium. Other specific organisms, such as those of leprosy and actinomycosis, are too rare to re- quire special mention. Secondary inflammation of bone, due to extension from structures near, is fre- quently met with. Ulceration of the skin, for instance, may extend into the sub- stance of an underlying bone and lead to caries ; or, in a poisoned wound of the finger, the inflammation may spread along the lymphatics to the tendon-sheath and the periosteum, and lead to acute suppurative periostitis. Varieties of Inflammation. Simple Traumatic. Contusions occasionally give rise to an effusion of blood under the periosteum or in the cancellous tissue ; but except in children it is rarely extensive. The sub- periosteal extravasation on the parietal bone in infants after difficult labor {cephal- hcefnatoma) is an exception. This may attain a very considerable size, though it is always strictly limited by the sutures, and may last for months before it is com- pletely absorbed, the edges becoming hard and organized while the centre remains soft and semi-fluid. In cases of fracture the extravasation is more extensive, fill- ing up the medullary canal and spreading into all the tissues around as well. The subsequent changes are the same as in other tissues : the blood coagulates, the liquid portion disappears, the vessels dilate, lymph pours out through their walls into the remainder of the clot, and all the tissues around become softened and swollen. In other words, the tension and the extravasated blood have caused a very slight degree of inflammation. (a) In the vast majority this is followed by resolution ; the broken-down clot is gradually removed, the exudation is absorbed, the blood-vessels shrink to their normal diameter, and the structure of the part is completely restored. {H) Occasionally organization takes place, and the lymph becomes converted into bone. This is always due to some slight but persistent irritant ; it maybe a OSTEITIS. 451 local one, as when organization occurs round the margin of a cephalhrematoma ; more frequently it is constitutional, as in syphilis or rheumatoid arthritis. In these diseases the general nutrition is so perverted that if the tissues become inflamed, no matter what the exciting cause may be, the attack is not allowed to subside; it is maintained and nuule chronic by the constitutional comjilaint. {c) In rare instances the death of the part of the bone that is injured takes place ; thrombosis occurs, and if the collateral circulation fails necrosis results. In the soft tissues the dead part is removed by fatty degeneration. In bone what is known as quiet necrosis follows. A jjortion of the shaft perishes, acts as a foreign body keeping up a slight amount of irritation, and leads to the formation of dense and thick layers of new bone around, so that sometimes an enormous degree of enlargement is produced. Suppuration is a complication and not an essential feature ; but generally the pyogenic organisms gain access to the injured tissue through the blood-stream, and a certain, amount of \)\\s is formed. If this occurs in the shaft of a long bone it is known as chronic osteomyelitis (Fig. 179) ; if in the cancellous end, as chronic abscess of bone (Fig. 178). Probably in these in- stances the tissues outside the immediate seat of injury are well nourished, the pyogenic irritants are few in number and capable of but little mischief, and sclerosis soon shuts them in. Symptoms. — (ecome Fig. 170. — Chronic Ab- r ' ' -^ ^ . ,, ' . ^ . , • ,, , scess in the Centre of carious from any cause, inflammation sets in and rapidly spreads fchronic°*^su"puraTve to the jieriosteum, the medulla, and the substance of the bone osteomyelitis) leading itself. The spougy part of the alveolar margin becomes exposed, the surface is which there to sclerosis and the deposit of new bone the outcr laycrs of the bone are eaten away, Th1;"i'ne''oy'the^"oTd''0"ghened, the medullary spaces filled with pus in shaft can still be is a uumbcr of iiiinutc .sequestra, and the medulla itself is com- pletely destroyed. Sometimes the disease remains limited to the alveolar margin ; more frequently the sequestra refuse to separate, and it extends until the whole of the bone has i)erished and is detached from the periosteum. In the case of the lower jaw there is nearly always a deposit of new bone at the angle, where the severity of the inflammation is less acute ; but it is of a peculiarly soft and spongy character, and adheres to the dead bone beneath, so that when the sequestrum is removed it nearly always comes away with it. ACUTE NECROSIS. 453 The symptoms may be of great severity. The gums l)ecome swollen ; the pain is very intense; there is a profuse discharge of jjus into the mouth, and partly from this constantly finding its way down into the lungs and the stomach, partly from the inability to take a proper supply of nourishment, the health soon begins to fail, the inflammation extends to the other parts of the face, and the patient becomes utterly worn out. Very little can be done in the way of treatment until the sequestra become loose. Dead projecting fragments may be removed from time to time; the mouth must be kept sweet by constantly washing it out with Condy's fluid or some other antiseptic ; abscesses may have to be opened, and the strength must be maintained as far as possible. In some cases the whole of the lower jaw, with the exception of the condyles and the attachment of the temporal muscle, can be removed. Reproduction usually takes place abundantly, and a massive bar of bone is devel- oped in its place ; but not unfrecjuently this atrophies again, and nothing but a fibrous band is left to support the mucous membrane. It has been recommended, where possible, not to remove the teeth, in the hope that, if their attachment to the mucous membrane could be preserved, they might retain a certain degree of vitality and become sufficiently firm again to prove of use. Fig. i8o. — Phosphorus Necrosis, most marked at the alveolar border, with a deposit of new and adherent bone at the angle. Mercurial Necrosis. Exposure to the fumes of mercury (as in a long since abandoned method of silvering glass), or its administration in excess, may cause necrosis either of the subcutaneous bones (the skull, sternum, tibia, or bones of the nose, for example), or of the jaws. In the latter case the origin is evidently local ; the mucous membrane first becomes affected, especially around carious roots or where there is an accumulation of tartar ; then the periosteum and the lining membrane of the alveoli ; the teeth become loose and drop out ; and finally the bone itself becomes involved. At the present day it is, fortunately, very rare. Acute Suppurative Osteitis. Acute Necrosis. This may begin either in the medulla or the periosteum {acute suppurative osteomyelitis ox periostitis') ; it is always the result of infection; it is much more common in children (especially in boys) than in adults, owing, in all probability, to the greater vascularity and more rapid nutritive changes in the bones during early life ; suppuration sets in almost at once, and it is attended with the most intense fever, so that it may prove fatal within three or four days, with all the symptoms of general blood-poisoning. 454 DISEASES AND INJURIES OF SPECIAL STRUCTURES. A closely similar form occurs in infants, attacking the growing layer at the epiphyses {acute c/'//>/ivsi/is) and leading to suppurative arthritis ; and occasionally after aniiMitation, in which the medullary canal has been ojjened.an intense form of osteomyelitis occurs from direct infection. Acute necrosis is most often met with between the ages of eight and eighteen, and it nearly always affects the long bones, sometimes beginning in the middle of the shaft, but more often in the neighborhood of the epiphyses. It may occur in perfectly healthy children, but fatigue and exhaustion are certainly predisposing causes. One of the most acute cases I have ever seen developed suddenly in the course of a chronic attack without its being possible to assign a reason. It has nothing to do with .scrofula. Causes. — There is usually a history of a blow or of some slight injury a day or two before ; but although this may determine the locality of the outbreak, and perhaps (when the bone is superficial and the inflammation begins in the perios- teum) assist the development of the poison by the extrava.sation it causes, it cannot be held resjjonsible for more. The immediate agent is undoubtedly an infective germ which enters the blood, either from .some cutaneous boil or through the ali- mentary or respiratory tracts, and which finds a suitable soil in the injured area. It is well known that in pyaemia abscesses are prone to develop at the seat of in- juries, and that suppuration sets in around simple fractures if animals are fed upon putrid food ; and it is jxjssible a similar explanation will hold good for this ; the germs are often pre.sent, but cannot develop without a suitable nidus having been prepared. Xo specific organisms have been found in connection with the disease ; the staphylococcus pyogenes aureus, which is met with in all forms of acute suppura- tion, occurs abundantly, so also does the staphylococcus pyogenes albus ; sometimes there is a streptococcus too ; and not seldom, especially in the worst cases, they are all found together, but they are in no way peculiar to it. In several instances acute necrosis appears to have been secondary to infection from boils ; and it has been shown that the pus from a case of this kind rubbed into the skin of the fore- arm is capable of producing pustules and furuncles in abundance. Morbid Appearances. — In acute osteomyelitis the changes are practically confined to the medulla; outside, the periosteum is thickened and .softened ; the fibrous layer, especially near the ei)iphysis, is separated by a purulent exudation from the bare, smooth bone beneath, and the tissues around are swollen and infil- trated with lymph ; but often before there is time for anything further the case proves fatal, with symptoms of the most intense blood poisoning. The medulla itself disappears ; the central canal is filled with purple extravasations and streaks of yellow pus ; and in the worst cases, if the disease has lasted more than a few days, even the cancellous ti.ssue at the ends of the bones is loaded with blood-stained pus, on the top of which is floating a scum of oily drops. In acute suj^purative periostitis this order is reversed ; and if the tough, fibrous layer gives way in time, so that the pus is not retained under such high tension, the morbid process spreads to the tissues around and causes more conspicuous changes. It usually commences on the shaft, in the neighborhood of one of the epiphyses, especially on the posterior surface of the lower end of the femur. Pos- sibly this is due to the extensive attachment of the gastrocnemius to the periosteum ; a sudden contraction might tear it from the bone. The tibia, however, suffers almost as frequently ; the bones of the upper extremity less often. Pus forms almost at once ; nearly always it is mixed with blood, and very often there are oil globules floating in it, coming from the medulla beneath. If it begins on the middle of the shaft, the whole of the periosteum may be stripped up within a few hours ; if it is near one of the epij^hyses it extends rapidly to the growing line, and then, being checked at this point by the much firmer attachment of the fibrous layer, turns inward between the shaft and the epiphysis and spreads into the cancellous tis.sue This peculiar limitation to the shaft is one of the most characteristic features of the disea.se. ACUTE NECROSIS. 455 The it is f How far the bone itself takes an active share in the inflammatory jjrocess is still an oj)en question. Certainly, if the disease continues unchecked, the super- ficial layers are killed ; and if it extends into the medulla the whole thickness perishes ; but if free exit is given to the pus at once, even though the bone under- neath is bare and white, recovery without any perceptible loss of tissue is not un- common. Left to itself, the further progress is simply a question of destruction, fibrous layer of the periosteum gives way ; .sometimes the tension to which subjected is so great that the whole of it sloughs. The pus, as soon as it gains the soft loose tissue outside, spreads in all directions, and forms huge diffuse abscesses between the muscles. The epiphyses become detached from the shaft ; if this occurs at both ends the whole length perishes (total necrosis). The neighboring joints become involved ; synovitis always occurs from the mere presence of such intense inflammation near ; not un- frequently acute suppurative arthritis follows ; either the inflammation spreads along the fibrous layer until it reaches the reflexion of the synovial membrane, or, as more commonly happens, the pus spreads in the soft medullary tissue of the epiphysis until it reaches the articular lamella underlying the cartilage of the joint ; this gives way ; a small round opening like a minute trephine-hole is formed, and the synovial cavity be- comes filled at once with intensely infected septic pus. Other tissues do not fare any better ; diffuse cellulitis spreads up and down the limb ; the skin becomes un- dermined ; abscesses form and point, perhaps a long way off, and at last symptoms of general pyjemia make their appearance. There is everything to favor such a termination — intensely infective pus, high tension, and inflammation of bone. Sometimes numerous metastatic abscesses form in all parts of the bodv, e.specially in the wall of the heart, causing purulent pericarditis : sometimes the constitutional infection is so severe that the result is fatal even before these have time to develop. Repair. — If the case does not prove fatal from acute blood poisoning within the first few days, the pro- cess of repair commences ; the inflammation ceases to spread ; the suppuration becomes limited ; the tissues that have been killed are gradually detached, and organization begins. (a) In the most intense form, when the periosteiim and medulla are both involved, the whole shaft perishes, and the destruction is too great for effective restoration. Fortunately,' it usually falls short of this ; the growing layer is left ; new bone is thrown out ; the sequestrum is gradually separated, and even if the shaft is destroyed from end to end and taken away, it is very fairly reproduced. (^) Repair is most easy in periostitis. As soon a.s the tension is relieved, and the inflammation ceases to spread, the living bone beneath the sequestrum becomes more va.scular ; rarefying osteitis sets in; a layer of granulations is formed ; and gradually the necrosed fragment is entirely detached. Further away, where the effect of the irritant is not felt so much, the lymph be- M^'^.^ :-r^:^ I Fig. i8i. — Acute Suppurative Perios- titis and O'^teomyelitis (Acute Necrosis) of Shaft of Tibia from a Child. The sequestrum has been removed, and the new shell, de- ficient in many parts where the periosteum sloughed (cloacae), is lef}. The epiphyses are in- tact. 456 DISEASES AND INJURIES OF SPECIAL STRUCTURES. comes organized and new bone is formed (osteosclerosis). Similar changes take place on the side of the periosteum, only they have the effect of locking the secjues- trum in, so that it can only be released by operation. 'I'he under surface facing the dead bone is converted into vascular granulation tissue ; in this organization soon begins and a sheath of new bone is formed, covering in the sequestrum, and continuous above and below with that which is still living. At first, like all new bone, it is soft and porous, traversed by numljerless little vessels running inward from the surface, just as in callus (Fig. i8i) ; but by degrees, if the sequestrum is removed, it becomes harder and denser; and in proportion as this occurs the amount diminishes, until at length the gap in the old bone is filled with ti.ssue, which in size, shape, and direction of blood-vessels, is practically the same as it was before. The sequestrum from a case of periostitis may always be recognized by its smooth external surface, and the rough worm-eaten jjart beneath, where it has been excavated and detached by granulations. In osteomyelitis this is of course reversed. The amount of new bone thrown out depends (so far as local conditions are concerned) partly upon the intensity of the inflammation, partly upon the length of time the sequestrum is allowed to remain and act as a foreign body. In the most severe cases, the periosteum, like the compact tissue beneath, is killed at the first, and no new bone is formed : the shell is deficient over a great part of the gap, although there is usually a certain amount at either end. \{ this occurs in the tibia, the two extremities, provided the epiphysis have remained intact, some- times form a connection with the fibula, and this, because of the increased weight it has to bear, becomes hypertrophied. If it is the femur or the humerus nothing can be done, except possibly transplantation : in one or two instances a bone has been built up by this. Even, however, in moderately acute cases portions of the periosteum usually slough, and deficiencies are left here and there in the new shell. These openings are known as cloaca and they serve as channels to convey the pus from the interior to the sinuses, by which it is discharged through the skin. Sometimes when the tension has been relieved by free incision at once, no necrosis at all takes place; the bone is exposed, bare and white, but as soon as the pus has free exit the inflammation ceases and the periosteum falls down on to its place again. Even in these, however, a very considerable amount of new bone is thrown out, leaving an osseous node which becomes absorbed very slowly. {c) In acute osteomyelitis, if the blood-poison- ing does not prove fatal, the same reparative changes take place ; but in most cases restoration is much less complete. This arises from the way in which the sequestrum is locked in. If the i)eriosteum and the outer portion of the compact tissue escape destruc- tion, and if (as in chronic abscessj layers of .sclerosed bone are formed around, the removal of the seques- trum becomes exceedingly difficult, no matter how insignificant the size. The longer the irritation lasts, the deeper it becomes buried ; and in old cases the bone becomes hardened, rugged, and enormously F.G. ,82.-chronic Osteomyelitis of thickcncd, over pcrhaps its wholc length. Sequestra Lower End of Tibia. The section lockcd in in this way in carlv life often give rise to across the shaft was solid, and the t ■ ^ ^ ^ i i ^i ^ / r cr medullary canal completely obiiier- such pcrsistcnt trouble that after many years of suffer- :"thsinust":;.hichie^Tin'ai."ditc' ^"g ^^c patient bcgs for amputation. It is not un- tions through it. it was amputated common at the lowcr end of the femur : a discharg- because of the disease of the knee • • i r^ ^i ^ j r^i i- l joint. ing Sinus IS left on the outer or inner side of the limb ; ACUTE NECROSIS. 457 the bone is enlarged, hardened, and perforated with suppurating channels ; the knee joint, from repeated attacks of synovitis, is utterly disorganized ; and the patient becomes a hopeless cripple (Fig. 182). Symptoms. — The onset is usually very insidious, unless the inflammation develops in connection with an already existing attack of pyaemia; then it may begin with a rigor. The first and most prominent feature is pain, at the begin- ning flying vaguely all over the body, but soon settling down to one part, and becoming intense, especially at night. The least pressure or the slightest move- ment makes it simply intolerable; and the limb is kept absolutely rigid, as if it were paralyzed, every contraction of them uscles pulling on the periosteum causes such agony. From the commencement the prostration appears unaccountably great ; the pulse is small and quick ; the temi)erature begins to rise at once ; and in severe cases may reach 104° F. by the second or third day ; the respiration is hurried ; the tongue and lips dry ; the skin burning hot ; the pupils dilated and staring, and the face peculiarly dusky. Delirium soon sets in, especially at night, and by the third or fourth day the general aspect is that of the most intense blood- poisoning. The local signs depend upon the situation. If the bone is superficial, as in the case of the tibia, the swelling can be detected at once ; the skin soon becomes red and oedematous, and it is tied down to the periosteum beneath, so that it can- not move freely over the bone. On the other hand, when it is the femur, especially when the back part is involved, they are much more obscure : the skin remains white until pus has formed and worked its way near the surface; often it is whiter than natural, from the tension of the deeper structures beneath, with slightly enlarged veins passing over it ; and no swelling can be distinctly made out. Usually, however, if the limbs are compared, the affected one looks more even in outline and more rounded than the other ; the intermuscular depressions are partly filled up ; and at the same time it feels more tense and firm, especially over the part where the pain and tenderness are most distinct. The temperature, too, is higher than that of the opposite limb ; and if the inflammation is near a joint there is always a certain degree of synovitis. In osteomyelitis the difficulty of diagnosis is even greater than in periostitis ; the constitutional symptoms are much more severe ; the local signs much less distinct. Later, when the pus has escaped from under the periosteum and spread into the tissues around, there is little or no difficulty. Dusky erythematous patches make their appearance upon the skin, the swelling becomes more distinct and localized, and deep-seated fluctuation is usually plain, especially if the patient is under an anaesthetic. The constitutional symptoms do not begin to subside until the pus has been evacuated. When the .medullary canal is involved the patient may sink from acute septi- caemia before any local signs other than tenderness and pain have time to develop. If this does not happen various complications set in, according to the direction in which the inflammation can extend most easily. Acute suppurative arthritis is one of the most common, the inflammation spreading through the cancellous tissue of the epiphysis, or outside it along the fibrous covering. Separation of the epiphysis is another, causing deformity and a peculiar soft kind of crepitus when the limb is moved. In severe cases other bones may be involved, one after another being attacked at intervals of a few days in distant parts of the body ; sometimes each outbreak is attended with a rigor, more frequently pain is the most prominent symptom, and the swelling is only detected on examination. Secondary attacks of this kind are rarely so deep or so extensive as primary ones. Fatty embolism is probably nearly always present, and finally pyaemia with metastatic abscesses may occur, the pericardium being involved with singular frequency. Diagnosis. — Acute suppurative osteomyelitis or periostitis may be mistaken for typhoid or other acute specific fevers, especially when the septicsemic symptoms are very strongly marked and fugitive erythemata are present upon the skin, but 30 458 DISEASES AND INJURIES OE SPECIAL STRUCTURES. careful examination can hardly fail to reveal a local cause. Occasionally it is mis- taken for diffuse cellulitis, which, however, unless it is due to a poisoned wound, rarely or never occurs in children ; and sometimes for acute rheumatic fever, especially when the lower end of the femur is involved on the posterior surface, so that the knee joint is fdled with fluid from the first. Treatment. — Division of fhc Periosteum. — Whenever there is a suspicion of acute suppuration in connection with bone, the patient should be ])laced under an aniiesthetic, and an incision made through the soft jjarts and the i)eriosteum on to the surface of the compact tissue, selecting the spot at which the tenderness is most marked. It is certainly not advisable to wait for a distinct sense of fluctua- tion ; the pus may separate the epiphysis from the shaft, or detach the periosteum from almost the whole circumference, before it forms a sufficiently thick layer of fluid for this. The extent of the incision depends upon the condition of the peri- osteum ; if it is only just separated from the bone beneath, a simjjle linear division may answer all requirements, free exit being provided for the effusion by means of a large drainage-tube. If, however, the separation is more extensive, the finger or a probe must be passed down to explore the surface thoroughly, so that counter- openings may be made where required. Drainage of the Medulla. — Sometimes the symptoms are relieved at once, the temperature falls, and it is clear the chief indication has been fully met. The limb must be kept perfectly quiet upon a splint, careful watch made that the open- ing does not close too soon or become valvular, and the periosteum will fall down on to the bone again, and very possibly there will be no necrosis. In other cases there is but a very short respite or none at all ; and it is clear that further exploration is required, that the separation of the periosteum was not the primary affection, but merely an indication of more deeply-seated inflammation. This is especially likely to happen when the chief seat of tenderness is close to the epiphysial line, and when there is at the same time effusion into the neighboring joints ; under these conditions it is more than probable that the inflammation involves, if it did not begin in, the layer of soft vascular growing bone on the end of the shaft, and that, if it has not done so already, it will almost certainly spread to the medullary canal. It is this form of necrosis which, if left to itself, leads to the death of the whole shaft and separation from the epiphysis at both ends. Under these cir- cumstances, or if the epiphysis is already separated before the incision is made, the central canal of the bone must be opened and drained as well. When the connection is already severed the end of the diaphysis may be removed at once ; with the medullary canal containing pus, with pus under the periosteum, and sup- puration between it and the epiphysis, that part of the bone will certainly perish if it has not done so already. By this free drainage is gained at one spot ; but that is not enough ; an opening must be made into the central canal lower down on the bone, so that it may be thoroughly washed out. As a rule there is no diffi- culty in ascertaining the proper situation for this, for in such cases the disease is always far advanced, and either there is at some point extreme tenderness on pressure, or the periosteum is already detached and suppurating, the pus having worked it way out through the shaft along the course of the nutrient vessels. Then the cavity must be syringed out thoroughly with an antiseptic solution, the medulla itself removed as far as possible, iodoform dusted in, and a drainage-tube passed through. In one case in which this was done, by Jones, of Manchester, the whole of the shaft of the humerus was drained, from its upper extremity where it faced the epiphysis to an opening made a short distance above the inner con- dyle. Subperiosteal Resection. — In the most acute cases, owing to the extreme rapid- ity with which the disease progresses, the time for this is already past. If the inflammation involves the periosteum only, free incision must be made down to the bone wherever fluctuation can be detected ; if the medulla, and if the shaft is already detached at the epiphysial line, the whole of it had better be removed at ACUTE NECROSIS. 459 once. This, w hich has been called subperiosteal resection, is most easily accom- plished by dividing the bone in the middle with a chain saw ; the two halves can then be readily twisted out. It relieves the limb at once of what is practically a foreign body keeping up a very great deal of irritation ; it lessens the danger to the neighboring articulations, and it obviates the necessity for a long and tedious operation afterward when the new shell of bone has been formed. An extra amount of care, of course, is required to support and protect the limb until the new bone is sufficiently firm. Other treatment is of little or no avail. Iodine and counter-irritants are worse than useless ; they simply waste valuable time, and the same may be said of iodide of potash. Quinine and antipyrin may be given when the temperature is very high, but they have little or no control over the disease itself. Afterward, during the long period of exhausting and wasting illness which not unfrequently follows, the former, with preparations of iron and cod-liver oil, is often indispens- able. The limb should be kept at perfect rest upon a suitable splint, especially in those cases in which, owing to separation at the epiphysial line, or to the early removal of the sequestrum, the central support is lost, and sometimes it is neces- sary to maintain a slight degree of extension to prevent too much shortening. Cold applications, lead and spirit lotion, for example, may be used at first ; but as soon as there is an escape for the pus, warmth is more serviceable, as the object then is to encourage the discharge of the poison as far as possible. Careful watch must be kept that the pus does not collect in the deep outlying recesses of the part and undergo decomposition, especially as when dead bone is present it is often peculiarly offensive. Counter-openings are often required, and drainage-tubes must be used freely. If the neighboring joint becomes involved, it must be laid open thoroughly on both sides (and in the case of the knee behind as well) and freely irrigated. Even after this has happened the limb ma\- be saved in exceptional instances ; the upper epiphysis of the tibia, for example, has been removed, with some of the shaft, leaving a shortened limb riddled with sinuses, but capable of bearing some weight ; nearly always, however, hectic and profuse suppuration set in ; the cartilage becomes eaten out by granulations springing from the opposite bone ; starting-pains make their appearance at night ; the patient becomes exceeding emaciated, and amputation is necessary to save life. The subsequent progress, if pyaemia and other complications do not set in, is dependent upon the situation and extent of the sequestrum. Sometimes, as already mentioned, it is completely separated within three wrecks or a month : the line of demarcation corresponds to the soft vascular bone at either end, no time is required for absorbing compact tissue, and the whole shaft, even of such a bone as the tibia, can be extracted entire, leaving behind a great space lined with periosteum, which rapidly becomes filled with new bone. In other cases the time required is much longer, and in some exceptional instances it may be a matter of years, owing, in all probability, to the density and hardness of the surround- ing osseous tissue. In young subjects the process is naturally much more rapid than in old, and it is somewhat quicker when the bones of the upper extremity are concerned. Where the periosteum only is concerned and the sequestrum is small and superficial, it may separate of itself and be discharged through an opening in the skin, by what is known as exfoliation, without the necessity for any further opera- tion. This is not uncommon on the skull (after injury, for acute necrosis rarely affects the flat bones) and on the subcutaneous surface of the tibia. A line of rarefying osteitis gradually forms around the dead part, the compact tissue that immediately borders it becomes more and more open ; at length it is completely absorbed, and the sequestrum is left resting on the surface of a bed of granula- tions. No new shell on the outside is ever formed by the pericranium to lock the dead bone in, and very often it is almost as defective on the tibia, owing to the 46o DISEASES AND INJURIES OF SPECIAL STRUCTURES. thinness and the peculiarly exposed situation of the periosteum. As soon as the line of demarcation is complete, the sequestrum is held in merely by the skin, and only recpiires the apitlication of a pair of forceps to remove it. In those cases in which no outside shell is formed, whether on the skull or elsewhere, the deficiency in the bone is rarely made good : the granulations gradually fill up the hollow and become organized, and the deeper layers become converted into bone, but the superficial part rarely passes beyond the stage of fibrous tissue. There is no doubt the periosteum is the main agent in reproduction, although it may not be the only one. In central necrosis, on the other hand, or when a shell of new bone has been formed around the secpiestrum, enclosing it and locking it in, extensive operations may have to be undertaken for its removal. The longer it is left after it has once become loose, the deeper it becomes buried and the more serious the changes that it induces, not only in the other structures near, but in the patient's general con- dition. The acute fever may have subsided long since and there may be only a slight evening rise of temperature ; but this, if continued, especially if connected with bone, is very prone to end in either hectic or amyloid. In the case of compact tissue it rarely happens that the living bone can separate itself from the dead under two or three months ; total necrosis is an apparent exception, but in this the line of separation runs along the soft vascular growing layer. During this time the appearance of the limb changes very con- siderably. The heat and swelling of the acute stage gradually become less and less ; the redness fades away, there is no longer such extreme tenderness on pressure, and the incisions, instead of gaping widely and giving exit to a mixture of pus and blood, gradually become contracted into narrow sinuses, lined with granulations and secreting only a small quantity of purulent fluid, which oozes slowly from a tiny orifice surrounded by a button-shaped mass of little vascular buds. A probe passed into the centre of this sinks almost of its own weight down a devious channel, until, after passing through one of the cloacae, it comes into contact with the sequestrum. The utmost gentleness must always be used ; if it is forced in any direction it is certain to catch somewhere against the walls, making them bleed, which they do with the greatest readiness, and causing pain. The presence of a sequestrum must be gathered from the sensation the probe conveys ; the hard, smooth surface, and the clear, ringing sound produced when a dead part is struck, differ completely from the soft, gritty sensation of carious bone, into which the probe can be driven with ease, and from the firm but roughened surface of uninjured periosteum. The size must be estimated partly from the position and direction of the sinuses, partly from the extent of the enlargement and the range of the original attack. Whether it is loose or not is very often a matter for conjecture rather than for belief; occasionally it is possible to move it slightly by firm pressure ; or, by introducing probes into two distant sinuses and pressing on them alternately, to convey a kind of shock from one to the other ; but very often the sole evidence is the peculiar hollow note when the sequestrum is sharply struck, and the length of time that has elapsed. The operation itself {sequestrotomy) naturally differs in every case. A time for it should always be selected when the patient's temperature is as even as pos- sible ; it very commonly happens when there is a sequestrum of any size that slight attacks of feverishness occur from time to time, each one marking the formation of a fresh abscess in the neighborhood of the old inflammation. The limb should be raised to a vertical position for a few minutes and an elastic strap buckled tightly round it ; or Esmarch's bandage may be used. It is of great advantage not only to control the hemorrhage at the time (and it is often very profuse), but to be able actually to see the condition of the bone. If the sequestrum is superficial, all that is necessary is to make an incision through the soft parts, either enlarging a sinus or connecting two that are close together, and twist it out with a pair of strong forceps ; but when it is central a great deal of ACUTE NECROSIS. 461 manipulation may be required. Sometimes the cloacae are large enough to allow it to pass through : a very long sequestrum, for instance, from the tibia may, if caught fLiirly at the end, be extracted through a comparatively small opening. More often they have to be enlarged, or, like the sinuses on the skin, thrown into one, the intervening soft new bone being divided with a chisel or cutting-forceps, and, as far as possible, reflected without being removed. Occasionally, as in sub- periosteal resection, the necrosed portion can be divided with a chain-saw and ex- tracted in two halves. After the removal a smooth cavity is left, lined with granulations which bleed freely as soon as the bandage is removed. This may be checked to a certain extent by washing out the interior with diluted tincture of iodine, or with very hot water, or by packing it with some antiseptic dressing ; but unless the cavity is of very large size it is generally sufficient to bandage the limb carefully and keep it well raised : the bleeding only comes from capillaries which have been torn and have lost their support ; it rarely happens that a vessel of any size is divided. After- ward the wound must be washed out at frequent intervals with some antiseptic, as it is rarely possible to drain it effectually, and such an amount of blood, allowed to collect at the temperature of the body exposed to the air, might prove a serious source of danger. In a very few days the sides begin to fall in and contract'; and as the granulations spring up and become organized, the amount of discharge grows less and less, until, in a comparatively very short time, the cavity is completely obliterated. It is not always that the operation is so easy or is followed by such immediate success. In many instances the sinuses are surrounded by structures of such im- portance that only a very slight degree of enlargement is possible. Sometimes the sequestrum is not sufficiently loose, and only some of the superficial part can be chipped off or cut away ; or it is so deeply buried that it cannot be extracted with- out almost cutting the bone in two. It is seldom that this happens as a result of acute osteomyelitis ; but when the inflammation has been chronic (in quiet necrosis, for example, when a portion of bone near the centre perishes without causing suppura- tion) the compact tissue on the outside becomes thickened to such an extent that it is scarcely possible to make an opening of sufficient size. In other cases again the shell of new bone formed by the periosteum is defective, so that the limb is in great danger of what has been called spontaneous fracture. This may arise, as in subperiosteal resection, merely from the early removal of the sequestrum, and then in a week or two the limb becomes sufficiently firm ; but occasionally it is due to sloughing of the periosteum. If it occurs in the tibia, the limb may still be pre- served and prove of use, the fibula being assisted by means of an artificial support ; in the femur, however, unless firm union can be obtained at the expense of the length of the limb, amputation must be performed. All these difficulties combined are not unfrequently met with in necrosis of the lower end of the femur. The popliteal vessels, the external popliteal nerve, and the synovial membrane of the knee joint are all in danger ; so that, unless the ab- scess is actually pointing elsewhere, the incision must be made in the outer side of the limb in front of and parallel to the biceps tendon. The sequestrum is very often only partially detached, even after years ; if it is central it is exceedingly hard to extract before the knee joint is involved, owing to the immense thickening and condensation of the bone above and around it ; if it is superficial and on the back of the bone (its usual situation), it is often in actual contact with the artery, owing to the absence or defective development of proper periosteal sheath ; and instances of its having ulcerated through and caused fatal hemorrhage are not un- known. Other troubles may follow at a later period. A certain amount of chronic osteitis is not uncommon ; there are frequent attacks of tenderness and pain, especially at night ; the bone becomes immensely thickened and irregular in shape ; and occasionally, even after long intervals, residual abscesses form, probably from the slow decay and death of some of the lowly organized inflammatory exudation. 462 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Sometimes sinuses persist for years, surrounded by dense, hard bone, and discharg- ing a thin, purulent fluid from the granulations that line them. Minute sequestra not unfret|uently become detached and slowly separate of themselves. In other cases the growth of the bone is arrested owing to premature ossification of the epiphysis ; or the neighboring joint becomes stiff, and even at length practically useless from the repeated attacks of synovitis ; and finally in some cases, even after the limb has been saved, amputation becomes necessary at last, either becau.se the part is useless, or to save the patient from hectic or amyloid disease. Acute Epiphysitis. This name has been given to a variety of acute suppurative osteomyelitis which attacks the bony nuclei in epiphyses, or more often the growing layer between the epiphysis and the shaft. Not unfrequently more than one bone is in- volved, and probably it is always pysemic in character, but nothing is known with regard to any exciting cause, other than it is usually said to follow some slight in- jury. 'Fhe larger epiphyses (at the hip and knee) are most often affected, though the smaller ones are not exempt. In children it usually commences at the line of growth and spreads from there to the periosteum, or to the medulla, or to both together, leading to one of the worst forms of acute necrosis. In infants (and it is not uncommon within the first few months of life) it sometimes attacks the bony nucleus embedded in the centre of the cartilage, giving rise to what has been described as acute arthritis of ittfants. Suppuration sets in at once with the greatest intensity ; the articular end of the bone Ijecomes hollowed out into an abscess-sac, and almost always the pus bursts into the neighboring joint, destroying it completely. If the case does not j)rove fatal from blood-poisoning, or later from hectic and prolonged suppuration, the end of the diaphysis becomes united to the opposite bone, and the limb is left more or less flail-like, shortened and incapable of its proportionate share of growth. The upper end of the femur, for example, as soon as the child bears any weight upon the limb, becomes displaced until the trochanter is on a level with the anterior superior spine. Septic Osteomyelitis. Acute suppurative osteomyelitis, after compound fractures or amputations in which the medullary canal has l)een opened, resembles acute necrosis very closely, though it differs in a few particulars. The infection, for example, is direct, through the wound, not through the blood ; the pus is asually very offensive, and the ten- sion, owing to the fact that there is a certain though an insufificient means of exit, is not so high. Minute sequestra are of common occurrence after amputations. A ring of bone on the end of a stump is killed by the saw, or by the separation of the j^eri- osteum, and after a time is detached without causing any constitutional disturbance, or giving rise to any more inconvenience than is due to the ])resence of a sinus. Sometimes the whole thickness of the bone perishes in this way just at the end. If, however, septic inflammation sets in and attacks the medulla, the result is very different. Masses of sprouting granulations project from the orifice ; the central canal becomes filled with intensely infectious pus which cannot escape with suffi- cient freedom ; the fever l)ecomes exceedingly severe, the periosteum is stripped up from the bone, and if pyaemia does not set in and prove rapidly fatal, the whole thickness of the lower end of the bone, and the inner lamelK-e for a very consider- able distance higher, are killed. In this way the long tubular sequestra are formed which are sometimes extracted from suppurating amputation wounds. At the end, where the inflammation is most intense, the periosteum and medulla are both killed, and the whole thickness of the bone perishes ; higher up, the periosteum and the outer layers, being further removed from the central irritant, manage to SEPTIC OSTEOMYELITIS. 463 survive, and the outer surflice of the secjuestrum is worm-eaten all over by the granulations which have cut it off from the rest; higher up still, the sequestrum grows smaller and smaller until it ends in irregular spikes formed from the layers immediately bordering the medulla (Fig. 184). Above this, and on the outer sur- face of the bone, under the periosteum, organization goes on all the time, and layers of new bone are formed, filling in the central canal, and sheathing the com- pact tissue of the shaft (Fig. 183). The symptoms and treatment are essentially the same as in acute infective osteomyelitis. The stump becomes red, glazed, and swollen ; red lines run up the skin to the neighboring glands ; all the tissues on the inner side of the limb are thickened and (edematous ; the edges of the wound separate from each other ; sometimes the end of the bone projects, bathed in pus, with the periosteum de- tached from its outer surface and the medullary canal filled with masses of sprout- ing granulations ; the amount of discharge increases ; frequently it pours out when a probe is introduced; if it is retained in the least it becomes offensive and the pain excruciating. Usually the attack commences with a rigor ; the fever from the first is extreme, and the temperature exceedingly irregular, the pulse is rapid and bounding, the face flushed, the tongue dry and brown, and the skin burning hot. Delirium sets in very soon ; sometimes there is profuse diarrhoea ; in other cases rigors occur in rapid succession, and either osteophlebitis and metastatic abscesses make their appearance, or the blood-poisoning proves fatal before there is time for this. Such cases used to be common after amputations through the shaft, and they still are met with in military surgery and where, from overcrowding or neglect of pro- per precautions, septic decomposition is rife ; with perfect cleanliness and thorough drainage they ought never to happen. At the first indication, as soon as the condition of the medulla is suspected, the patient should be placed under an anaesthetic, the end of the bone freely exposed, and if the suspicion is confirmed and the cavity is found to be filled with offensive pus, the whole of the fungating suppurating mass that protrudes must be thoroughly scraped away. Then the canal must be washed out with an antiseptic by means of a long rubber tube or catheter, and filled with iodoform. In this way the progress of the disease has several times been arrested with- out very extensive necrosis. In compound fractures this is hardly practicable, and the only course is speedy amputation before the disease has advanced too far and the constitutional symptoms are too marked. In the case of the tibia it fig is probable that disarticulation at the knee would be the safest measure, so as to get well above the disease ; but if the femur is in question this is almost hopeless. Ampu- tation higher up may be tried, on the chance that the medulla at the seat of section is sufficiently healthy, and in one or two in- stances this has succeeded. Possibly this, combined with free drainage of the canal, would afford a better prospect than disarticulation at the hip. ( S3. — Section through Bone after Amputation, showing effects of Septic Osteomyelitis. At the end, medulla and perios- teum have both been killed, and the whole thickness is dead ; higher up, the periosteum, not being subjected to such tension, survived, and has thrown out a sheath of new bone ; higher still, the medulla has been able to do the same. Fig. 184. — Tubular Sequestrum from a similar case, show- ing the Smooth External Surface, where the perios- teum was killed, and the rough, worm-eaten one de- tached by the granulations springing from the living bone. 464 D/SFAS/':s AND INJURIES OF SPECIAL STRUCTURES. E.xanthcmatous Necrosis. Inllammation of the periosteum and the bone, followed by suppuration and very often by necrosis, is not an unfrequent complication of the acute exanthe- mata. Sometimes it occurs during the height of the attack, but much more fre- tpiently it breaks out during the period of convalescence. In some instances it is probably py;x;mic, originating by infection from some of the sores or ulcers ; but there is very often a history of its having followed a slight injury, and it certainly is prone to affect superficial bones. It is quite intelligible that a trivial bruise, such as would not be noticed during health, might, under such circumstances, be fol- lowed by supiniration and sloughing. There is, moreover, very little tendency for this form of necrosis to become diffuse, and the sequestra are usually small. After typhoid fever it is not at all uncommon, especially on the tibia, and sometimes it is symmetrical ; but it may also occur upon the ulna, scainda, j^arietal bones, or upon the ribs, sometimes ending in necrosis, sometimes clearing up. The jaws are more frequently involved after scarlatina and variola. Syphilitic Disease of Bone. (i) /// Acquired Syphilis. In all stages of acquired syphilis inflammation of bone is exceedingly com- mon. Like the other manifestations, in the early period of the disease it is acute, attended with hypereemia, but with only a slight amount of exudation ; and it begins suddenly, runs a rapid course, and yields readily to treatment. In the later, on the other hand, it is much more chronic, the amount of exudation is larger, and caries and necrosis with suppuration are very prone to occur. At the beginning of the secondary symptoms patients often complain of a feeling of soreness in the bones, sometimes amounting to actual pain, keeping them awake at night and flying all over the body, the so-called ostcocopic pains. The bones are very tender, but there is no swelling and no increased heat over them. Probably, as the parts involved are those in which secondary syphilitic periostitis is especially prone to occur, they are due to a transient hypen^mia of the periosteum scarcely amounting to inflammation. A little later, after the skin eruption, true periosteal nodes make their ajjpear- ance. A slightly raised, exceedingly tense swelling forms upon the shaft of one of the long bones (the til)ia, ulna, or clavicle i)articularly), or upon the skull. It is so painful and so tender, that the patient will not allow a finger to come near it, and at night cannot bear the contact of the bed-clothes. The skin over it is white and shining, from the way in which it is stretched ; the temperature is slightly raised, and the whole bone is more or less tender. The size of the swel- ling is very small ; there is no definite outline to it ; it is very low and shades off gradually at the margin. Sometimes it is single ; not unfrecjuently, however, more than one bone is involved, and in the early secondary stage it is very often symmetrical. The amount of exudation jjresent in these cases and the changes it undergoes depend to a great extent upon the period of the disease. Nodes that are very acute are limited in size and attended with byt a slight degree of small-celled infiltration, so that absorption takes place w^ith great rapidity ; the pericsteum, especially the deeper layer, is thickened, softened, and more vascular ; the bone is scarcely affected, or it may be slightly too porous on the surface, and the swelling disapjiears under treatment without leaving behind any visible alteration of structure. Those that occur later are more chronic, and affect the bone as well as the periosteum. The pain is not so intense, for the tissues have time to soften and yield ; the amount of exudation is much greater in proportion to the hyjiera^mia ; SYPHILITIC DISEASE OF BONE. 465 the edges of the swelling are more distinct, and the bone underneath plays a much more im])ortant part. Rarefying osteitis sets in ; the cancellous spaces are filled with syi)hilitic exudation, and even when resolution occurs comparatively early, some permanent alteration is usually left. The hypera;mia disappears, of course, and much of the exudation is al)sorbed ; but a considerable proportion usually becomes organized and forms a i)ermanent enlargement with dense osteosclerosis around it and under its base {an osseous iiodt-). 'i'he skull is an exception : peri- cranial nodes do not ossify ; and if the external table of the bone is absorbed, the defect is not filled up (except with fibrous tissue) and the depression is permanent. Later still, in the tertiary stage the amount of gummatous infiltration is very much greater, and it not only involves the superficial part of the bone, but spreads deeply into its substance, attacking the medulla both in the central canal and in the cancellous spaces. The swelling is much more chronic; instead of being sujierficial and limited, it may extend over the whole length and circumference of the bone ; the Haversian canals are enlarged ; the bony trabecular and the com- pact tissue are absorbed ; and the medulla and the deeper layers of the periosteum are converted into a soft, reddish-yellow substance, which readily undergoes case- ous degeneration. Interstitial syphilitic osteomyelitis, or what has been called dif- fuse gummatous infiltration, has been added to the periostitis. Sometimes, on the cranium for example, the exudation is greater in one part than in another ; there is immense thickening along one of the sutures or over the eminences ; but not unfrequently, especially when one of the long bones is concerned, the whole length is irregularly enlarged, thickened, and tender, and the soft parts and the skin around and over it are swollen and reddened. Like gummata elsewhere, these tertiary nodes are much more lasting, and lead to much more serious results than simple periostitis. The exudation may be absorbed almost entirely ; more often, especially at the edges farthest away from the chief focus, it becomes organized, and the bone becomes hard, heavy, and dense ; in most cases, unless it is treated very soon, suppuration sets in ; the skin gives way, the contents of the abscess are discharged, and the surface beneath is left bare and rough, necrosed and carious, according to whether it is compact or can- cellous. In rarer cases the bone perishes, apparently from condensation, the Haversian canals at length becoming so narrow that the compact tissue is cut off from its blood-supply and dies. On the cranium syphilitic nodes are exceedingly common. Early ones are soon absorbed ; later ones are more chronic and leave depressions ; tertiary ones that ulcerate and break down lead to the most extensive destruction. The vault is the favorite place ; the whole of the exterior may be covered over with carious ulcers, varied here and there with patches which have undergone necrosis. Some- times the external table only is diseased, although the internal always shows signs of increased vascularity ; sometimes the whole thickness perishes, and more or less circular sequestra are formed. In most the ulceration is annular ; the bone becomes rough and worm-eaten ; a circular groove forms round it, and gradually the granu- lations grow beneath it and separate it from the rest. More rarely it is pitted ; the compact tissue of the outer table is eaten away in little dots all over ; and some- times it is tuberculated here and there, nodules of new bone being formed, and subsequently in their turn becoming ulcerated and destroyed. Occasionally very extensive absorption of bone takes place without suppuration (Fig. 185). Condensation and sclerosis more often affect the diploe and the inner table, particularly in the frontal region. The bone may become absolutely solid and hard all through, so that there is no trace left of cancellous spaces, and huge masses of dense osseous tissue may be thrown out on the inner surface, between the inner table and the dura mater (subcranial nodes). These are usually sym- metrical, arranged on either side of the superior longitudinal sinus (Fig. 186). Suppurating gummata in the diploe are more rare ; sometimes, however, they cause inmiense expansion, which chiefly affects the outer table and reduces the interveniniH'.. The effect i)roduced by these changes is easily A' '*).'» >ii,i^<'''' imagined ; the soft tissue at the epiphysial ends of .■'*/'r.'Ji)t» ~'fH!''\t\\' the long bones yields before the ]jressure it has to sustain, and bulges out at the sides, forming the peculiar tender and characteristic enlargement ; the shafts of the bones, the strength of which is impaired by the advancing absorption, give way and bend at their weakest i)art ; the curves that are normally present become exaggerated ; and in some cases they are so strongly marked that, when the bones are subcutaneous, like the clavicle, it maybe Fig. i8c)-Section through Lower End of .^^ , 1- • -11 r • 1 / Bone affected with Rickets, showing dlmcult to distinguish them from greenstick frac- the enormous thickness of the gelati- tures, especially as the tenderness on pressure is not of°\he''iyne ofossSor '"'^"'"'"''y unfrequently quite as great.- As soon as the morbid process comes to an end and health is regained, ossifi- cation sets in and proceeds at an unusually rapid rate. The compact tissue of the shaft becomes peculiarly dense and hard ; the growing layer at the end, where it abuts upon the epiphysis, is converted into bone, so that development is stopped too soon : and the osteoid tissue under the periosteum undergoes the same change so far as the concavity of the curve is concerned. On the convexity it is absorbed and disappears, and the compact layer of the shaft is left thinner than normal. This change is produced gradually, and, like the similar ones that occur in con- nection with badly united fractures, is the result, not of the rickets, but of the alteration in the shape of the bones. The concavity is strengthened because it has to sustain the weight of the part and has more than its normal share of work ; the convexity becomes thinner for the opposite reason. The extent to which the various bones are affected depends upon the age and habits of the child, whether it is unable to stand or whether it has commenced to walk. Every part of the body may be more or less distorted. The cranium becomes peculiarly square and flat on the top; ossification is delayed along the sutures ; the anterior fontanelle, instead of closing at the twentieth month, remains open until the third or fourth year ; and, owing to their being unable to resist the internal pressure, the bones separate to a certain extent from each other. This is usually associated with some degree of chronic hydro- cephalus. If the child lies upon its back (and very often the same position is retained for hours together, owing to the pain caused by muscular exertion) the occipital bone becomes flattened and in places absorbed (cratiiotabes). The con- stant pressure of the brain causes such wasting that opposite the convolutions the bone completely disappears ; the dura mater comes into contact with the peri- cranium ; the wall of the skull becomes as thin as parchment ; and especially at the sides of the occipital bone, w^here ossification is normally later than elsewhere, firm pressure wdth the finger makes it crackle and bend in. The growth of the face is checked : in many instances this is more apparent than real, owing to the way in which it is overhung by the forehead ; but later in life, at puberty, the arrest of development cannot be mistaken. The temporary teeth are always cut very late ; and when at last they do appear, they break off and decay in a very short time. In certain rare cases the bones of the skull, in particular those devel- oped in membrane, become enormously thickened, soft, and porous ; the orbits are partially blocked and the optic nerves atrophy ; but this, though common in 476 DISEASES AND INJURIES OF SPECIAL STRUCTURES. animals, is very unusual in man. and is so different that by many it is not consid- ered due to rickets. If the child is old enough to sit \\\), the vertebral column becomes distorted and bent. The head is usually thrown back, so that the sjjines of the cervical vertebrae are deeply sunken, and the whole of the dorso-lumbar regions form one great curve with its convexity backward. As a rule, this extends from the lower cervical region to the sacrum, and is perfectly uniform, so that there is no fear of mistaking it for the angular curvature of caries. Sometimes, however, it is very shari)Iy marked, esi)ecially in the lower dorsal region, and the resemblance then is exceedingly close, especially as, at the same time, the muscles are rigidly con- tracted, owing to the pain that movement causes. In other instances, when the disease first begins at a later period, the natural curves may be simply exaggerated ; or lateral curvature with rotation of the bodies may come on and end in the most extreme distortion. The deformity the thorax undergoes {pigeon breast) is characteristic. The sternum is thrust forward by the ribs, partly from the increased cur- vature of the spine, partly from the yielding and sinking in of the w-alls of the thorax at the costo-chondral line. The chest is flattened at the sides (less so on the right, owing to the liver, than on the left) ; there is an abrupt bending inward of the ribs near their junction with the cartilages, leading to the formation of a groove on the antero-lateral wall of the che.st, from the third rib downward and slightly outward, and at the lower border of the sternum this becomes continuous with a nearly horizontal constriction corresponding to the attachment of the diaphragm. In addition, the costochondral line is marked by a series of enlargements (the so-called beading of the ribs) analogous to the thickening and softening of the epiphyses on the ends of the long bones. Very often these nodes are so distinct upon the inner surface as to form distinct imi^ressionsupon the lungs and even upon the liver. The brim of the pelvis is widened and flattened by the jiressure of „ J r JTU- r. <• „ jv T3- 1 . Tu the abdominal organs from above : Fics. 190 and 191. — Femur and 1 ibia Deformed by Rickets. The . .0 ' bones are exceedingly short (premature ossification of the epi- but the Cavity is verV' mUCh COn- physes), the natural curves are much exaggerated, and the con- . . j it \ \ • 1 1 ^^ >f distant organs ; so that even if amputation ^ ,^J ^ ^z is performed as soon as the diagno.sis is ^ made, the stump may remain healthy to the ItcI- hill- cf>ronrlTr\- CTrnwfl-iQ nrp almnQl" tjiirf Fig. 202.— Skeleton ofa Periosteal Sarcoma Growing last, out SeCOnaar) grOWtnS are almost sure fro^ L^^-er End of Femur; the epiohyslsis not to appear within the twelvemonth. The yet united. 490 DISEASES AND INJURIES OF SPECIAL STRUCTURES. liability to fracture, of course, is less than in the central variety ; hut the other signs due to the extension of the growth into the .structures around are, as a rule, more distinct. Symptoms. — In the early stages these are very indefinite. Pain is rarely absent ; olten it is very severe, especially at night. In the periosteal form a dis- tinct swelling, projecting from one side of the bone, is one of the earliest symp- toms ; in the central it is rarely perceptible until the disease is far advanced ; and when the growth commences in the interstitial medulla, at one of the cancellous ends, it is often entirely absent until the whole framework has disapi)eared. The outline of the enlargement is fusiform, spreading along the bone and ill-defined in the periosteal ; in the central it is rounded and more distinctly limited. Its consistence is equally variable ; sometimes it is soft and fluctuating ; sometimes hard and dense, according to the character of the predominant tissue. Egg-shell crackling is only met with in the central variety. Spontaneous fracture may occur in either, but it is less common in the perios- teal. Occasionally it takes place without any evidence of tumor or new growth except pain ; but the swelling rarely fails to make its appearance immediately after, and soon attains an enormous size. Rapid growth, enlarged cutaneous veins over the tumor, softness, and above all pulsation, are most important. Any tumor attached to bone that doubles its size within six months must be regarded with very grave suspicion, ])articularly if it occurs in a young person and in the neighborhood of the knee joint. Pulsation is present in a large proportion of central sarcomata, and in periosteal ones, when they grow from the flat bones ; and when it occurs it is practically definite. It is entirely different from the heaving impulse of an aneurysm ; and though it may be accompanied l)y a distinct thrill and bruit, these are only present over a small portion of the swelling. The pulse in the limb below is unaffected unless the tumor compresses the main artery against the bone ; and the swelling cannot be materially les.sened by pressure. If the diagnosis is uncertain the swelling should be explored without delay with a fair-sized trocar and cannula. In many cases this penetrates into the bone in such a way that there can be no doubt as to the change it has undergone ; in others, myeloid cells, or other structures that can be recognized as sarcomatous, come away with the blood and can be recognized under the microscope. Diagnosis. — Innocent tumors of bone are distinguished by the slowness of their growth, and by the al)sence of pain and increased vascularity. Gummata occasionally presents some difficulty, as the history of syphilis does not exclude the presence of sarcoma. Any doubt, however, can usually be dis- pelled in a few days by the administration of iodide of potash. It relieves the pain of sarcoma, so far as this is dependent upon accompanying periostitis, but it has no effect upon the size. When the sarcoma occupies the cancellous end of one of the long bones it may be entirely concealed by the symptoms of inflammation of the neighboring joint. This chiefly occurs at the knee ; the position of the limb is characteristic of disea.se of the joint ; movement is painful and limited ; the synovial sac is filled with fluid ; and though the lower end of the femur or the upper end of the tibia is replaced completely by a new growth, there is no enlargement of the bone. The same mistake may easily occur in the acute suppurative arthritis of infants, especially as rapidly-grown ng sarcomata, such as simulate abscesses, are often at- tended with a typically hectic temperature. Chronic inflammation of bone, with the formation of a sequestrum (quiet ne- crosis), is most deceptive, especially when the shaft of one of the long bones is concerned. Even after s|)ontaneous fracture has occurred it is sometimes impossi- ble to make a diagnosis without free exploration. A few instances have been recorded of pulsating tumors of bone without any sarcomatous growth (osteo-aneurysm) ; such, howe\er, are very rare. True aneurysm may sometimes cause a certain amount of difficulty, but in nearly every TUMORS OF BONE. 491 case the position, the relation it bears to the artery, the fact that the sac can be emptied by pressure, or tlie history, settles the cpiestion at once. Treatment. — i. Central Sarcomata. — Excision may be practiced when the structure of the part allows it, and the growth has not become diffused too widely. Thus, the upper end of the fibula may be completely removed, or part of the ulna ; and the upper end of the humerus even has been treated in the same way, leaving a fairly useful limb. But all such cases must be very carefully watched, for fear of local recurrence. Where this is not possible, am])utation should be ijerformed sufficiently far above the growth to make sure that the tissues are healthy, and if the I)one is divided the cut surface of the medulla should be very carefully examined. 2. Periosteal Sarcomata. — For these, amputation is the only resource. If the growth is situated at the distal end of one of the long bones, and the disease is not of long standing, the operation may be performed through the shaft, at a suffi- cient distance above. Recurrence is very probable, but if the sawn section of the bone is healthy, it may not take place in the stump. When the disease is situated higher up, disarticulation should be practiced, except in the case of the hip. Am- putation at this joint for periosteal sarcoma at or above the middle of the bone is practically hopeless. Portions of the clavicle have been excised successfully for central sarcoma ; but when the growth is periosteal, or when it has invaded neighboring structures, it must rest with the patierit whether such an operation should be undertaken. Resection of the inferior angle of the scapula is not a serious or difficult matter, if it is done as soon as the nature of the tumor is recognized. The whole bone has been removed on some twenty occasions, with preservation of the arm ; and more than once the whole of the upper extremity, with the scapula and part of the clavicle, has been taken away. Nearly all of these, however, have terminated fatally within the twelvemonth, from secondary deposits in the lungs. Cysts. Hydatid cysts are occasionally found in bones ; and chronic abscesses some- times leave behind them smooth-walled spaces with clear contents ; but unless they lead to great dilatation or to spontaneous fracture, they are not likely to be diagnosed. Cysts, due to softening, degeneration, or hemorrhage, are very common in connection with .sarcomata, especially central ones ; but, except some occurring in the jaws, which, owing to their special character, are described by themselves, other forms are almost unknown. Carcinoma. It is doubtful whether, in the absence of epithelial elements, primary carci- noma of bone can occur. Secondary deposits, however, are not unfrequent; cancer of the vertebrae, for example, may occur in scirrhus of the breast; and especially in the leg, over the subcutaneous surface of the tibia, epithelioma may gradually extend down into the substance of the bone. 492 DISEASES AND INJURIES OF SPECIAL STRUCTURES. SECTION IV.— INJURIES OF JOINTS. These, like injuries of bones, are divided into two classes. In the one there is no external wound ; the skin is unbroken ; the tissue changes that follow are rarelv more than is required for rei)air, and inflammation is rarely severe unless there is some additional irritant, such as gout or scrofula, to keep it up. In the other the interior of the joint is filled with fluid and exposed to the air ; decomposition may set in at any moment ; and if it does, it is certain to cause an attack of inflam- mation, which is very likely to end in the destruction of the joint or i)lace life itself in danger. Wounds oy Joints. Punctures and clean incised wounds are caused by stabs and cuts ; lacerated ones are usually associated with compound fractures or gun-shot injuries ; but they may be produced by any crushing or tearing force, and may be of any extent, from a puncture, the very existence of which is doubtful, to a rent which lays open the joint from side to side. In many instances the diagnosis is clear at the first glance ; the interior of the joint can be seen ; or there is an escape of synovia, recognized, even when mixed with blood, by its peculiar glutinous feel ; or the joint in a very few moments becomes distended with fluid. But in a few it is a matter of some difficulty, either from the nature and direction of the wound, or from the presence of neighboring spaces, such as burs», tendon sheaths and cysts, which contain the same kind of fluid, and which sometimes do, and sometimes do not, communicate with the central cavity. If there is the least ground for suspicion, the case must be treated with exactly the same precautions as if the joint were really opened ; and no attempt should ever be made to explore the wound with the probe or the finger merely for the purpose of making certain. This, of course, does not apply to any case in which the wound is dirty, or inflicted with a dirty instrument, or in which there is the least probability of such a thing; thorough exi)loration, then, is essential. Pathological Changes. — These are the same as those that follow other injuries ; the danger arises from the size and complexity of the cavity, its extent of absorbing surface, and the difficulty of draining it effectually. Suppuration rarely occurs in small joints, and extensive wounds often heal with the least dis- turbance, because the risk of decomposing material being confined under high tension is so much less. Large vessels are not often divided, but the small ones bleed profusely, and often before their orifices are closed the synovial cavity and the loose spaces around are filled with blood. Then the edges of the wound become red and swollen, the ves.sels dilate, lymph pours out through their walls, the perisynovial tissues become infiltrated and gelatinous, and the cavity grows fiiller and fuller. Soon the irrita- tation spreads to the lining of the sac, the endothelium falls away, the surface loses its polish, the folds and fringes become hyperremic and swollen, small extravasa- tions take place here and there, especially along the line of attachment of the capsule, and the joint becomes distended with a turbid, blood-stained mixture of synovia and lymph. The subsequent course depends upon the kind and the persistence of the irri- tant. If there is no tension or decomposition, if the only injury is that which was inflicted at the moment of the accident and no other is added, the hypercemia soon begins to subside, the quantity of fluid diminishes, the swelling of the cellu- lar tissue disappears, the cells on the surface of the synovial membrane gradually resume their normal character, the edyes of the wound cohere together, and the INJURIES OF JOINTS— WOUNDS. 493 joint is left souiul, though weakened a little and inclined to be irritable for a short time. If, on the other hand, the original hurt is not the only one, if it is supple- mented by some other acting jjcrsistently on already damaged structures, the tissue changes become excessive, altogether beyond what is needed for repair, and inflam- mation sets in. The severity of the attack dejtends uj^on the nature of the irritant. Where it is merely high tension or want of rest, supi)uration, though it may occur, is decidedly rare. The nutrition of the tissues is impaired, but they are still strong enough to destroy any pyogenic germs that may reach them. The joint continues painful and swollen after the wound has healed, the skin is warmer than natural, and even a little reddened ; a certain amount of thickening is left, so that the synovial membrane does not unfold itself smoothly and easily as the joint moves, or the amount of fluid is excessive ; a certain degree of inflammation, in short, persists, but it is rare for it to be dangerous or severe. If infection occurs, the difference is very marked. The fluid with which the joint is filled at once becomes the most vinilent poison ; the whole of the synovial sac is involved ; the hyperasmia and exudation spread wider and wider ; stasis and thrombosis occur ; some of the tissues perish at once ; others, less severely injured, yield to the pyogenic microbes that find their way in through the wound or through the blood, and break down into pus ; only those at a distance resist, and strive to limit the area of de.struction by forming a wall of vascular granulations. The ligaments become soft and yield, so that one bone is displaced upon another ; abscesses form in the cellular spaces around either independently or by direct ex- tension from the joint ; the cartilages turn yellow and sodden ; where there is pressure they fall off" in large necrosed flakes, which bring away with them the articular lamella of the bone ; at the margins they grow thinner and thinner until they look like pieces of wet wash-leather ; the bones become soft and carious upon the surface, and the joint is utterly disorganized. Symptoms. — These depend upon the size of the joint and the consequences that follow. If the wound heals at once, by the first intention, there may be nothing noticeable ; but nearly always the point is swollen and tender for the first few days ; the skin is warmer than natural, the muscles are rigid, in order to keep the part at rest, and if the synovial membrane is large, so that there is rapid absorption, the patient is feverish and uncomfortable, though the rise of tempera- ture is scarcely more than one or two degrees. In other cases the symptoms are more marked and the injury is followed by an amount of synovitis sufiicient to cause a certain degree of anxiety. The joint is as full as it can be, the skin is red and even oedematous, the pain and constitu- tional disturbance are more severe ; but even then, if the onset is gradual — if three, or, better still, four, days pass by without the symptoms becoming urgent — there is reasonable hope that the inflammation is due to other causes than decom- position, and that it will subside without running on to suppuration. If infection does occur in the interior of one of the larger joints, the symp- toms are generally beyond question. From the first few hours they are infinitely more intense, and they grow worse and worse with such rapidity that in the course of three or four days, if the case is left to itself, the condition of the joint is al- most hopeless. Acute suppurative arthritis sets in with the utmost virulence. The edges of the wound are reddened and everted, and a thin, serous pus oozes out ; the skin is dusky with enlarged veins running in it ; it is boggy and oedematous, pitting deeply in places, and it almost scorches the hand. The swelling is no longer the shape of the synovial sac, it is more rounded and uniform ; or it extends a greater distance along the limb, particularly on its inner side ; the pain is intense, and is no longer of the same character ; the joint burns or throbs as if it were bursting ; it is held rigidly fixed in a position of semi-flexion ; the slightest attempt at movement causes the utmost dread ; and the fever is of the severest type, the temperature, if it is the knee, reaching 105° or even 106°, so that the patient 494 DISEASES AND INJURIES OF SPECIAL STRUCTURES. becomes delirious. When rii^ors, or what are known as starting-pains, make their aj)pearance, the prognosis is even more grave. The former may mean the onset of suppuration or the beginning of pyaemia; the latter jjoints to necrosis and destruction of the cartilages. Later, if the ))atient does not die from .septic ab- .sor))tion, the fever alters its character, and as granulations are thrown out, assumes the hectic tyjje, fresh abscesses, each causing a new outbreak, forming every now and then in the cellular tissue around. Finally, if the patient is not attacked by py;v;mia or other comjilications, and does not sink from exhaustion, the constitu- tional disturbance gradually subsides as the wound becomes smaller, and the limb is left stiffened, wasted, and covered with scars. Treatment. — C"oni])ouivl (open) fractures into joints, comjjound (open) dislocations, and wounds of joints accompanied by injury to important structures near, will be dealt with by themselves. The age and constitution of the patient, the size and importance of the joint, whether it is in the upper or the lower limb, and the extent of the injury sustained by the soft parts and the bones respectively, are the chief factors in determining what is to be done. The choice lies in each case between preservation, excision, and amputation. In the case of a wound the first thing is to prevent infection. A simple incision, such as that inflicted by a surgeon for the removal of a foreign body, should be closed at once. If it is large a catgut suture may be inserted ; if small, the edges may be brought together and sealed with collodion, or covered with iodoform, or closed with lint dipjied in Friar's balsam. A lacerated or dirty wound, on the other hand, or one the condition of which is even suspicious, must be thoroughly and perfectly cleansed. Whether the joint should be washed out or not, depends upon the character of the injury and the length of time it has been inflicted ; but if there is any doubt it should certainly be done, additional open- ings being made if the cavity is a large one. In the case of the ankle, wrist, and elbow, it is an excellent plan to immerse the limb bodily in a corrosive sublimate bath for an hour each day, syringing the joint out thoroughly through a piece of rubber tubing inserted into the wound. I have on several occasions treated com- pound fractures into the wrist-joint, and they perhaps are the worst of the three, in this manner with excellent results. If it is the knee, this is hardly practicable, and infection must be prevented in other ways. Washing out the joint, even with the most active antiseptic, is rarely enough : it is very difficult to make it pene- trate eiificiently into all the recesses, especially in the case of a person who is somewhat advanced in life : in children it may answer, as the shape of the sac is more simple. Constant irrigation is more likely to succeed, esi)ecially if com- menced at once : the products of decomjjosition can hardly collect then ; and Treves has shown that if it is thoroughly carried out, and kept uj) night and day, even with simple water, a knee joint that has already begun to supjnirate may recover Avith almost jierfect mobility. It is equally important to prevent tension and to secure perfect rest. A lacerated or contused wound should be left partially open and covered with a small piece of non-adhesive dressing, so that the exudation can escape at once ; or if the synovial lining is very com]jlex and ill-adai)ted for drainage, additional openings should be made, and tubes inserted into every pocket. When the knee- joint is concerned, the simplest way is to push a i)air of dressing-forceps down through the wound, until it projects in the po])liteal space, when a small incision may be made over the end, the tube grasped and drawn back again. Then the whole joint should be covered over with an abundance of wood-wool or some other thoroughly absorbent dressing. The limb must be placed upon a splint in the most comfortable position (always provided it is a suitable one) and fixed securely ; it should be raised if possible, well bandaged, and kept cool by means of an ice-bag or Leiter's coils. The patient must be placed on low diet, the bowels well opened, and sleep and quiet ensured by opium or chloral. The temperature is the best guide to the subsequent treatment. If there is INJURIES OF JOINTS—SPRAINS. 495 only a slight rise and the pain a])oiit the joint is not severe, the wound should not be touched (iniless drainage-tubes reiiuire to be taken away) until it is sound, the l)art meantime being enveloj^ed in cotton-wool and well bandaged to prevent any distention of the capsule. If, however, the temperature rises more than one or two degrees, if the joint becomes distended and [)ainful, i)articularly if it begins to throb, the condition is much more critical. Cold and compre.ssion with layers of cotton-wool may still be tried ; leeches placed all round the joint ; an ice-bag laid upon the main artery of the limb (the femoral has been tied for acute sup- ]Kiration in the knee joint) ; or even the joint as]Mrated to reduce the tension ; but if the skin is boggy and (jedematous, and if the swelling is diffuse, no longer confined to the synovial sac, it is very doubtful whether supjmration can be pre- vented. If there is not speedy imi)rovement, the joint must be laid open freely on both sides (small incisions are worse than useless) and irrigated so thoroughly that retention of decomposing material is impossible. Then the limb jnust be fixed to a splint in such a position that if ankylosis does occur, it may still Ije of some service. Sometimes even after this the articulation recovers, especially in children, with a surprising degree of mobility. More often the severity of the inflammation subsides ; granulations spring up ; the amount of pus diminishes ; organization sets in ; and fibrous or bony ankylosis results. Occasionally abscesses continue to make their appearance along the limb funder the quadriceps in the case of the knee), and either the patient sinks under the prolonged suppuration or amputation is performed. Subcutaneous Injuries. Sprai7is and Contusions. Under this heading are included almost all injuries of joints that are not attended by permanent displacement of the articular surfaces. There may be merely a slight effusion into the capsule of a joint with a little stretching of some of the fibres ; or the synovial sac may be filled with blood, the ligaments torn or wrenched off the bone, the muscles lacerated, the tendons displaced from their grooves, and the tissues torn and crushed as severely as if it were a dislocation. In many cases the sole difference between a sprain and a dislocation is that, in the one, the bones, which are wrenched asunder at the time of the accident, resume their normal relation as soon as the force is spent ; in the other, they either remain fi.xed where they are or slip a little further aside. Contusions are the result of direct violence, such as blows and kicks, and may be serious from the extent of the bruising or from the tension set up by the blood that pours into the cavity of the joint. Sprains, on the other hand, are due to violent and sudden twists, wrenching the joint when the muscles are either tired out or are caught unawares ; probably, without this, they would very rarely occur. Astley Cooper said of dislocations that it was only possible for them to take place when the muscles were unprepared for resistance, and the same is nearly as true of sprains. The atnoiitit of injiirx is very variable. In some there is only a spot or two of extravasated blood, just at the attached margin of the capsule ; in others the joint, and the loose cellular tissue that extends along the bone and under the skin, are filled with it. Sometimes it is uncertain whether there is a rent or not ; or the strongest ligaments in the body, such as the internal lateral ligament of the knee or ankle, may be torn in two. Nearly always when this happens they drag away with them a thin scale from off the bone. In severe cases the muscles always suffer, and sometimes they are extensively lacerated, possibly in the sudden spas- modic effort at recovery : the tendon sheaths are bruised and filled with blood ; the nerves are stretched and torn ; and even the bones show at times deep ecchy- moses in their cancellous substance. The pain at the moment is intense and of a peculiar sickening character, so 496 DISEASES AND INJURIES OF SPECIAL STRUCTURES. that the patient may fall clown fainting; later the i)art becomes numbed, with a dull aching sensation, due to the tension of the nerves. Swelling generally sets in at once, and the synovial cavity is distended to its utmost in the course of a few moments ; but sometimes, when it is due rather to inflammatory exudation, it is more gradual, and does not attain its maximum for twelve or even twenty-four hours. The skin is exceedingly tender, esjtecially over the spot where the liga- ments have given way ; the least attempt at movement is looked upon with dread ; and discoloration soon begins to make its appearance. In the case of a sprained ankle, if there are many small varicose veins round the joint, the ecchymosis may reach as far as the knee in a very short time. Recovery is often im])erfect. Inflammation does not occur unless there is some other irritant as well, but very often the joint remains cold, stiff, and pain- ful whenever an attempt is made to use it. This may be caused in various ways. Adhesions may have formed, binding tendons down to their sheaths, or even unit- ing two articular surfaces to each other ; the cajjsule and the loose tissue around may have become dense and unyielding (especially on the inner side where it is soft and thrown into folds) ; the muscles may be matted together ; or the synovial sac may remain distended ; but in many instances nothing can be found. Move- ment is restricted and painful, at one spot in particular, but there is nothing out of place. There is a sense of weakness about the joint, so that it does not feel as if it could be trusted, or it becomes swollen whenever it is used, but there is no inflammation ; the skin rather is unnaturally cold ; it is smooth, glossy, and livid, showing that the circulation through it is imperfect ; the tissues, in short, are starved, from prolonged inactivity ; they are unable to work, because they never get a proper supply of blood ; and the only remedy lies in encouraging the circu- lation as much as i)Ossible. Treatment. — Slight sprains, when the tissues are stretched rather than torn, are treated most successfully by massage and bandaging; but it must be carried out carefully and thoroughly. The limb must be raised, the muscles relaxed, and all constricting garments removed. At first the movement must be exceedingly light, and directed so as to diminish the sensitiveness of the skin, commencing above the injured joint, where the swelling has not yet shown itself, and working gradually nearer to it. The direction must always be toward the trunk ; the thumb, or the tips of the fingers, or the palm of the hand, may be used, accord- ing to the shape of the surface ; and the tender spots must be left to the last. If this is properly carried out, the swelling begins to diminish in a few minutes, and, as the circulation improves, absorption becomes more rapid, and the tendency to start and the involuntary shrinking disappear. Then more attention may be paid to the spaces in which the extravasated blood has collected ; the tii)S of the fingers or the thumb may be made to trace out the irregular intervals between the bony prominences, moving round and round in small circles upon the skin ; and grad- ually firmer and firmer pressure may be used, as the superficial structures become accustomed to it. This must be kept up until the effusion has almost disappeared, and slight passive movements, of such a nature as not to exert any traction on the injured ligaments, are allowed without resistance. Then the joint must be cov- ered with several layers of cotton-wool, and compressed as firmly as possible with a flannel or a domett bandage. Generally speaking, this has to be repeated for two or three days, but each time the sitting is shorter and less irksome. In more severe injuries, where from the tenderness over certain spots it is clear that some of the ligaments have given way, the same plan may be tried ; but naturally a longer time is necessary for repair. Heat and cold, if used with suffi- cient energy, are of excellent service as temporary remedies. They help to check the effusion l)y constricting the small vessels, but they do not assist absorption ; and the sooner methodical compression is applied the better. Care, of course, must be taken that the pressure really falls upon the parts that need it — not, for ex- ample, in the ankle, on the heel and the malleoli. Passive motion should be commenced as soon as the effusion is absorbed, on the second or third day. Even DISL O CA TIONS. 49 7 if the ligaments are torn, the joints may be moved gently through a very wide range, without throwing the least strain upon them. For this reason a fixed ap- paratus, such as plaster-of- Paris, should never be employed in sprains. Dislocations. A dislocation is a sudden displacement of one of the bones of a joint from its normal position. (Gradual displacements, which result either from disease (pathological) or from malformation (congenital), are better dealt with by themselves. Dislocations are said to be complete when the articular surfaces are entirely separated from each other, incomplete when they are still to a certain extent in contact, as usually happens, for example, in the case of the knee. They are sim- ple if the skin is unbroken, compound {open) if there is a wound exposing the interior of the joint ; and the distal segment of a limb is always described as being displaced from the proximal. Causes. — These are either predisposing or immediate. 1. Predisposing. — Dislocations are met with at all times of life, from birth to old age, but with very different degrees of frequency. With the exception of the elbow-joint, they are much more common in adult life, because then the bones are at their strongest, and naturally they are more often met with among men than among women. But, independently of this, there is a certain class of persons in whom they are peculiarly liable to occur. The muscles are poorly developed, the bony prominences feebly marked, and the ligaments loose and yielding, so that the slightest force, if the muscles are caught unawares, is enough to cause displace- ment. Fortunately in many of these the capsule is not torn and the injury is really only a subluxation, but occasionally it gives way under the strain and the head of the bone is forced through the rent. Certain joints are especially liable to dislocation. In many instances this may be explained by their situation or construction. The shoulder, for example, which depends for its security mainly on the muscles that surround it, not on the shape of its articular surfaces or on the strength of the ligaments, is dislocated more frequently than all the rest of the joints together. In children, again, dis- location of the elbow is particularly common, owing to the small size and smooth, rounded surface of the coronoid, which does not offer so much resistance as the sharply marked process of adult life. In other instances the tendency is acquired ; a shoulder-joint that has once been dislocated is more likely to be dislocated a second time ; and if this happens often, the joint becomes so insecure that the bone slips in and out of the socket whenever the arm is raised from the side. 2. Im/nediate. — These are muscular action and external violence. (i) Muscular Action. — In some instances, notably the lower jaw and the pa- tella, this acts entirely by itself ; in most, however, it is only of secondary impor- tance, fixing the segments of the joint and rendering other articulations rigid, so that force is transmitted unbroken along the limb ; and in dislocations by direct violence it plays no part at all. 0*1 the other hand, it is almost entirely responsi- ble for what is known as consecutive displacement, that is, the alteration in the position of the dislocated bone after it has been driven through the capsule. (2) External Violence. — This may be either direct or indirect. The former is not common , but it occasionally happens that the head of the humerus is driven directly through the capsule of the joint by a blow upon the shoulder ; or, when the body is much flexed, the head of the femur forced out from the acetabulum on to the dorsum. In dislocations by indirect violence the force is applied at some distance from the articulation, either to the sauie bone, or, as it falls upon the hand, to the other end of the limb. The neck of the bone is fixed and acts as a fulcrum, and the head, which represent the short arm of the lever, is tilted out from its socket and 498 DISEASES AND INJURIES OF SPECIAL STRUCTURES. forced against the capsule until it is driven through it. The spasmodic contrac- tion of the muscles and the weight of the jjart drag it still further aside. Pathology. — ihe immediate effects of a dislocation are more extensive than woidd be expected from the api)earance of the i)art and from the ease with which repair is carried out when the skin is unbroken. (Generally speaking, the tissues on one side of a limb are strained and rent, those on the other crushed and bruised by the pressure of the displaced bone. Ecchymosis, sometimes making its appear- ance a long way off, and perhai:)S days after the injury, is always a prominent fea- ture. The capsule is usually torn at its weakest spot, sometimes it is stripped off tne bone, and occasionally it drags away with it portions of the articular margin. The ligaments suffer in the same way, excejit the stronger ones, such as the ilio- femoral band at the hip, and the interosseous one between the tibia and fibula at their lower extremity ; these either resi.st successfully, or only give way after the bones are broken. The muscles are always more or less cru.shed and bruised ; in many instances they are extensively torn, unless, as sometimes happens, they wrench away with them the process of bone to which they are attached. Arteries and veins share the same fate, but though they are not unfrequently compressed and bruised, so that the circulation through the limb is interfered with and even inter- rupted altogether, the larger ones are rarely torn across in recent dislocations, unless the violence is extreme. Nerves escape even better : they are so tough that they rarely give way, but if they are compressed there may be most intense jiain. and if it is kept up for any length of time permanent loss of power may follow. The bones are frequently broken ; sometimes, as already mentioned, merely a process is torn off; sometimes, as in the case of the fibula, when the ankle is dis- located, the shaft gives way, perhaps at a distance from the seat of injury. Occa- sionally other structures that lie near are injured too ; the trachea, for example, may be seriously compressed in dislocations of the clavicle, and the spinal cord of the medulla may be crushed in displacement of the vertebrae. As soon as reduction is accomplished these effects begin to pass away; the blood becomes absorlied, the effusion into the synovial sac and the spaces near it disajjpear, and the lymph thrown out by the injured structures gradually becomes organized. In some instances, where the capsule is very extensively torn, the rent is never thoroughly repaired, and the joint remains weak and untrustworthy. In others an excessive amount of lymph is thrown out ; for want of properly regulated passive motion, adhesions form between adjacent parts, and the joint becomes stiff and more or less crippled and painful. The same thing may happen from injury to the neighboring muscles. Occasionally inflammation sets in — suppurative arthritis very rarely, so long as the skin is unbroken ; but rheumatoid arthritis, or gout, or strumous disease, according to the particular diathesis, not uncommonly. If the dislocation is not reduced the head of the bone and the surrounding structures mutually adapt themselves to each other. The old cavity gradually be- comes contracted and shallow ; in many cases the outline becomes angular from the pressure of the displaced head resting on one of its borders ; the cartilage at the bottom grows thinner and thinner, and either disappears altogether, or is replaced by fibrous tissue which fuses with the shrunken and collapsed remains of the cap- sule ; and, at length, though some seml)lance of its original character is always preserved, the socket becomes so altered that even if the head of the bone were replaced it could no longer play its proper part. How soon these changes take jjlace depends mainly upon the age of the patient and the presence or absence of that kind of inflammation which so often complicates joint injuries. On the one hand, the glenoid fossa has been found so altered within thirteen weeks of the acci- dent that reduction could not have been effected ; on the other, the acetabulum has been shown to be to all intents and purposes intact after as many years. The changes in the displaced bone depend chiefly upon the character of the bed upon which it rests and the extent to which the limb is exercised. If the articular surface is imbedded in muscles, or lies upon a soft ma.ss of connective DISLOCATIONS. 499 .^f>s. \ tissue, the cartilage slowly becomes fibroid and disapjiears, the ends of the bones waste away, and lose their characteristic shape, and adhesions form between them and the structures around. Where, on the other hand, it is directly in contact with the periosteum, as in subcoracoid dislocation of the humerus, the surfaces wear each other away and become moulded together in such a fashion that the original outline can hardly be traced. In most instances the cartilage disap- jiears and the articular lamella beneath becomes hard and eburnated, as in rheu- matoid arthritis (Fig. 203) ; sometimes it becomes fibrous, and a dense layer of simi- lar material forms on the opposing surface, so that movement is smooth and free. In time, if the part is sufficiently used, a new socket is developed, ])artly worn out by ab- sorption, partly built up by the deposit round the margin from the irritated periosteum ; and the lymph thrown out by the surround- ing tissues becomes modeled into a capsule, lined with a membrane like that found in adventitious bursre, and filled with a similar kind of fluid (Figs. 204 and 205). Occa- sionally this is carried to such an extent that the joint becomes nearly as- useful as it was before; but as a rule, hinge joints do not succeed so well as ball-and-socket ones. All the structures that lie near are more or less affected ; the old capsule shrinks and contracts or becomes adherent to the car- tilage ; the muscles waste from disuse and become fatty ; the bone is hollowed out in the interior ; and the tissues are matted together l)y bands of organized lymph. Sometimes the displaced bone is firmly fixed ; sometimes it is so movable that it becomes Fig. 203— Old Subcoracoid Luxation of Humerus. T CTrnvp QniirrP nf inr^nnvf^niAno^ Doz-acinn '^^^ "*^ cavity is for the most part eburnated; a grave source 01 inconvenience. occasion- around is a new capsule of fibrous tissue, while ally it causes very serious consequences by someoftheoldisstiUleft asafringeon theedgeof ■' . ■' . ^ . •' the glenoid fossa. pressing upon or becoming adherent to im- portant structures, such as nerves and blood-vessels. In all probability this is the reason why rupture of the axillary artery occurs so frequently in reducing old dis- locations of the humerus. The vessel is bound down to the head of the bone by adhesions, so that the strain falls directly upon it as soon as any traction is made upon the limb. Symptoms and Diagnosis. — The only certain sign of a dislocation is the sudden disappearance of the articular end of a bone from its normal situation, or its sudden appearance somewhere else. The account of the accident, though it should always be carefully enquired into, is only of use as confirmation, and the pain depends mainly upon accidental circumstances. In most instances it is severe and long-continued, but when the dislocation has already occurred several times it may be comparatively slight. Only in such cases as when the head of the humerus presses upon the brachial plexus and causes intense neuralgia down the arm, can it be looked upon as a diagnostic sign. The first thing, therefore, is to compare the injured part with the corre- sponding joint on the opposite side of the body. Sometimes the alteration in outline is conspicuous at the first glance, as in the sterno-clavicular articulation ; or, as in dislocations of the hip, the position of the limb is enough to prove, not only that the head of the bone has been forced out of its socket, but that it has been driven in one definite direction. If inspection fails, there may be some marked alteration in the length of the limb ; or local measurements, especially in v^-" 5oo DISEASES AND INJURIES OF SPECIAL STRUCTURES. such joints as the elbow, where the bony prominences are close beneath the skin, may supply the necessary evidence. If the diagnosis is still uncertain, deep pressure may reveal the altered position of the bones ; natural {)rominences may have disappeared, or some depression may be filled up. Finally, before an attempt is made to move the part, valuable information may sometimes be obtained from other evidence of local pressure ; the arm, for example, may be cedematous, from the head of the humerus resting upon the axillary vein, or the pulse at the wrist may be absent, from compression of the artery. Inspection, measurement, and palpation may prove the existence of a disloca- tion ; manipulation only can determine the particular variety and exclude all other injuries. Owing to the pain it causes, it should always be postponed to the last ; and, particularly in the case of the hip and elbow, it is often necessary to admin- ister an aniEsthetic ; the strength and the size of the muscles in the one, and the amount of swelling in the other, render it a matter of very great difficulty without. Voluntary movements are always restricted ; in many instances, as in dislocations of the lower jaw, they are altogether impossible ; passive movements are more variable ; sometimes, when the soft parts are very extensively torn, they are unnat- FiG5. 204 and 205. — New Sockets in Old Pubic and Subspinous Dislocations of Hip. urally free, especially when the patient is under an anaesthetic ; but nearly always they are restricted in at least one direction, either by the locking of the bones or by the tightening up of ligaments that have not given way. The diagnosis has to be made from severe sprains, fractures in the neighbor- hood of a joint, and the separation of epiphyses. The chief features are the absence of crepitus, the character of the deformity, the fact that when it has once been rectified it does not return, and the immobility of the part, both as regards active and passive movement ; but not one of these by itself can be regarded as sufficient. Crepitus is absent in many fractures and present in many dislocations, because there is a fracture combined with them ; moreover, false crepitus, due to the displaced bone rubbing over tendons or pressing on bursx filled with extrava- sated blood, is sometimes very difficult to distinguish from real. Deformity, too, may return at once, unless steps are taken to prevent it (as in dislocations of the ankle), and immobility, passive as well as active, is not by any means a sure guide. In each case it is absolutely necessary to weigh the whole of the evidence before coming to a positive decision. A peculiar condition is occasionally met with in ball-and-socket joints (espe- DISL O CA T/ONS. 5 o i cially the shoulder), wliith, though not a dislocation in the strict sense of the term, yet resembles it in many respects. The head of the bone and the socket are both intact, but they are not in apposition. The capsule is stretched ; the articular surfaces are separated ; there is complete loss of power ; the position of the limb is that of a real dislocation, but there is undue mobility. In the case of the humerus there is generally paralysis of the muscles, passing from the trunk to the arm, and the head of the bone can be replaced at once by raising the elbow ; in other joints it seems to be the result of chronic distention of the capsule: the fluid in- sinuates itself between the articular surfaces, and the fil)res become softened and stretched until they can no longer liold the bones in jjosition. It cannot be called a dislocation, because the head of the bone still lies within the capsule ; but neither can it be compared with those cases in which, as a result of rheumatoid arthritis or strumous inflammation, the cartilages are eroded, the bones exposed, and the cap- sule completely destroyed. Treatment. — Dislocations should in all cases be reduced as soon as possible. The obstacles are of two kinds. One is mechanical ; the head of the bone, for example, no longer corresponds to the rent in the capsule ; or it is caught by some ligament or tendon, or locked against some other bone. The other is the contrac- tion of neighboring muscles. Immediately after the accident they are relaxed and offer but slight resistance. In a short time they begin to contract and drag the dislocated bone further and further away. Soon they become absolutely rigid, and at length they undergo a kind of fibroid degeneration ; a great deal of their exten- sibility is lost, and they tear sooner than stretch. In recent dislocations this source of difficulty disai)pears entirely under an anc^sthetic ; in old ones it is added to the rest. There are two methods of effecting reduction, manipulation and extension. In the former, which is almost always used for ball-and-socket joints, the muscles are relaxed, either by placing the patient under an anaesthetic or by moving the limb in suitable directions ; the head of the bone is disentangled from the structures that hold it, and brought back along the route it has taken until it is opposite the rent in the capsule ; then it is either lifted over the margin of the socket or tilted in by using the untorn portion of the capsule as a fulcrum and making the limb the long arm of the lever. In the latter the muscles are stretched until they either yield or tear, all obstacles are broken down or pushed aside by main strength, until the head of the bone is free and can be forced into position again. Extension may be made with, or without, the aid of appliances, but in recent dislocations it rarely happens that more than a jack-towel is required. The trunk or the proximal segment of the limb must be securely held for counter-extension. If it is the humerus, the knee or the foot may be placed in the axilla ; or a well- padded towel or leather belt passed round the arm and fixed to a hook or staple in the opposite wall ; but it is of great advantage to have an assistant who, besides helping to fix the scapula, can manipulate and disengage the head of the bone at the same time. In the case of the femur, if manipulation has failed and extension is being tried, this is always one person's duty. In recent dislocations, simple manual extension is generally suificient, espe- cially if the muscles are relaxed by an anaesthetic ; and the limb may be grasped at the most convenient situation — the wrist, for example, in dislocations of the humerus. If more than this is required, a jack-towel may be made into a clove- hitch and fastened round the limb ; but the skin must be perfectly protected by means of a wet bandage, and extension must be made from the lower end of the displaced bone without an intervening joint. If the limb is grasped with the hands, and the loop of the towel is passed over the shoulder of the operator, so that he can bring into play the muscles of his back, sufficient power may be obtained to overcome the resistance of any joint but the hip. If the dislocation has already lasted some length of time, so that the muscles have degenerated and the lymph has become organized, mechanical contrivances, such as multiplying pulleys, may be required. The adhesions are first broken 502 DISEASES AND INJURIES OF SPECIAL SIKUCTUKES. clown hy inaniptilatiun and rotation ; then the limb is carefully bandaged with a wet roller to prevent slipping and to protect the skin ; counter-extension arranged so as to avoid bruising, and to leave the part accessible; and the leather collar to which the cord of the pulley is attached buckled round the lower end of the dis- placed bone. An anaesthetic is indisijensable. The other end of the pulleys is then made secure, and the rope tightened very gradually and quietly, avoiding anything like a sudden jerk, and making extension in the axis of the limb. The amount of force must be regulated by the case : the operator must keep his hands upon the head of the bone, assisting it as far as he can in the right direction by manipula- tion and rotation, and watching carefully the progress tliat it makes and the tension upon the skin. Very serious injuries have before now been inflicted in cases of this kind, and sometimes important structures have been torn across, even when the amount of force used was quite insignificant, probably ow-ing to the tissues being bound together by adhesions, or softened and weakened by degeneration. When pulleys are not available, a very efficient substitute may be manufactured out of a simple piece of rope doubled once or twice upon itself. By placing a ruler in the middle and twisting it up, any required degree of traction may be obtained, slowly and evenly. No estimate, it is true, can be formed as to the actual amount of force employed ; but it is more than doubtful whether .such is really of any use ; each case must be decided on its own merits. As soon as the head of the bone is brought down, an attempt must be made to carry it in the direction of the socket. If it is the humerus, the arm is draw^n across the chest, making use of the surgical neck as a fulcrum, or it is abducted as far as it can go ; or, while the arm is fixed, the trunk is swayed slowly from side to side. If the femur, a broad band is looped round the thigh to lift the bone up- ward, or outward, according to the direction of the displacement. In the case of the lower jaw, again, firm pressure is made in a backward direction upon the coronoid processes. In short, in each dislocation the method of manipulation, when once the head of the bone has been forced down, must be guided by the structure of the joint, the direction of the misplacement, and the character of the obstacles that stand in the way. After a certain period, varying for each joint, reduction becomes impossible. Even if it could be effected, it is more than doubtful whether the use of the part w^ould in any way be improved, owing to the extensive changes that take place about the articular ends. In such cases all that can be done is to break down the adhesions as thoroughly as possible, and by means of massage, friction, galvanism, and passive motion, improve the nutrition and freedom of the parts as far as may be. In recent dislocations, when the patient is not under the influence of an anaes- thetic, as soon as the head of the bone is brought opposite to the rent, it is pulled into the socket, with a sudden, sometimes almost audible, snap. In old ones, how- ever, or when the muscles are relaxed, and in paralyzed limbs, rejilacement is gradual, and may even be imperceptible, except for the restoration of the full range of movement, and a certain amount of alteration in shape. The treatment of a dislocation, after it has been reduced, does not differ from that of a severe sprain : the joint must l)e secured, so that there is no danger of a recurrence ; kept perfectly quiet, and either liandaged or covered with some evap- orating lotion, or with Leiter's coils. Inflammation rarely follows, j^robably be- cause the capsule is extensively torn, and intra-articular tension is impossible ; but, for all that, every precaution .should be taken to prevent its occurrence. The length of time the joint should be kept at rest dei)ends more upon its kind and construction than on the injury that has been inflicted. There are dangers on either side. On the one hand, if the part is kept at rest too long, adhesions may form between contiguous surfaces, or the capsules become hard and rigid. On the other, if movement is allowed too soon, there is always the possibility of the rent in the capsules never being repaired, or, worse still, of inflammation setting in. The question turns mainly upon the kind of movement. Passive motion is perfectly DISLOCATIONS. 503 safe, and, if carn'ccl out under proper sui)ervisi()n, may be commenced in the first week ; it stretches out tiie folds of the capsule, prevents the muscles and ligaments becoming shortened, and checks the formation of adhesions, without entlangering the prospect of union or giving the faintest reason for inflammation. Active move- ment, on the other hand, because it cannot be so well controlled, must be postponed until passive motion is free from pain, and until all risk of recurrence has disap- peared. \\\ the hip and elbow, where the security of the joint is dependent upon the shape of the articular surfaces, it may be allowed with certain precautions after the first few days; in the lower jaw, however, and still more in the shoulder, free movement without restriction cannot be permitted lor at least a month, and certain particular actions are especially to be forbidden. A variable amount of stiffness is always present after a dislocation, and the muscles atrophy to some degree, particu- larly the extensors ; but this soon disappears. Massage and galvanism are of very great service if it shows the least tendency to persist. It must not, however, be forgotten that a rapidly progressive form of osteo-arthritis is not an uncommon complication of joint injuries, especially in those who are gouty or rheumatic, and that muscular wasting is one of its earliest signs. Coi)ipoit)id{i}peii) dislocations, in which, in addition to the displacements of the bones, the skin is torn or cut and the synovial cavity of the joint exposed, are ex- ceedingly serious, even when they are not complicated by the addition of fractures or other injuries. The danger is the occurrence of suppurative arthritis. If this breaks out, the joint rarely recovers without some degree of ankylosis ; often the cavity is entirely obliterated and the articular surfaces are united together by dense fibrous tissue or by bone. Even this result, however, cannot always be obtained. If suppuration once develops it is impossible to say when or where it will stop, and the risk, as regards life as well as limb, increases with the size and complexity of the synovial membrane. Abscesses may form in the tissues near ; the pus may spread in the tendon sheaths, or in the loose tissue around them half-way along a limb ; erysipelas, cellulitis, or pyeemia may break out at any moment ; the bones may be eaten away on the surface or even perish completely ; and at length, if the patient does not succumb from septic absorption, and if the limb does recover, it may be so stiff and oedematous as to be absolutely useless, or there may be such an amount of discharge that it has to be removed for fear of hectic or amyloid disease. The treatment of open dislocations must be guided by the same considera- tions as that of open fractures into joints. The choice lies between an attempt to save the part, excision or amputation ; and the decision must be determined in each case partly by the age and constitution of the patient, partly by the situation of the joint and the extent of the injury. The first question is whether it is pos- sible to save the limb without running too great a risk, and whether, supposing this is successful, the limb is likely to be of any use afterward. In open dislocations of the knee joint there is rarely any hope unless the tissues at the back are quite intact ; but in other joints, especially in those of the upper extremity, it can often be managed, if only the vessels are unhurt and the skin not too much torn or stripped up. Nerves do not seem to be of so much consequence in this matter ; they are so tough that they rarely give way, and even if they do they may often be joined again by means of sutures. Whether the joint should be excised or not depends upon the condition of the ends of the bones. If they are comminuted, and the soft parts not seriously injured, this may be done with great success, especially in the case of the shoulder and elbow ; but it must always be remembered that primary excision is not to be com- pared, either in its course or its results, with the same operation when performed for disease. The smaller joints, those in the fingers, for example, sometimes suc- ceed very well. If it is decided to try and save the joint, the protruding bone and the surround- ing skin must first be thoroughly cleansed with some antiseptic ; fragments that are too much bruised or ground-in with dirt to live, removed ; and reduction effected 504 DISEASES AND INJURIES OF SPECIAL STRUCTURES. as soon as possible. (lenerally there is no difticulty in this, owing to the extent of the laceration ; but sometimes the head of the bone is so. tightly embraced by the skin that the opening has to be carefully enlarged. Then the cavity of the joint must be washed out again and again, and laid freely open, so that there may be thorough drainage. The most efficient method of carrying this out is either to immerse the part bodily for an hour each day in a bath of corrosive sublimate or carbolic, with the wounds widely open, or to use continuous irrigation with water as already described in speaking of penetrating wounds. Merely i)assing a drainage-tube through the synovial cavity is of little or no service, and small incisions are worse than useless ; the discharge must be thor- oughly removed. The limb may then be placed upon a splint, well bandaged, raised and kept at perfect rest in the position that will ultimately be most useful. An ice-bag laid upon the joint, or over the course of the main artery of the limb, is of some assistance in controlling the amount of blood flowing to the part ; but care should be taken that the application is really continuous. The further course must be guided by the temi)erature and the degree of inflammation that ensues. Careful watch must be kept that the discharge cannot collect anywhere. If suppuration sets in the freest possible incisions may still be tried ; but unless it is checked at once the cartilages necrose, the synovial lining is destroyed, the cavity is filled with granulation tissue, and abscesses form every- where in the cellular tissue around. At first the constitutional disturbance is ex- ceedingly severe, especially in the case of the larger joints ; gradually, as the tissues gain the upper hand, the fever begins to drop of a morning, and if no further com- jjlication sets in assumes the hectic type ; and then again it may become a question whether the patient's strength is sufficient ; or whether it may not be advisable to perform some secondary operation, excision, or even amputation. Fractures and dislocations are not unfrequently combined, and occasionally, a fracture is present as a complication ; the humerus, for example, is dislocated, and the surgical neck broken by the same force. When this occurs it has been recom- mended to allow the fracture to unite before attempting to reduce the dislocation, but if it is possible the head of the bone should be replaced at once. The patient should be placed under an anesthetic, the fracture securely fixed between splints, and the displaced bone manipulated as far as it can be in the right direction. Ex- tension may be tried if the fracture is at some distance, at the other end of a long bone, or even in the middle ; but if the injury is near the joint it is rarely prac- ticable. If this fails the only course left is either to lay the part open, and convert the fracture into a compound one communicating with a synovial cavity, or by passive motion to encourage as far as possible the formation of a false joint. Dislocations of the Lower Jaw. Dislocation of the lower jaw may be unilateral or bilateral, but it can only take place in one direction, forward. As the mouth opens the condyle and the fibro-cartilage are brought forward together upon the eminentia articularis ; the external lateral ligament, which normally runs downward and backward, becomes nearly vertical ; the internal and posterior are stretched, and the coronoid pro- cess is lowered into a slanting direction. If at this moment the external pterygoid contracts, or if a slight blow is delivered in a downward direction upon the incisor teeth, the condyle slips forward on to the front of the eminence and is carried up into the temporal fossa by the combined action of the temporal, masseter, and internal pterygoid. The capsule appears to stretch rather than tear, though the tension on some of it must be \ery severe, and sometimes the temporal muscle is a little torn. Causes. — Dislocation may be produced either by muscular action alone, or by indirect violence, but neither of these is capable of effecting it unless the mouth is widely open. If it is the former of the two, the condyle is pulled DISLOCATION OF THE LOWER JAW. 505 forward ; if the latter, the bone is converted into a lever, of which the coronoid process, fixed by the temporal muscle, is the fulcrum ; the force is applied to the symphysis, and the condyle is driven forward. It often happens from yawning or shouting, but it may be caused by blows with the fist, by forcing into the mouth anything that is too large, and even by such operations as the extrac- tion of teeth and taking wax casts of the alveolar arch. It is rare in children, because in them the eminence hardly exists, and because, owing to the shape of the jaw, the temporal muscle does not obtain such lever- age ; and it appears to be more common in women than in men. If both sides are dislocated the symp- toms are very characteristic. The patient supports the lower jaw with his hand, to prevent further movement, the mouth is widely open, the chin protrudes, the saliva dribbles away, and speech is exceedingly difficult. Labial consonants cannot be pro- nounced at all. In place of the natural projection in front of the ear, caused by the condyle, there is a depression ; in front of this, making it more distinct, the skin is Fig. 206.— Dislocation of the Lower jaw. raised, partly by the bone, partly by the irregular contraction of the fibres of the masseter ; and movement, except to a very slight extent in a down\vard direction, is out of the question. The first time the dislocation happens the pain is very severe, but in old recurring cases it may be so slight as not to cause any complaint. If the displacement is only on one side, the lower jaw appears to be pushed toward the other one ; the face is much less distorted ; and though the general symptoms are the same, they are often so slight as to lie in some danger of being overlooked. Subluxation or partial dislocation forward, is very common in young people, and sometimes gives rise to much inconvenience, as it is liable to occur whenever the mouth is widely open. The jaw is caught, as it were, and held until the condyle is forced back by pressing the chin upward ; formal reduction is rarely necessary. Treatment. — The patient should be seated with the mouth wide open ; the head is thrown back and supported from behind, the thumbs (protected with a handkerchief or some lint so that they may not be bitten) are placed on the molar teeth as far back as possible, the fingers brought round under the chin, and pres- sure made downward and backward with the one, while the symphysis is raised by means of the others. By this the lower jaw is converted into a lever of the first order, the thumbs form the fulcrum, and ought therefore to be placed as far back as they can ; the downward pressure helps to disengage the condyles, and as soon as they become free the muscles pull the jaw back with a sudden snap. Gen- erally the two sides slip back together ; but in old dislocations, or if there is any difficulty, an attempt may be made upon one first, only care must be taken not to displace it again while the other is being reduced. Sometimes reduction is im- peded by the coronoid process becoming entangled in the fibres of the temporal muscle ; and in one case, at least, it is certain that it caught against the malar process ; but this can generally be obviated by depressing the chin somewhat further before trying to raise it. If this plan fails other measures must be adopted to obtain more pow'er. Wedges of cork or wood may be placed between the molar teeth and the chin drawn up by main force ; in one case, four months old, Pollock made use of a 35 5o6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. strap tourniquet, which was passed round the head, under the chin, and slowly screwed uj). The angle may be dejiressed by resting one end of a flat piece of wood about a foot long upon the molars, and pulling the other upward, the teeth of the upper jaw serving as a fulcrum ; or a stout pair of forceps may be intro- duced as far back as possible, and the blades separated from each other. Direct pressure backward upon the coronoid processes from the inside of the mouth is sometimes successful, even in dislocations of long standing. A four-tailed bandage must be worn for a week or ten days after, and the patient should be warned that yawning or opening the mouth wide for any other purpose is exceedingly likely to reproduce the displacement for months to come. If the dislocation is not reduced, the amount of movement gradually increases until the patient is able to close the lips and to o]jen the mouth fairly wide, but the teeth can never be brought properly into apposition with each other. Dislocation of the Clavicle. The sternal end of the clavicle is rarely displaced, although the articular sur- faces are very little adapted to each other. The shoulder is so freely movable that no severe strain falls upon the joint, unless the force is applied to the clavicle directly, and the inter-articular fibro-cartilage, and the ligaments that hold the bones together, are so strong and secured so well by the muscles, that the clavicle, as a rule, gives way before the joint. The natural movements take place either on a vertical axis between the fibro-cartilage and the sternum, or on an antero-pos- terior one between the same structure and the clavicle. When they are carried too far the capsule gives way, and the articular end of the bone is forced through the rent, either forward, backward, or upward. In spite of the backward direction of the articular facet on the sternum, and the hook-like j^rojection on the j)osterior margin of the clavicle, dislocation for- ward is the most common of these. The sternal end of the bone is carried on to the front of the manubrium, and stands out beneath the skin ; the clavicular por- tion of the sterno-mastoid is tense and rigid ; the head is inclined downward and forward ; the shoulder is approximated to the middle line, and all the movements of the arm, but particularly any attempt to bring the shoulders forward, are attended by severe pain. Dislocation backward is equally plain, only in this case there is a well-marked depression by the side of the manubrium instead of an elevation, and the shoulder is brought forward, as well as toward the middle line. Sometimes the head of the bone presses upon the trachea or oesophagus, causing extreme dyspna:a or dysphagia, and in one instance coma is said to have ensued from pressure upon the innominate vein. Dislocation upward is more rare, and might almost be regarded^ as a variety of the former, as the articular end is always carried backward as well to some extent, sometimes sufficiently far to press upon the trachea. It lies behind the sternal portion of the sterno-mastoid, between it and the sterno-hyoid, fdling up the episternal notch ; the shoulder is carried far inward toward the middle line, and the neck is bent, as much to relieve the respiration as to relax the muscles. In all of these the rent in the capsule is very extensive ; the rhomboid liga- ment either gives way, or the cartilage of the first rib is torn ; the fibro-cartilage in the interior of the joint is separated from the clavicle, or more often from the sternum ; and the muscles, especially the sterno-mastoid, are put upon the stretch, and sometimes torn. Causes. — Dislocation of the sternal end of the clavicle may be produced either by direct or indirect violence. In the former case the force is ai>j>lied to the inner end of the bone, as when a cart-wheel passes over the chest ; the dis- placement must be either backward, or backward and upward ; and often the surrounding structures, such as the ribs and sternum, are crushed as well. In the DISLOCATION OF THE CLAVICLE. 507 latter, where the force acts either on the shoulder or on the outer end of the bone, the displacement may take any direction, except downward. A blow, for exam- ple, on the front of the shoulder, forcing it backward, causes the clavicle to rotate on its centre, and throws the strain upon the anterior sterno-clavicular ligament, the joint opening out in front. If the force continues, the head of the bone is dis- placed forward until the ligaments give way, and it is carried on to the front of the manubrium. In a similar manner, a force applied from behind, or violent traction on the arm from the front, causes the clavicle to rotate in the opposite direction, and tends to produce dislocation backward. But while the cause of these dislocations is fairly clear, the mechanism by which they are produced is not so easily understood. Owing to the convexity forward of the inner part of the clavicle, it is impossible for the first rib to act as the fulcrum of a lever ; and these dislocations cannot be produced in the dead subject, without previous division of some of the ligaments. They cannot therefore be the result merely of traction or pressure apjjlied to the outer end of the bone, regardless of everything else. The contraction of the surrounding muscles is of some assistance, and rigidity of the thorax is very likely essential (they have been produced on several occasions by pressure in crowds, and by wrestling), but probably the most important element is the position of the vertebral column at the moment of the receipt of the injury. In some cases of extreme spinal curvature, gradual displacement has resulted from this alone without the occurrence of any accident. Partial dislocation, without tearing of the capsule, is common among yourg people of weak muscular development ; and is often noticed for the first time after some sudden strain or unusual muscular exertion. The bone projects on the front of the articulation forward, or forward and upward, but slips back again into its position as soon as the weight of the limb is taken off. The chief inconvenience is the weakness of the arm and the sense of insecurity ; sometimes this is so markecf that the use of the limb is seriously impaired. Treatment. — The method of reduction is the same for a]l of these. The patient is seated upon a low stool, with his back to the operator. The latter places his knee against the spine, between the scapulae, and grasping the shoulders, draws them backward, the patient's elbows being kept in front of the median- lateral line. Generally the head of the bone slips in either at once or with a little manipulation ; if it resist, a stout pad may be placed in the axilla, and the elbow be drawn into the side, so as to pry it out. The difficulty is after reduction has been effected ; there is nothing to retain the bone in its proper position ; the articu- lar surfaces are almost flat ; all the ligaments are torn ; the whole weight of the arm rests upon it ; and every movement, even that of respiration, affects it. In the backward, or the backward and upward dislocation, Velpeau's plan is the best. The bone is held in position ; the axilla carefully padded so as to square up as far as possible the conical shape of the thorax ; the elbow brought forward to the middle line, and well raised by strips of pla.ster, and the hand fastened against the opposite shoulder. In the forward dislocation, which in this respect is the worst of the three, a double figure-of-eight succeeds better. A stout pad or a thickly covered splint is placed between the shoulders, and the bandage is carried round them alternately, to draw them back as far as possible. Astley Cooper recommended that well-padded straps should be carried round the axillae, and fastened back by leather bands to a splint, fitting against the spine, and well secured round the body. In any ca.se it is important to fix the scapulae against the ribs ; and where there is serious concern about the deformity, the best plan is to keep the patient in bed, in the supine position, as long as he can be induced to stand it. If the dislocation is forward, a well-fitting pad over the projection, firmly strapped down, is often of great a.ssistance. Whichever method is adopted, the arm must be kept rigidly fixed for at least three weeks ; if plaster is not used, the bandages must be secured with starch or dextrin, as Velpeau recommends; after that the confinement may be relaxed to some extent, but no movement should be allowed for at least as long again ; and 5oS DISEASES AND INJURIES OF SPECIAL STRUCTURES. some protection, either a pad or a properly made truss, must be worn until it is certain that repair is perfect. In some instances it is impossible to retain the l)one in position. If the displacement is forward this is not so serious, though the de- formity is very unsightly, as a new joint soon forms, and the arm regains a great deal of its power and freedom of movement ; but when the bone lies wedged between the posterior surface of the sternum and the trachea, and either cannot be dislodged, or cannot be prevented from slipping back, it has been found necessary to divide the shaft and remove the inner extremity. [Gunn's rule in all dislocations : Place the dislocated bone on the position which characterized it at the moment of its escape from the articular cavity , and then reduce by appropriate manipulation.^ Dislocation of the Scapula. The acromion may be dislocated from the clavicle in two directions, upward or downward. The former is exceedingly rare ; the latter, in spite of the shape of the articular surfaces, is not so common as might be expected, owing to the strength of the conoid and trapezoid ligaments, which form the main bond of union between the bones. The cause is nearly always a fall or a blow upon the shoulder delivered from behind and above, so as to drive the point of the acromion downward and for- ward. Partial displacement, however, is met with now and then in rai)idly grow- ing girls, merely from carrying heavy weights upon the arm. Proljably in these cases the fibres of the capsule do not give way completely. Complete dislocation can hardly be mistaken. The head is inclined to the injured side ; the margin of the trapezius stands out distinctly ; the outer end of the clavicle is rai.sed and forms a great projection upon the acromion, and the scapula is depressed and rotated. There is tenderness on j^ressure over the cora- coid, the movements of the arm are painful and very limited, and raising it even to the level of the shoulder is impossible. Like the preceding, this dislocation is very easy to reduce and very difficult to keep in position ; all that is necessary is to draw the shoulder back, press the clavicle down, and the scapula slips out from underneath at once ; but as soon as the pressure is relaxed the displacement appears again. Very often the bones can- not be made secure, and then a new joint is gradually developed in the upper sur- face of the acromion, and, though the projection is very unsightly, the arm regains nearly the whole of its power, except for overhand movements. The most successful method of treating this dislocation is by means of Velpeau's dextrin bandage, only substituting Holland plaster, which never stretches. Great care must be taken to prevent sloughing of the skin. If this fails a pad may be placed over the acromial end of the clavicle and strapped firmly down by means of a broad webbing band carried over it and under the point of the elbow. In such a case the axilla must be well padded and the scapula fixed as far as possible against the wall of the thorax. Where deformity is the first con- sideration, the patient must be kept lying flat on the back in bed for a week or ten days ; the scapula is fixed perfectly ; the weight of the limb is taken off ; the trapezius is relaxed ; and the clavicle can easily be prevented from riding up. Dislocations of the Humerus. The shoulder is dislocated more frequently than all the other joints in the body together. This is due to its anatomical construction ; its security is de- pendent almost entirely on the muscles and tendons that surround it ; the glenoid fossa is so flat and shallow that it can afford no protection for the head ; the cap- sule, wnth the exception of one jart, is exceedingly loose and weak ; the move- ments are unusually free in all directions ; and the length of the arm gives such enor- mous leverage that when the head of the bone is driven against the capsule it tears it with the greatest ease. The cause is nearly always indirect violence — a fall upon the elbow or the DISLOCATIONS OF THE HUMERUS. 509 outstretched hand ; occasionally direct — a blow, for instance, upon tlie back of the shoulder while the arm is abducted ; in a few rare instances, muscular action by itself, without outside assistance. 1. Dislocation by Indirect Violence. — This is always the result of abduction. As the arm is lifted away from the side, the great tuberosity comes into contact with the upper margin of the glenoid fossa and the surgical neck with the acromio- clavicular arch ; if the scapula is fixed and the force continues, the head projects against the under and inner part of the capsule until it tears it across, leaving the strong upper part tensely stretched by the strain that falls upon it ; then as soon as the force is expended the weight of the arm and the contraction of the muscles carry the head of the bone along the margin of the glenoid fossa, until it either reaches the base of the coracoid or is buried in the substance of the subscapularis. In the first part of the act, the great tuberosity or the surgical neck forms the t"ul- crum of the lever ; as soon as the dislocation is effected, the upper untorn i)ortion of the capsule (the coraco-humerai ligament included) becomes the fixed point, and the head of the bone glides upward as the hand sinks. In a few instances, owing to the head of the bone in some way being caught immediately after burst- ing through the capsule, this consecutive displacement does not take place, and the arm remains in the i)osition of extreme abduction (liixatio erecta). Complete abduction, however, is not absolutely necessary. If the arm is held only a moderate distance from the side, a blow upon the inner condyle of the humerus, or an outward pull- upon the arm, may dislocate the head of the bone. One part of the humerus is fixed by the coraco-humeral ligament ; another a little lower down, by the muscles, especially the deltoid ; some point between the two serves as a fulcrum, and the force applied to the inner side of the elbow levers the head of the humerus out. 2. /;/ dislocations by muscular action, which are much more rare, the mechan- ism is somewhat the same, only the force in this case is the momentum of the arm. When it is moderately abducted, the upper part of the shaft of the humerus is fixed between the abductors (the deltoid) and the adductors (the pectoralis major and the latissimus dorsi), so that a kind of fulcrum forms, upon which the arm swings. If at the moment this takes place the lower part of the arm is moving vigorously in the direction of abduction, the head of the bone is driven to the opposite side, against the front and inner part of the capsule, and may be forced through into the subscapular fossa. 3. Dislocation from direct violence is not very uncommon. It can easily be produced by a blow upon the shoulder when the arm is abducted and held in a horizontal position. The scapula yields a little, the head is driven against a weak part of the capsule, and the bone is dislocated either backward or forward, accord- ing to the position of the arm and the direction of the blow. Varieties. With the exception of some of those that are produced by direct violence, all dislocations of the humerus are primarily downward into the axilla, but it is only in the rare cases of what is known as luxatio erecta that the bone retains that posi- tion. Nearly always it is carried, partly by the weight of the limb, partly by the contraction of the muscles, either in a forward or backward direction, upward along the margin of the glenoid fossa. There are four well-marked varieties of this consecutive displacement : three forward — subglenoid, subcoracoid, and subclavicular ; and one backward — sub- spinous. Besides these, minor varieties have been described — subacromial, for instance, and supra-coracoid ; but they are very uncommon, and the latter at least cannot take place without the presence of fracture as well. I. Subcoracoid Dislocation. — This is by far the most common ; indeed, it is the only dislocation that is usually met with, the others are all exceptional. The rent in the capsule lies on the inner and lower border of the glenoid fossa, often 5IO DISEASES AND INJURIES OF SPECIAL STRUCTURES. commencing at the opening for the bursa ; the head of the humerus is pushed between the bone and the subscapularis muscle up to the root of the coracoid, until the anatomical neck rests upon the anterior margin of the glenoid cavity ; the muscle is bruised and stripped uj) from its attachment, the upper and back part of the capsule is strained across the glenoid cavity, the tendon of the biceps is lifted out of the groove as far as the capsule will allow it, and the external rotators attached to the great tuberosity are stretched or torn. If, as sometimes happens, they give way completely or wrench the tuberosity away from the shaft, the bone is drawn more toward the middle line and is less rotated. Sometimes the axillary vessels and the brachial plexus are compressed, but this is not so common or so well marked as in the subglenoid form. 2. Subglenoid Dislocation. — In this, which is the next most frequent, the head of the bone either escapes below the subscapularis, between it and the teres muscles, or is driven through its substance and pulled up until it rests upon it opposite the lower margin of the glenoid fossa. The rent in«the capsule may be the same as in the subcoracoid variety, or the fibres may be torn away from the under and inner l)art of the humerus, but the difference does not appear to be material. The ex- ternal rotators and the other muscles suffer to much the same extent, but the vessels and nerves are more likely to be compressed. 3. Subclavicular Dislocation. — This is the rarest of the four ordinary forms : in it the head of the bone is carried under the pectoral muscles to the inner side of the coracoid process, so that it projects underneath the skin and can no longer be 7 Fig. 207. — Old Dislocaiion of Humerus, seen from above, showing the way in which the head of the bone and the glenoid edge mutually wear each other away and simulate a partial dislocation. felt in the axilla. It can only be produced by extreme violence, rupturing the ex- ternal rotators, or tearing the tuberosity away from the shaft ; and the amount of damage inflicted on the surrounding structures is proportionately great. 4. Subspinous Dislocation. — Under this may be included all the forms of back- ward displacement in which the head of the bone rests upon the dorsal surface of the scapula beneath the infraspinatus. The rent in the capsule must involve the lower part, but probably in the majority of instances it extends nearly round the whole, the upper part only being left strained across the glenoid cavity. The subscapularis may be merely stretched, or it may be torn away from the humerus. 5. In the supracoracoid variety the head of the bone is dri\ en ujjward between the coracoid and acromion, fracturing one or other until it rests upon the coraco- acromial ligament and projects through the substance of the deltoid. Only three cases are on record. Partial dislocations have often been described, but probably, in most in- stances, they have really been either old unreduced complete ones or the result of chronic rheumatoid arthritis. In the former case, when the head of the bone has been resting for many years on the front margin of the glenoid cavity, it gradually wears it away until it seems as if it were lying partly in the fossa itself, partly on the bone in front of it ; in the latter, when the biceps tendon has been absorbed or torn across, the head of the bone is pulled upward and forward under the acromio-clavicular arch, and forms there a new socket for itself, with a capsule DISLOCATIONS OF THE HUMERUS. 5" partly adapted from the old one, partly formed afresh (Fig. 244). Genuine cases, however, are occasionally met with ; in one under my care, the patient, a tall overgrown girl of seventeen, was unable to place her hand at the back of her head, as, owing to the feeble develoi)ment of the short muscles, the bone always slii)ped forward on to the anterior margin of the glenoid fossa, stretching the capsule more and more each time. In other cases, the same result is stated to have been due to the unusual development of the Inirsa under the subscapularis, and in one in- stance it was proved by dissection that the capsule had been torn in a way that would allow the head to be partially displaced. Recurrent Dislocatio7is. — A similar condition of things is sometimes met with after the reduction of an ordinary dislocation : the arm, when an attempt is made to use it, feels too insecure ; if it is raised in the least, the head of the bone slips forward, and though it generally falls back again into the fossa as soon as it is lowered, sometimes it is caught and requires to be released by manipulation. This is probably caused by loss of power over the short external rotators, which are often damaged or torn in dislocations ; but it may be due to part of the lip of the glenoid cavity having been pulled off by the capsule. Symptoms. — The appearance presented by a patient with a dislocated shoulder is very characteristic ; the head is bent toward the affected side ; the fore- arm is supported by the other hand ; the elbow is flexed owing to the tension on the biceps, and the shoulder has completely lost its rounded shape ; the point of the acromion stands out beneath the skin ; instead of the normal curve, the line falls almost vertically ; the infra-clavicular fossa is obliterated ; and sometimes the head of the bone projects through the substance of the muscles. The arm is abducted from the side, especially in the subglenoid variety; in the subcoracoid it may still almost touch, in spite of the convexity of the thorax : its axis does not run in the normal direction toward the glenoid fossa, but too much inward ; the elbow, except in the subspinous form, has an inclination backward, though it does not pass the mid-lateral line of the body, and there is a general look of helpless- ness about the part. Sometimes the arm is swollen from pressure upon the axillary vein ; or the radial pulse cannot be felt ; or again there is intense pain down some of the branches of the brachial plexus. If, in order to compare the two sides together more accurately, measurements are taken, the results vary according to the kind of dislocation : in the subglenoid, owing to the head of the bone lying below its normal level, there is length- ening with marked abduction (mainly due to the coraco-humeral band, but partly perhaps to the muscles) ; in the subcoracoid the abduction is less and there is no certain alteration in length ; and in the subclavicular, in which the head of the bone is carried far inward, the arm points outward and is greatly shortened. One measurement, however, that is always increased is the vertical cir- cumference of the shoulder, taken round the acromion and the axilla. These results are next to be con- firmed by palpation. Under the acromion there is a great depression ; the finger cannot be made to touch the glenoid fossa, owing to the deltoid and the external rotator mus- cles that cover it, but it seems to sink right in. In the subclavicular form the head of the humerus projects in such ■i I// i 1 Bi^i Fig. 208. — Subcoracoid Dislocation of Humerus. 512 DISEASES AND INJURIES OF SPECIAL STRUCTURES. a way as to strike the eye at once ; in the subcoracoid it is not so prominent as this, but it always obliterates the natural hollow beneath the clavicle, and in addition can easily be felt by pressing the fingers ui)ward into the axilla. In the subglenoid this is plainer still ; the head of the bone lies lower down ; there is a hollow between it and the coracoid ; and the anterior fold of the axilla is less prominent, owing to the drawing downward of the pectoralis major. I have only seen two examples of dislocation backward, but in neither was there any difficulty in making out the exact position of the head. Finally, any doubt may be set at rest at once by manipulation. Voluntary movement is almost out of the question ; pa.ssive movement, though more free, is very painful, and definitely limited. The head of the bone rotates easily in its new situation, though not so freely as when in the glenoid fo.ssa ; abduction to a certain extent is possible still ; but adduction, so as to make the elbow touch the side, especially when the fingers are laid upon the oj)posite shoulder, is absolutely impossible in all forms of dislocation — the shape of the thorax is such that it can- FiG. 209. — Subcoracoid Dislocation, with the Capsule Laid Open and Turned Back. not be done. This and the vertical measurement round the axilla are almost con- clusive. The diagnosis of dislocation has to be made from : — 1. Fracture of the neck of the scapula, in which the glenoid fossa and the coracoid process are separated from the rest of the bone, carrying the arm with them. 2. Fracture of the anatomical neck of the humerus. 3. Fracture of the surgical neck. 4. Separation of the great tuberosity, in which the head of the bone is always dragged forward by the other muscles, until it rests upon the anterior margin of the glenoid cavity, but within the capsule. 5. Paralysis of the mu.scles passing from the trunk to the arm, with conse- quent dropping of the head of the bone, until a great hollow makes its appearance beneath the acromion. This may occur in adults, but is more common in new- born infants, from the pressure of forceps in delivery. In all of these, however, instead of rigidity and immobility, pa.ssive motion is DISLOCATIONS OF THE HUMERUS. 513 unduly free, and the ell)o\v can be made to touch the side with ease ; indeed, it generally is already in contact with it. This is especially true of separation of the great tuberosity, where the difficulty is often a very real one. In all the other J¥ /! Fig. 210.— a similar Dislocation, showing the effecu of Rotation Outward, Abduction and Traction Backward. The head is just passing over the anterior edge of the glenoid. Fig. 211 — Rotation Outward, 10 be followed by Abduction. fractures crepitus can easily be made out, unless they are either impacted or already in part united. Treatment. — Immediately after the accident, or in a moderately recent 5t4 DISEASES AND INJURIES OF SPECIAL STRUCTURES. case, when the muscles are relaxed by an ana.^sthetic, the only difficulty is the mechanical one. The head, for example, no longer corresponds to the rent in the capsule, or it is fixed by the tension of some of the ligaments. After a few hours, however, others are added ; the muscles contract and become rigid ; later still they undergo fibroid degeneration ; adhesions form between surrounding structures ; the lymph that has been thrown out becomes organized ; the rei\t in the capsule is repaired, and sometimes even the glenoid fossa is filled in. Reduction is effected partly by the aid of the coraco-humeral band, which now runs downward and inward from the l)ase of the coracoid to the tul)erosities, partly by the tension of the short external rotator muscles and the posterior portion of the capsule, which are tightly strained across the glenoid fossa. The first thing is to fix the scapula, which may be done by an assistant standing behind and press- ing it down upon the thorax, while his fingers help to manipulate the head of the bone. This lies underneath the subscapularis or in its substance, suspended as it Fig. 212. — Circumduction of Elbow, after Rotation. were by the muscles and ligaments attached to the great tuberosity, and fixed firmly against the projecting anterior lip of the glenoid fossa (Fig. 209). In many cases it may be released at once by rotation outward, or rotation combined with traction. If the elbow (which is already flexed owing to tension on the biceps) is pressed firmly into the side, and then the forearm rotated out- ward as far as it can go, the outer and posterior portions of the capsule, which are strained tightly against the glenoid fossa, are lifted away from it by the great tuberosity ; the edges of the rent are held apart ; and, if the opening is high up, as in most cases of subcoracoid dislocation, the head of the bone is fixed between the upper and lower parts of the capsule (both of which are still tense) on the anterior lip of the glenoid fossa, close to the spot at which it burst through (Fig. 210). Sometimes then a little outward pressure from the axilla or backward traction from the elbow is sufficient to make it describe the arc of a circle, of which the upper untorn portion of the capsule is the radius, and it slips at once over the edge into its socket. A greater amount of force may be obtained by DISLOCATIONS OF THE HUMERUS. 515 pulling the upper jjart of tlic humerus outward, while the elbow is drawn across the front of the chest. I( this does not succeed, further manipulation must be tried ; the forearm must still be kept flexed and rotated out as far as it will go, but the elbow must now be brought forward until the arm is horizontal (Fig. 211). By this the ui)per part of the capsule is relaxed, as well as the external rotator muscles, and the only portion left tense is the lower and posterior ; this fixes the neck of the humerus and prevents the head from moving further forward. If now the forearm is circimiducted inward, so that the fingers touch the other shoulder, the head of the bone is forced to move in the opposite direction and can hardly fail to be carried into its socket (Fig. 212). It is essen- tial, however, that the move- ments should be carried out slowly and deliberately and to their full extent. Inward rotation from the first is simpler still, and is more successfiil when the rent in the capsule is low down, as in the subglenoid form. The position of the patient is the same ; the same precaution must be taken with regard to the elbow and the shoulder ; then the arm is a little abducted, drawn down to release the head from the fibres of the muscle that surround it, and rotated in (Fig. 213). The coraco-humeral band and the short external rotators are stretched as tightly as they can p,j. ^13 be, and the head of the bone travels round the inner margin of the glenoid fossa until it is compelled to rise over the edge f / Forced Rotation Inward, tightening up the short external rotators and the iintorn parts of the capsule. Drawing the Fig. 214. — Reduction of Dislocation by Heel in the Axilla. lower end of the humerus across the body, while the upper part is either being pulled or pressed outward at the same time, is of great assistance. 5i6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. If manipulation and rotation l)oth fail (and even when the patient is under an anaesthetic they will do so sometimes, either because of the peculiar position of the rent in the capsule, or from the changes that occur when the case is left to itself) extension must be tried. The most successful of all methods is by means of the heel in the axilla. The patient is directed to lie down upon a low couch, close to the edge ; the surgeon (having first removed his boot) seats himself on the edge on the same side as the dislocated arm, facing the jjatient ; he then takes hold of the limb by the wrist, and placing his heel (not the sole) well up in the axilla, so that it comes in contact with the axillary border of the .scaimla, proceeds to make traction upon the limb in its abnormal direction, slightly abducted, that is to say (Fig. 214). The foot acts as a counter-extending force; the heel and the traction combined fix the scapula ; and if the arm is rotated a little or gently swayed from side to side, or if the head of the bone can be manipulated from above by an assistant, it slips out at once, and is carried up by the muscles into the fossa with a sudden snap. In older cases, or when the muscles are relaxed by an anaesthetic, the foot has to act the part of a fulcrum as well ; the head of the bone is gradually drawn down until it is disengaged ; then the hand is brought across the chest, and the upper end of the humerus is levered outward in the direction of its socket. A greater amount of force may be obtained by means of a jack-towel made into a clove-hitch. -A wet bandage must first be placed round the arm to protect the skin as well as to prevent the towel slipping ; the clove-hitch is adjusted above the Fig. 213— ciove-hiich. elbow ; and the loop of the towel passed over one shoulder of the operator and under the other arm ; by this means he can bring into play the extensor muscles of the back and at the same time leave his hands free to grasp the wrist and aid in reduction by rotating and abducting the arm. In cases of still longer standing, in which rotation has failed and it is considered advisable to make further trial, the pulleys may be adjusted to the arm above the elbow in the manner already described. The same result is aimed at by means of the knee in the axilla (Astley Cooper's method), but it is not so successful ; the patient is seated on a low chair; the surgeon stands behind, and resting his foot upon the edge of the chair, places his knee in the axilla; then, grasping the arm above the ell)ow with one hand, and pressing down upon the acromion with the other, he makes traction downward, and at the same time, by raising his foot upon his toes, forces the neck of the humerus outward, thus combining traction and abduction with leverage. One other method, that of hyper-abduction, must be mentioned, as the prin- ciple upon which it is conducted is rather different, and it sometimes succeeds when others fail. The arm is raised from the side, and abducted until it is in a line with the patient's body ; the deltoid and the untorn part of the capsule are re- laxed ; the acromio-clavicular arch is made use of as a fulcrum, and the head of the bone is first of all pulled downward, and then, as the scai)ula shifts, pulled out at right angles to the glenoid fossa, until it is sufficiently released to ride over its edge. It may be carried out in various ways. The patient may be seated on the floor, and the surgeon stand on a chair over him ; or he may be lying down on a sofa, near the edge, so that nothing can impede the upward movement of the arm (Fig. 216) ; and counter-extension may be effected, either by making a slit in a towel, passing the arm through it, and then giving it to some one else to hold on the opposite side of the patient, so that the scapula is i)ulled down upon the thorax — or by the surgeon himself pressing his foot or his hand (fowu upon the shoulder from above and behind while making extension upon the arm. It is scarcely ad- visable for dislocations of long standing until other measures have been tried and DISLOCATIONS OF THE HUMERUS. 517 failed, as, owing to the extent of movement of tlie head of the bone, it must expose the axillary vessels to a certain amount of risk. After reduction has been effected the axilla must be dusted over with oxide of zinc powder and carefully padded with cotton wool, partly to prevent any forward displacement of the arm, which might occur from the injury sustained by the muscles attached to the great tuberosity, partly to assist by its pressure i'l the ab- sorjjtion of the exudation that is thrown out. Then the arm must be bandaged to the side. Passive motion should be commenced not later than the end of the first week ; if carefully carried out there is no ri.sk of causing re-dislocation ; and it is the best method for checking the stiffness that is liable to occur from confinement of the joint. Whether the limb after that period should be merely carried in a sling, or should each time be secured by bandages again, mu.st depend upon the patient and the amount of care he will take of himself. Active movement should certainly not be allowed for three weeks, and no overhand movement for a much longer period. Unreduced Dislocations. Dislocations of the humerus are very frequently neglected or overlooked, and it is by no means uncommon for the patient to apply for treatment for the first time Fig. 216. — Reduction of Dislocation by Upward Traction. months after the accident. The question then arises whether an attempt should be made to effect reduction, or whether it would not be better merely to break down the adhesions, and, by means of exercise and passive motion, encourage as far as possible the formation of a new joint. The time that has elapsed is of course the most important element, but it is not the only one — the age of the patient and the usefulness of the arm have to be considered. Up to four months success is com- mon, and may be looked for, and the arm generally recovers ; but many instances of failure, more or less complete, after much shorter periods than that, have been recorded. After four months it becomes more and more doubtful each day, although cases have succeeded after as long as two years. The best guide probably is the amount of pain the patient suffers ; if it is severe — and sometimes it is so bad as to justify excision of the head of the humerus — the limb is sure to be kept at rest, and will become completely stiff; if, on the other hand, movement is already free and painless, and the part is fairly useful, it is certainly not advisable to try too much. The patient may be placed under an anaesthetic, the head of the humerus rotated from side to side, and the various methods of manipulation practiced, with the prospect, even if reduction is not effected, of materially improving the use of the part ; but if, after this has had a fair trial, the head of the bone shows no 5iS DISEASES AND INJURIES OE SPECIAL STRUCTURES. inclination to return, it is doubtful whether much improvement is likely to result from the use of tlie pulleys. Complications. — Dislocations of the shoulder are always attended by bruis- ing and laceration of the surrounding structures ; but, unless the injury is very extensive or involves some i)art that usually escapes, it ought not to rank as a com- plication. ^Extravasation of blood into the axilla, for example, rarely deserves to be counted as one, though sometimes, owing to the number of small vessels torn across and the loose spaces in the cellular tissue, it is very considerable in amount ; but occasionally the axillary artery gives way, or, what is ecpially grave, one of its large branches is torn off from it, and an arterial h?ematoma of the most serious description forms at once. The axilla becomes distended to its utmost ; the pulse at the wrist cea.ses ; the arm becomes ocdematous and cold ; and the patient falls into a -state of collapse. In such a case there is no alternative ; the subclavian must be compressed ; the axilla opened ; the blood turned out ; and the artery tied above and below the seat of injury. Only when the swelling cea.ses to increase, while the arm still retains its warmth and feeling, it is admissible to wait. Pos- sibly, when this is the case, the swelling has become accidentally circumscribed, and an aneurysm will form, which can be dealt with later on ; or the opening in the artery has become temporarily blocked by a coagulum, which may not give way again, although it nearly always does. At any rate, in such circumstances there is no need to proceed at once to such a serious operation, although the ca.se must be very carefully watched. Ligature of the subclavian, if the swelling is dif- fuse, will not check the hemorrhage and may cause gangrene. It is more common for the artery to be bruised by the head of the bone, but this rarely leads to anything more serious than a temporary cessation of the pulse. Sometimes, however, a thrombus forms, probably from the injury to the inner coat, and the artery is permanently closed ; and occasionally an aneurysm develops later on. In a few instances //?^?w>z has been ruptured as well. , The brachial plexus, owing to its strength, nearly always escapes ; but there is very often intense pain down some of the nerves, from the pressure of the head of the humerus ; and sometimes, probably from the same cause, this is followed by loss of power. It rarely, however, persists for any length of time. The circinnflex nerve is not so fortunate. Atrophy of the deltoid is not uncommon after disloca- tions, and though in many instances it is the result of rheumatoid arthritis, setting in after the accident, sometimes at least it is due to the bruising or tearing this nerve has sustained. The effect on the muscles has been already mentioned ; the short external rotators suffer the most ; .sometimes they are completely torn across, or what is equally serious, drag away with them the great tuberosity. The others may be badly bruised, but there is seldom any graver injury ; even the long tendon of the biceps, though it is subjected to a considerable strain, is very rarely torn or dis- placed. Fracture of the surgical neck, whether it is the result of the original accident (the force continuing to act after the dislocation has been produced) or is due to attempts at reduction, is a most serious complication. In the former case the patient must be placed under an anaesthetic, and every effort made to manipulate the bone back into its socket ; in the latter, it is probably best to push the uj^per end of the shaft into the glenoid fo.ssa, and try to establish a false joint. Eracture of the lip of the glenoid cavity sometimes occurs, and, like separation of the greater tuberosity, is important, as it tends to impair the security of the joint after reduction. These complications occur much more frecpiently from trying to reduce dis- locations of long standing. Even when the attempt succeeds without much man- ipulation, the cellular tissue is bruised and torn, the adhesions broken down, and the muscles lacerated to such an extent that, especially if pulleys have been used, it is not uncommon to find the side of the chest and the axilla black and blue for weeks afterward. But worse consequences than these have often happened. The DJSL O CA TIONS A T THE ELBOW. 519 bone, for example, has been ])roken many times, especially at the surgical neck ; it becomes atroi)hied to a certain extent from disuse, and as soon as any leverage is put upon it, it gives way at its weakest part. The artery has been torn, and though on a few occasions this has been the result of excessive violence, it has happened to the most careful surgeons from mere manipulation. It is probably due to adhesions having formed between it and the head of the bone, so that, when the latter is moved to a very slight degree, the whole of the tension falls on a limited portion of the wall of the vessel. The same thing has happened to the vein : the brachial plexus has been torn out from the spinal cord ; the ribs have been broken ; the soft parts hopelessly damaged j and even the arm itself has been torn off. Compound dislocations are very rare, and the treatment must be guided by the amount of injury sustained by the soft structures round the joint ; unless these are verv extensively hurt, the dislocation should be reduced and an attempt made to save the limb. Dislocations at the Elbow^ Joint. Under this are included dislocations of the ulna and radius together, of either of the two by itself, and of the two separately, the one being driven forward and the other backward. Of these the first named and dislocation of the radius by itself are common, the others are very rare. They may occur at all ages, but, owing to the smooth and rounded shape of the articular surfaces in childhood, they are much more frequently met with at this period than in any other. All the processes, especially the coronoid, at that time of life are low and cartilagi- nous ; the depressions are not deep or well-defined ; and the head of the radius is not only smaller in proportion to the shaft, but is not marked off from it so dis- tinctly as it is in later years. Dislocation of Radius and Ulna together. This may be complete or incomplete, that is to say, the two bones may either have lost all relation to the lower end of the humerus, or they may still be to a certain extent in contact with it, and it may take place in any one of the four directions, backward (Fig. 217), forward, outward, or inward ; or it may be diagonal, backward and outward, or backward and inward. Of these the dislocations back- ward, and backward and outward, are the two most common ; the others are very rare, the prominence of the olecranon prevents one, the direction and shape of the trochlear surface of the humerus prevents another, and complete lateral dislocation in either Fig. 217— Dislocation of Bones of Forearm direction can hardly take place without the (Back), injury becoming compound. Causes. — These injuries are nearly always the result of a fall upon the hand, with or without violence applied to the elbow itself, but the way in which they are produced is not always the same. In many cases they are due to over- extension : the tip of the olecranon is pressed against the posterior surface of the humerus, and forms the fixed point ; then, if the force continues, the strain falls upon the anterior ligament, the biceps and brachialis anticus being either over- come or taken unawares ; the sigmoid cavity of the ulna is separated from the trochlea, and the two bones are carried together, behind the humerus, until the coronoid process passes the centre of the articular surface. If it is carried right up to the olecranon fossa (it cannot lodge in it so long as the radio-ulnar ligaments are intact), the dislocation is complete ; if it falls short of this it is incomplete. 520 DISEASES AND INJURIES OE SPECIAL STRUCTURES. Dislocation backward and outward (which corresponds very nearly to that described by Malgaigne as "incomplete backward ") can also be produced by over-extension. In a fall upon the hand the arm forms a rigid bar between the resistance in front and the momentum of the body behind; if, at the moment that the bones are separating and the ulna slipping behind the humerus, the elbow bends a little to one side, the strain falls ujjon one of the lateral ligaments more than on the other, and the displacement becomes diagonal, nearly always backward and outward. In many instances, however, leaving dislocation forward and directly outward altogether on one side, over-extension never takes place. The primary displace- ment is due either to lateral bending or to rotation inward, and when the coronoid process has in this way been shifted from its position in front of the trochlea, the bones are carried upward and backward by the muscles. This is easily accom- plished in children. The hand is fixed by the momentum of the fall, the inner side of the forearm or elbow comes into contact with the ground, the internal lateral ligament tears across, or the internal epicondyle gives way, either from direct violence or because it is unequal to the strain, the sigmoid cavity is separ- ated slightly from the trochlea, and the ulna is dragged upward and backward. The amount of lateral displacement depends upon the degree of force applied to the side of the elbow ; I have known pure outward dislocation ^incomplete) caused in this way even in an adult ; more often it is backward and outward, and occasionally it is directly backward. Dislocation inward and complete dislocation outward (in which the ulna as well as the radius is carried to the outer side of the capitellum) can only be pro- duced by a very great degree of violence applied directly to the joint. Disloca- tion of both bones forward, so that the olecranon rests against the anterior surface of the humerus, has been caused on several occasions by a blow on the back of the joint when in a position of extreme flexion. Symptoms and Diagnosis. — In adults it is generally easy to say whether there is dislocation, though it may be very difficult to determine the exact extent of the injury ; in children, on the other hand, it is often impossible to come to a conclusion without a prolonged examination under an anaesthetic. The injury is frequently complicated by Iracture or by separation of the epiphyses ; the bony prominences are not well defined or easily felt, and the j^art becomes so swollen in the course of a i^w minutes that accurate measurements are almost out of the question. Dislocation backward is the most characteristic : the forearm is flexed almost to a right angle and shortened, the hand is generally supinated (it may be pro- nated), the tip of the olecranon stands out behind, and the triceps runs down toward it, leaving a well-marked hollow on either side ; while in front, especially if the arm is slightly extended, the lower end of the humerus projects beneath the skin, filling up the hollow of the elbow. Active movement is out of the question, passive is very much restricted, and any attempt causes severe pain. But the most important test is the relative position of the bony prominences : when the elbow is at a right angle a line drawn horizontally from one epicondyle to the other lies above the tip of the olecranon ; the head of the radius can be felt and can be made to rotate about half an inch in front of the external condyle, and the olecranon fossa can be clearly made out. In dislocation — not only in dislocation backward — this is all changed, the relations are no longer the same, and they are altered to such an extent that even when the swelling around the joint is extreme some essential difference can always be made out. Dislocation backward and outward is more difficult, as all the signs are much less distinct. The position of the forearm is the same, but there is not so much shortening ; the deformity is less ; the head of the radius, instead of being clearly felt behind the external condyle, is partly concealed by it ; the olecranon is scarcely more prominent than natural, as the sigmoid cavity embraces the capi- tellum to some extent, and it is hardly raised at all ; passive motion is much more DISLOCATIONS AT THE ELBOW. 521 free ; ev(*n a certain aniouiU of active extension is jjossible ; the external condyle and the external lateral lii^ament are unhurt, though the hollow behind is filled up, and the internal epicondyle is very often not so [)rominent as might l)e expected, as it is fretpiently either torn away or knocketl off, antl is partly buried behind the trochlea, partly concealed by the extravasation. In the other forms of dislocation the deformity is so conspicuous that it can scarcely fail to be recognized at once. The diagnosis has to be made from supra-condyloid and condyloid fracture, separation of the lower epiphysis of the humerus, wholly or in part, displacement backward with fracture of the coronoid process, and effusion into the bursa behind the olecranon, which occasionally causes a deformity something like that of a dislocation. The first named presents but little difficulty. It is true there is a prqminence in front of the bend of the elbow, caused by the lower end of the upper fragment, and another behind, from the olecranon being carried backward ; but the former is always sharp and angular, not rounded like the articular surface of the humerus, and they can both be made to disappear and reappear by making or relaxing exten- sion. Moreover, instead of the joint being rigid, there is undue mobility, the weight of the forearm causing it to drop at once ; crepitus can usually be made out, and what is most important of all, the head of the radius and the olecranon preserve strictly their normal relation to the two condyles. The same may be said, with slight modification, of separation of either condyle ; but in children, if the outer part of the lower epiphysis of the humerus is detached from the shaft, leaving the internal condyle unhurt, the difficulty of diagnosis is often very serious. Crepitus is absent, or there is only that soft variety which may be easily imitated in a disloca- tion ; the swelling may be so great as to keep the joint rigid ; the bony prominences are almost obscured ; and unless great care is taken it is very easy to be deceived by the position of the olecranon, as, owing to its retaining its connection with the external part of the joint, it does not materially alter its relation to the line joining the two epicondyles. Both kinds of accident are of frequent occurrence, and as it is absolutely essential to form an accurate diagnosis, there should be no hesitation in giving an anaesthetic in order to make the examination as thorough as possible. If the displacement is not corrected, or if the olecranon fossa becomes partly filled up, the range of movement is seriously interfered with. I have known the same difficulty occur in adults when the external condyle of the humerus was detached from the shaft, carrying the bones of the forearm with it. Fracture of the coronoid process is a very rare complication, but may be sus- pected if, when the dislocation has been reduced, it returns again at once. Treatment. — The chief obstacles are the tension of the muscles and the position of the coronoid process which catches behind the humerus. The former may of course be relaxed at once by an anaesthetic, but this is seldom necessary. In many instances, all that is required is to fix the humerus, pressing it somewhat backward, and make slight traction upon the forearm in the extended position ; the coronoid readily slips over the smooth cartilaginous surface, and the bones re- turn at once with a jerk. If this does not succeed, a slight degree of over-exten- sion will probably disengage it. Dislocation outward, and outward and backw-ard, may be reduced in the same way ; the obstacles are the same. The lateral displace- ment, however, if strongly marked, should be corrected first ; in one instance it is recorded that, owing to the soft structures catching behind the condyle, reduction was impossible. The plan ordinarily described as Sir Astley Cooper's hardly ever fails, but it is open to some objections. According to his description the patient is seated on a low chair, and the surgeon, placing his knee on the inner side of the elbow joint, in the bend, takes hold of the wrist and flexes the arm. At the same time he presses upon the radius and ulna with his knee, so as to separate them from the humerus and disengage the coronoid process; while this pressure is sustained by the knee, the arm is to be forcibly but slowly bent, and the reduction is soon e.Tected. The 34 522 niSEASES AND INJURIES OF SPECIAL STRUCTURES. \\ rist is at the end of the long arm of a lever ; the knee is the fulrnini ;• and the olecranon the short arm. The resistance to be overcome is made up of the miis- (des (on both sides of the joint), the lateral ligaments and the fascia ; all of these structures nnist l)e torn or stretched sufficiently to allow the coronoid to slip under the humerus while the arm and forearm are at right angles to each other. The method is very successful ; but if these structures are not already torn, they must give way, owing to the force that is used. The after-treatment is very simple. There is no fear of recurrence, as in the case of the humerus, unless the coronoid has been broken off ; but the amount of ex- travasation and swelling is sometimes very considerable ; and especially in children — there is some risk of inflammation setting in. The limb should be placed on an in- side angular splint, and cold and compres- sion applied until the swelling has gone down and the fear of inflammation is passed. Passive motion may in ordinary cases be commenced at the end of a week ; after that, unless there is something unusual, it is sufficient if the forearm is sui)i)orted in Fig. 218. — Unreduced Dislocation of Elbow. ,. T^ /- • 11 a slmg. Perfect movement is generally regained, unless there has been a fracture through the lower end of the humerus. Old dislocations may be reduced up to the end of three weeks or a month without much difficulty ; after that it becomes doubtful, and though reduction has been accomplished as late as four months, this is cjuite the exception (Fig. 218). In one or two cases in which all attempts have failed, and the position of the arm has been such that it was almost useless, the olecranon has been sawn through transversely from behind, the joint opened up, all obstructions divided, the muscles separated from the condyles, the olecranon fossa and the sigmoid cavity cleaned out, and the bone replaced. The olecranon must be wired together and the limb treated as after excision of the elbow. In some cases there has been distinct im- provement, but in others, especially those in which there was at the same time a fracture through the lower end of the humerus, the gain was not great ; if sup- puration sets in bony ankylosis is almost sure to follow. Compound dislocations must be treated in the same way as compound frac- tures into the elbow joint. The question turns first on the age and condition of the patient, then upon the extent of injury to the soft structures ; and the choice lies between reduction, with an attempt to secure primary union of the wounds ; reduction with free incision, and thorough (very thorough) drainage ; excision, or ami)utation. Dislocation of the Ulna by itself is a very unusual occurrence, and is generally accompanied by partial displace- ment of the radius. Sometimes the separation is carried so far that the ligaments connecting the two bones are torn completely across, and one is displaced forward and the other backward. This can only be produced by extreme pronation ; the ulna must be twisted on its axis until the internal lateral ligament gives way and the bone is forced behind the internal condyle. The forearm is held semi-flexed, but completely pronated. Dislocation of the Radius may be either forward, backward, or outward ; the first is the most common, thelast very rare. In adults it seldom occurs unless there is fracture of the ulna; the force first breaks this bone, and then wrenches the radius from its socket. In children it is tolerably frequent, owing to the small size of the head, the absence of DISLOCATIONS AT THE ELBOW. 523 distinction between it and the shaft, and the comparative looseness of the orbicular ligament. The rent in the capsule is not always the same ; in adults the ligament appears generally to be torn away from one or other end of the lesser sigmoid cavity ; in infants and children the head of the bone either slips out from under it or is forced through it, just where it is joined by the fd)res of the external lateral ligament. Probably this serves to explain the serious difficulty that is occasionally met with in reduction. Causes. — Dislocation of the radius by itself is nearly always the result of in- direct violence — a fall upon the palm of the hand; but sometimes it is produced by pulling upon the forearm (swinging a child by the hand, for instance), and there are a few cases on record in which it has resulted from force applied directly to the elbow, the external condyle of the humerus or the capitellum being cru.shed first. It is very doubtful if it can be produced by mere pronation ; if this is carried to its fullest extent it makes the head of bone project against the front of the cap- sule ; but before this gives way, either the internal lateral ligament tears across and both bones are dislocated backward, or the radius itself breaks. The ulna in the living subject cannot act as a lever for the radius. It is possible that it may be effected by supination ; but probably not as a rule, for, if the hand is violently supinated, the inferior radio-ulnar articulation gives way first, and then either the radius, or, in children, the lower epiphysis of the humerus. If, however, forcible lateral bending of the joint (adduction or abduction) is combined with pronation or supination, the orbicular ligament gives way readily, and the head of the bone is carried either forward or backward, according to the position of the elbow at the moment and the direction of the force. In a fall upon the hand the limb is nearly or quite extended ; its lower extremity is fixed against the ground ; then the momentum of the body drives the elbow joint to one side or the other, and at the same time violently pronates or supinates the forearm. Symptoms. — The signs of this injury are usually distinct; the head of the radius projects, either in front of the joint under the supinators, or behind in the hollow below the external condyle ; and its peculiar shape can be recognized at once on rotating the hand. The elbow is flexed ; the radial side of the forearm appears shortened ; generally it is moderately pronated, and sometimes this is ex- treme ; voluntary movement is very much restricted, and passive motion, espe- cially when the displacement is forward, is limited by the head of the bone coming into contact with the anterior surface of the humerus. In older cases, when the articular end has become wasted and has worn a cavity for itself, this is more free ; and sometimes, when it can slip to one side, a considerable degree of flexion is possible, but this is not common. The depression left by the displacement of the bone can always be felt below the external condyle. Treatment. — Reduction may, as a rule, be readily accomplished by fixing the humerus, making extension from the hand, and pressing the head of the bone into position ; but every now and then great difficulty is experienced, probably owing to the intervention of a portion of the capsule ; and sometimes, in spite of manipulation in all directions, and pronation and supination, reduction remains impossible. If the orbicular ligament has given way, the difficulty of retaining the head of the bone in position is equally great ; an anterior rectangular splint may be tried, or the limb may be put up in a position of complete extension with a pad over the head of the bone. If this fails, complL-te flexion sometimes an- swers, having regard to the circulation ; but the condition is not unlikely to become permanent. Unreduced dislocations of the radius are not uncommon. If the head of the bone gives rise to serious inconvenience, if, for example, it pre- vents flexion of the elbow, or, from pressing upon the posterior interosseous nerve, interferes with the extensor muscles, it must be excised. Generally the arm re- gains a good deal of its power, partly no doubt because of the age at wiiich the injury usually occurs; but pronation and supination are never very satisfactory. 524 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Su/'/t/xa/ion of the Radius. This accident, which was first correctly described by Duverney, is common in children under three years old, but is hardly ever met with after six. It is always produced in the same way : traction with adduction and possibly prona- tion. A young child is lifted up or swung round by the hand ; there is a sudden cry of pain, and when the arm is released it either hangs hcli^lessly down by the side or is supported across the chest in the flexed i)osition. Nor is the child able to use it. In most cases no displacement can be found ; sometimes the head of the radius appears slightly ])rominent in front, or is a very little separated from the capitellum ; and sometimes there is a certain amount of swelling at the back of the wrist. Passive motion is perfectly free, and almost painless — in all directions except supination ; that stops rather abruptly ; and there is distinct tenderness and pain at the outer side of the elbow when it is attempted. In a few instances the wrist has been painful too. From experiments on dead subjects (there are no post- mortem records) it is tolerably clear that the symptoms are caused by the head of the radius being drawn out from inside the orbicular ligament until its anterior edge catches and is held below the lower border of the ring, thus slightly separ- ating it from the capitellum (Fig. 219). If in addition there is forced pronation, the head of the bone projects slightly in front (Pingaud). Possibly in those cases in which extreme pronation is the prominent cause, the displacement is made worse by the posterior portion of the head of the bone separating sufficiently from the capitellum to allow a portion of the cajisule to be scpieezed in between the two bones by atmospheric pressure. In either case reduction is usually effected at once by sudden extension combined with supination (J. Hutchinson, junior, recommends pronation with flexion) ; probably in many instances it takes place spontaneously ; but, as Stimson remarks, there is reason to think that some cases of forward dislocation of the radius found in adults, i)ersisting from childhood, were originally of this kind, the head of the bone gradually being displaced further and further. Where the pain and swelling are confined to the back of the wrist joint, without the elbow showing any sign, or where both parts are affected together, it is jjossible, as sug- gested by Goyraud, that the injury really consists in a dis- location of the triangular fibro-cartilage from the lower surface of the ulna. Fig. 2JQ — Subluxation of Radius in an Infant. Shows supinator bievis and orbicular ligament turned aside, showing head of radius. Exter- nally is seen the mus- culo-spiral nerve and its two branches, the radial and interosseus nerves. Dislocation at the Wrist Joint is a rare form of accident, which formerly was often confiised with Colles' frac- ture. The carjMis and hand are detached from the radius and fibro-cartilage and carried either toward the dorsum or the palm, according to the direction of the force. The projection on the back of the wrist, in the one case corresponding to the articular surface of the carpus, in the other to the lower end of the radius and ulna, can be recognized from its shape ; but the most important sign is the posi- tion of the styloid processes ; in dislocations their relation is normal ; in fracture the radial one is separated and follows the hand. Reduction is ea.sy, but, in spite of pa.ssive motion, is liable to be followed by stiffness. Dislocation of the lower end of the radius, with rupture of the triangular fibro-cartilage, may occur from extreme pronation or supination. DISLOCATIONS OF THE THUMB. 525 In the transverse carpal dislocation the distal row of bones is separated from the proximal, and is driven either toward the j)alm or the dorsum; in the meta- carpal the bones of the hand are displaced ; but though this is not unfrequent in the case of the metacarpal bone of the thumb by itself, and occasionally happens to the others, there does not appear to be any instance in which it has involved all at once. Dislocation of the os magnum by itself is not uncommon, the head of the bone being tilted out from the concavity of the semilunar by a fall upon the back of the hand. The projection can be recognized at once and is easy to reduce, but it is very apt to recur, even though the hand is kept extended for two or three weeks. It is stated to be more common among women than men, and it has been produced by violent muscular contraction during parturition. The pisiform bone, with the tendon of the flexor carpi ulnaris, is occasionally dislocated to one side, but this rarely happens to any of the others. They may be crushed and displaced in severe accidents, but then the injury is nearly always compound and must be treated as a compound fracture into the wrist joint. Dislocation of the Metacarpal Boxe of the Thumb is nearly always dorsal, and may be easily recognized by the prominence on the trapezium and the shortening of the thumb, which is usually flexed. It may be the result of direct violence, as in the bursting of a gun, or of forced flexion into the palm of the hand. Usually there is no difficulty in the reduction, but sometimes it is almost impossible to keep the bone in position, probably because, in some of these instances at any rate, there is an oblique fracture running through the bone, detaching the palmar portion of its base. Dislocation of the Proximal Phalanx of the Thumb. This, too, is usually dorsal (Fig. 221), palmar displacement being prevented by the contact of the soft parts in flexion. The cause is forced extension ; the palmar ligament is torn from the metacarpal bone close to its attachment, and the phalanx is carried backward over the articular surface, until in complete cases it rests upon the neck, projecting almost at a right angle. One lateral ligament is generally torn, but both have been found intact ; the tendons of the flexor brevis with the sesamoids lie on either side of the neck, and the distal phalanx is bent down by the tension of the long flexor, which usually lies to the inner side of the head of the metacarpal. Reduction is sometimes quite easy ; more often it is a matter of very great diffi- culty, and, occasionally, it cannot be effected at all. Chloroform is of very little help, and the numerous for- Fig. 22c.-Thumb Forceps. ceps that have been invented are not much more, for if the attempt succeeds it generally does so at once, and the hold on the thumb is quite sufficient (Fig. 220). The head of the metacarpal bone is prolonged inward on its palmar aspect, so as to form a rounded eminence for articulation with the sesamoid bones. These are firmly united to the phalanx and to the palmar glenoid ligament which separates the long flexor tendon from the joint, and extends up on either side of the head, forming a large share of the socket. On the other hand the fibro- cartilaginous pad is very loosely attached to the metacarpal bone ; and when dorsal extension is carried too far, tears off at once, and with the sesamoids follows all the movements of the phalanx. 526 DISEASES AND INJURIES OF SPECIAL STRUCTURES. n-y Three forms of this dislocation have been described by Faraboeuf, differing in degree. 1. Incomplete. — This can be produced in many young i)eoi)le vohmtarily. The articular surfaces are not com])letely separated, and the ]:)halanx is held by the tension of the muscles attached to its base, rigidly fixed on the dorsal edge of the articulation, from which it slips off with a jerk. 2. Complete. — The articular surfaces completely separated ; the base of the phalanx rests upon the dorsum of the metacarpal, dragging with it the glenoid ligament (which has been torn off) and the sesamoid bones ; the tendon of the long flexor lies to the inner side (generally) and the head of the metacarpal pro- jects through the rent in the capsule embraced by the muscles attached to the phalanx. The jjroximal ])halanx ])rojects at right angles, the terminal one is flexed strongly, and the head of the metacarpal stands out under the skin (Fig. 222). 3. Complex. — If, in a complete dislocation,' the phalanx is brought into a straight line with the meta- carpal, the tension of the muscles on the sesamoid bones may pull them (and the glenoid ligament with them) backward over the dorsal surface of the meta- carpal until they lie flat upon it. If, now, reduction is attempted the ligament is dragged over the head of the metacarpal by the phalanx until it is interposed between the two bones and effectually prevents proper apposition (Fig. 223). This has been found by dissec- tion on several occasions ; in another a sesamoid bone was in the way, and in three, at least, the long flexor tendon had followed the ligament round the head of the bone, so that reduction was impossible until it was divided. Exactly the same occurs sometimes in the case of the fingers. According to Faraboeuf, complete dislocations are rendered complex by ill-advised manipulation, especially by premature attempts at flexion. The metacarpal bone must be pressed well down into the palm to relax the short muscles as far as possible ; then the phalanx must be over-extended l^^ Fic 221. — Dislocation of Proximal Phalanx of Thumb. / -^i^ '-Vi-" Fig. 222. — Complete Dislocation of ph.ilanx of Thumb. The glenoid ligament torn from the metacarp.il but preserving its normal relation. Fig. 223. — Complex Dislocation. The glenoid ligament displaced on to the dorsal surface of the phalanx. until its back nearly touches that of the metacarpal, and pushed forward along it until its edge slips on to the articular surface ; then it suddenly becomes flexed. The position of the long flexor tendon, whether it lies to the inner or the outer side, should, if possible^ be made out, as this is sometimes material. The former DISLOCATIONS OF THE HIP JOINT. 527 is the more coamion, and then as the phalanx is being brought up it should be slightly rotated, so as to bring its inner edge into position before the outer, and, if "possible, push the tendon over the head of the bone in front of it. In the com])lex form, when the sesamoids and the glenoid ligament are turned up behind the head of the metacarpal, the only hope lies in extreme extension of the phalanx, so that its dorsal surface shall touch that of the meta- carpal before it is pushed on. In this way they can sometimes be lifted sufficiently to lall into their position again. If this fails it is better to abandon the attempt for a time and to keep the joint perfectly cool and (piiet for a week or ten days ; then a free incision may be made down one side, the cause of the difficulty ascertained and removed. Ten- otomy of the flexor brevis has been recommended, but if the cause is the inter- position of some extraneous substance it would hardly meet the case. Division of the long flexor has been successful, and probably it would have succeeded in the three cases in which the tendon was found between the surfaces. No operation, however, may be attempted at once, or, owing to the bruising of the tissues, suppuration is almost certain to set in. As a last resort the joint must be excised. Old unreduced dislocations are not uncommon ; the phalanx can be bent back almost on to the metacarpal, but cannot be brought quite into the same straight line, or flexed into the palm. The deformity is very unsightly, but the use of the part is, singularly, lit- tle affected. «i-iiimiiiv t^^^w mm mw ' m^^ -» Similar displacements jLM\l^^^*^'i»ifcw,i w^ X --"^i^ ^\ occur in connection with ^^, ^ ^^^ . ^.^ the metacarpo phalangeal ^Xi^ ««<^; .-y- Mi'i'"'. and the inter-phalangeal W/*''''^-6 joints of the fingers ; the deformity is not so great as Fig. 224.— Dislocation of Finger. * that of a real dislocation, and it cannot be rectified. In some instances the fibro-cartilaginous palmar liga- ment has been found between the bones, and has been removed ; in one under my care the first attempt proved successful after division of the flexor tendon. Besides this, true dislocations, both palmar and dorsal (Fig. 224), are met with, but much more rarely. i\ 1\ DISLOCATIONS OF THE HIP-JOINT. In spite of the shape and depth of the acetabulum and of the strength of the muscles and ligaments that surround it, this accident is not so uncommon as might have been expected. This is due partly to the enormous leverage afforded by the lower limb, partly to the fact that in certain positions the head of the bone sinks to a great extent out of the cavity and rests against the weakest portion of the capsule. It may occur at any age, but naturally is much more common during adult life ; in children it has occasionally been produced by direct traction upon the limb ; as a rule it only results from extreme violence, when, for example, a man is crushed to the ground by a heavy weight falling on his back as he is stooping forward. Varieties. The head of the bone may come to rest at any point round the socket ; but so long as the anterior portion of the capsule is untorn, its range is limited and it practically occupies one of three positions. These are known as regular disloca- tions, each having many sub-varieties, in contradistinction to the irregular or 52S DISEASES AND INJURIES OF SPECIAL STRUCTURES. anomalous ones, in which, owing to this part of the capsule having given way, the neck of the femur is no longer fixed and the head may travel anywhere. I. Displacement Backward. — The head of the bone rests on the dorsum of the ilium (Fig. 225), or on the i)Osterior surface of the ischium (Fig. 226), some- where between the edge of the acetabulum and the margin of the great sacro-sciatic foramen ; possibly on the spine of the ischium, but never in the foramen. 2 Displacenu'tif Dcnvinvard. — The head of the bone rests on the thyroid foramen (Fig. 227), hardly having moved after its immediate exit from the aceta- bulum ; or it is carried further still into the perineum. 3. Displacement Inward on to the pubes, at the spot where the horizontal ramus joins the ilium (Fig. 2 28). In none of these is the anterior part of the capsule, the so-called Y ligament torn ; the rent lies behind, generally along the inner margin of the acetabulum and the posterior surface of the neck of the femur ; the ligamentum teres is pulled in two, or more frequently separated from its pit on the femur, bringing away with it some of the articular cartilage ; and the muscles round the joint, especially the short external rotators, are badly lacerated. The Mechanism of Dislocation. — Except perhaps in pubic dislocation (which may be produced in extension) the limb is always flexed. If it is flexed and addiicted, the head of the bone is driven directly through a tolerably strong part of the capsule on to the ilium or ischium ; if it is flexed and abducted, the edge of the acetabulum acts as the fulcrum of a lever, the head is tilted out from its socket and slips through where the fibres are thinnest, at the lower and inner margin. Then it becomes displaced secondarily, either backward or forward, by the weight of the limb and the contraction of the muscles. It is still a matter of question which of these two (the direct or indirect) is the more common. The shape of the acetabulum certainly favors the latter ; the ui)per and back part of the cavity is of immense strength and very deep ; the inner, on the other hand, is low and interrupted for nearly an inch by the cotyloid notch. In abduc- tion the head of the bone rolls more and more toward this side until it projects above the edge, half resting against the weakest portion of the capsule. In this position a very slight push is sufficient to tear the thin membrane across, and, the round ligament being relaxed, to dislocate the head of the bone. Its ultimate resting-place is regulated by the degree of flexion and rotation. Sometimes it moves slightly inward and remains on the thyroid foramen. Very rarely, only indeed when the limb is everted and extended, it ascends on to the pubes. Much more often, owing to the inversion of the head, it forces its way backward, below the tendon of the obturator internus, and either remains upon some part of the ischium, or, if the capsule and the short external rotator muscles are badly torn, makes its way higher up until it lies upon the dorsum (Fig. 230). According to this view% which is strongly advocated by Morris, all dislocations are primarily downward, the head of the bone emerging somewhere between the ischial tuber- osity and the thyroid foramen ; the other varieties are merely consecutive displace- ments, due partly to the weight of the limb as it becomes extended, partly to muscular contraction ; and the i)articular variety is dependent upon the position of the limb at the moment that the head is leaving the socket. Now it is certainly true that sometimes during manipulation under an anaes- thetic instead of the head of the bone rising up into its socket, it rolls along the lower margin of the acetabulum, passing from the thyroid foramen to the ischium and back again, according to the position of the limb ; and there is no doubt that all the four regular dislocations can be produced in this way in the dead subject ; but it is no less true that this explanation will not serve in all cases. In many instances (probably in most) the limb, instead of being abducted, is strongly adducted at the moment of the accident ; further, the rent in the cap.suledoes not always run along the thinnest ])art, by the margin of the acetabulum and the pos- terior surface of the femur. The pubo-femoral portion of the capsule may be intact; and, as Humphry has shown, there may be at the back a tri-radiate rent, DISLOCATIONS OF THE HIP JOINT. 529 Fig. 225. — Dorsal Dislocation. Fig. 226. — Sciatic Dislocation. Fig. 227. — Thyroid Dislocation. Fig. 228.— Pubic Dislocation. 530 DISEASES AND INJURIES OF SPECIAL STRUCTURES. forming a kind of valve, with its apex opposite the lower part of the tuberosity. Such an injury can only be produced by the head of the femur being driven directly backward, in the flexed position. If the joint is nearly straight at the moment the limb receives the shock, the lip of the acetabulum may be chipped off; if moder- ately flexed, the head of the bone is driven out, above the oljturator internus, or through its substance, tearing the capsule away from its attachment, or dragging off part of the bone (Fig. 229) ; when the flexion is extreme (as it nearly always is in these accidents) the head passes out beneath tlie tendon (Fig. 230), and either comes to rest upon the ischium, or, if the force continues to act after the disloca- tion is produced, tears its way further through the muscles until it reaches the dorsum. Dislocation Baclrivard. This is hy far the most common, and includes Ix^tli the dorsal and the sciatic varieties ; they are produced by the same kind of accident ; the attitude of the limb is the same, although it varies in degree ; and the method of reduction is the y - Fig. 229. — Dislocation on to Dorsum above the Tendon. Fig. 230. — Dislocation on to Sciatic Notch below the Tendon. Secondary displace- ment brings the two almost into the same position. same. The difference depends upon the position of the rent in the capsule and the extent of the injury to the muscles. If the opening is high up, the displace- ment is dorsal from the first ; if the lower part is torn, it is sciatic ; but, if the rent is large and the short external rotators are much lacerated, the head of the bone plows its way up subsequently, and the sciatic dislocation becomes dorsal by secondary displacement. Causes. — The most common is a violent l)low ujjon the back, while the body is bent forward in a stooping position. The hip is always flexed ; if the limb is adducted and inverted, the pelvis is driven down on to the femur until the head of the bone is forced through the capsule; if it is abducted and inverted, the pelvis is twisted, the head of the bone tilted out of the lowest part of the socket, and then forced below the tendon of the ol)turator internus. The ultimate position is the same, because that is dependent upon the untorn portion of the capsule and the muscles. Other causes are falling with the legs wide apart; sudden abduction DISLOCATIONS OF THE HIP JOINT. 531 of one limb when the other slips down a hole ; or a wheel passing over the hip. One case of double dislocation is especially important : a man was standing on an incline with his feet wide apart, the right leg being lower down and therefore straighter than the left ; suddenly he was crushed to the ground by a heavy weight falling uijon his back; both hips were dislocated at the same instant; the right, which was least flexed, was driven on to the dorsum ; the left on to the sciatic notch. Pathology. — The round ligament is almost always broken ; sometimes it is pulled away from the bone ; the inner or posterior part of the capsule is torn, as described already; or the back part of the acetabulum is dragged off; the short external rotators always suffer ; in some cases they are completely ruptured, and the head of the bone lies in the substance of the glutei ; in others the ([uadratus femoris and the inferior gemellus only are lacerated, though the rest are bruised by the pressure of the bone; the pectineus usually gives way, and the psoas and iliacus are very much stretched. Occasionally the great sciatic nerve is seriously injured, either from the accident itself or from the efforts at reduction. The anterior part of the capsule is always intact ; generally it is very tense, but this is not invariable. Symptoms and Diagnosis. — Dislocation on the dorsum can be recog- nized at once by the position of the limb. The thigh is flexed, adducted, and in- verted until the axis of the femur crosses the lower third of the opposite one ; the knee is semi-flexed, and the ball of the great toe rests upon the instep of the other foot. In the sciatic this is le.ss conspicuous : the limb is nearly straight, and almost extended, although immediately after the accident the inversion is sometimes even greater. The contour of the hip is altered, the extent varying with the con- dition of the patient. The buttock is flattened, and broader than the other; the gluteal fold is raised, and the trochanter more prominent ; it rises above Nelaton's line, and approaches the anterior superior spine ; but in this respect again sciatic dislocation is much less distinct than dorsal. The next thing is to confirm this by measurement. The limb is always shortened, in the dorsal dislocation as much as two and even three inches ; in the sciatic rarely more than one; and as this takes place entirely at the hip-joint, it may be appreciated best by Bryant's triangle, the three sides of which all measure less than normal. It is noteworthy that in sciatic dislocation, owing to the head of the bone lying behind the acetabulum, though the amount of shortening is slight when the limb is extended, it becomes very conspicuous as soon as it is flexed to a right angle (Fig. 231). The head of the bone can be generally felt by deep pressure where the disloca- tion is on the dorsum, unless the patient is very stout ; but this is rarely possible in the sciatic form, even when the limb is rotated from side to side. There is often, it is true, a sense of resistance ; but that is all. . In one or two instances the head of the bone has been felt per vaginam. In front, the hollow left can be readily appreciated, even in a moderately stout person, the femoral vessels seeming to dip back suddenly after passing under Poupart's ligament. In thin people the finger seems to sink almost into the acetabulum. Passive motion, which should always be left to the last, is conclusive. If the knee and hip are flexed, so that the .sole of the foot rests on the bed by the side of the other knee, it is impossible to evert the limb ; the opposite side of the pelvis rises at once. In any case of fracture (except in that very rare accident in which the head of the bone is driven through the floor of the acetabulum), if the limb is not already in this position, it can be made to assume it so easily that it appears to fall out almost of its own weight. Voluntary movements are very much restricted ; of passive ones flexion is the least affected ; the limb cannot be completely extended, and abduction, adduction, and rotation are all limited. Sometimes, however, in a sciatic dislocation a few days old the range of passive motion is nearly as wide and as easy as in the unin- 532 DISEASES AND INJURIES OF SPECIAL STRUCTURES. jured limb, with the exception of abduction and eversion when the hi]) is flexed, and the power of vohintary action is to a great extent regained. Pain, of course, is always present ; in many instances it is very severe, and it may extend down the course of the sciatic nerve ; the back is arched, especially if any attempt is made to extend the limb, and spurious crepitus can nearly always be felt on manipulation. Sometimes, if the lip of the acetabulum has been broken, true crepitus can be felt as well, but only by direct pressure above and behind the trochanter while traction is being made upon the limb. In no case is it wise to come to a conclusion without examining the patient under an anaesthetic, not only on account of pain, but because, unless the disloca- tion is very recent, it is impossible to manipulate the limb sufficiently freely. Im- pacted fracture of the neck of the femur with inversion of the limb is the most difficult to distinguish, especially if a portion of the trochanter has been broken off; for this, if pulled up on to the dorsum, may easily be mistaken for the head of the bone ; but the range of passive motion is totally different. Fracture of the lij) of the acetabulum, if the portion broken off is small, will probably escape notice altogether ; but if the cup is much injured, the head of the femur slips out on to Fig. 231.— View of Pelvis from below, with Hips Flexed to a Right Angle, showing the Difference in Position and the Amount of Shortening in a case of Sciatic Dislocation. the ilium, and the limb assumes the position of a dislocation. Reduction is easy, but as soon as the limb is left to itself it resumes its former attitude. Treatment. — Dislocation backward is always caused by flexion, and unless everything that resists is torn across, can only be reduced by flexion. The thigh is bent at the moment of the accident, generally to its fullest extent, whatever atti- tude it assumes afterward, and the first thing to do is to restore it to this position, so as to bring the head of the bone opposite the rent through which it escaped. The knee must be bent to relax the hamstrings and the sciatic nerve ; and then the hip, until the front of the thigh is pressed against the abdomen. The ilio-femoral band is relaxed by this, the femur is brought into its proper line, the inversion ceases, because now there is no tension on the external limb of the Y- ligament, and the head of the bone is lifted out from between the rotator muscles until it rests under the margin of the acetabulum. Sometimes a little adduction or rotation inward helps to push the tendons aside. If now the pelvis is held down by pressure upon the ilia, and the knee is lifted vertically upward, in many cases the head of the bone slips at once over the rim into its socket. The amount of force required is very slight, especially if the patient is under an anaesthetic. DISLOCATIONS OF THE HIP JOINT. 533 If this does not answer, there must Ijc some mechanical reason for it. The neck of the bone may be entangled in the obturator internus tendon ; or the sci- atic nerve, or the tendon of the obturator externus, may be twisted around it ; the rent in the capsule may be more on one side ; or a portion of muscle or of the capsule may constantly get in the way and partly fill the cavity. \Vhatever it is, an attempt must be made by rotating the limb from side to side, and by abducting and adducting it, to stretch the o|)ening and disengage the head. The next jjroceeding, if the heatl of the bone cannot be lifted directly into its socket, is to try and tilt it in l)y turning the femur into a lever. The base of the neck is fixed by the Y-shaped ligament, and forms the fulcrum ; the limb is the long arm, and the head the short one, so that the power is enormous. The thigh is flexed as before, but slightly abducted ; this brings the head a litde toward the inner side of the cup, where the rim is lowest, and helps also to stretch the open- ing in the capsule. Then, if it is rotated outward and extended, the ilio-femoral band is tightened up and the head is forced to travel round the cavity until it reaches the lowest part of the rim, over which it rolls at once. During the first part of the manipulation the thigh should be forced down upon the abdomen, as the object is to raise the head from among the muscles ; but when the limb is being rotated, as a preliminary to extension, it. should be held at right angles to the body ; if it is more flexed than this, or if it is much abducted, the head of the bone, when the limb descends, slips to the inner side of the acetabulum, instead of rising over the edge, and the dislocation becomes thyroid. These two methods have practically superseded extension ; even for old dis- locations it is never used now, unless they have failed. Sometimes the ilio-femoral ligament is partly torn, so that the fulcrum is not held firm, or a fold of the cap- sule gets in the way, or the head is so surrounded and button-holed that it cannot be released, and then extension is the only thing left ; but, as a rule, in these circumstances the parts are so torn (to some extent by the manipulation) that it can be done by the hands at once, or a jack-towel and pulleys are not required. Thyroid Dislocation. Thyroid dislocation (dislocation downward or downward and forward into the obturator foramen) is much more rare. It can only be caused by abduction, combined with slight eversion, and of the four regular dislocations is the one that undergoes the least degree of consecutive displacement Jumping from a height with the feet wide apart, or the sudden movement of a carriage while a person is in the act of mounting, may be regarded as typical. The head of the bone lies upon the thyroid foramen, in the substance of the obturator externus, below and a little to the inner side of the acetabulum ; the rent in the capsule runs through the thin- nest part, but the pubo-femoral band may be torn as well ; the ligamentum teres is ruptured, the pectineus and the adductors very much stretched and generally torn, and the anterior part of the capsule and the ilio-psoas as tense as they can be. The position is unmistakable ; the patient lies with the body bent toward the injured side, and the pelvis tilted in such a way that the limb appears much longer than its fellow ; the knee is bent, the foot everted, and the thigh abducted and flexed. The degree to which this takes place depends upon the ilio-femoral band and the psoas ; the further the head is from the acetabulum, the greater the amount of distortion. Actual measurement shows that the limb is really shortened. The trochanter is sunken inward, the gluteal fold is lowered, the abductors stand out rigidly on the inner side of the thigh, and the head of the bone can generally be felt. Voluntary movement is out of the question ; passive flexion is fairly easy ; but so long as it is extended the limb cannot be inverted or brought to the middle line. If the dislocation is unreduced, the limb gradually becomes straighter and may acquire a considerable range of movement, but not so much as in the case of the sciatic. 534 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Reduction may be effected either by vertical extension or leverage, as in the dorsal form, only adduction and inversion must be used instead of abduction and eversion. The patient should be placed under an anaesthetic, the limb flexed right on to the alDdomen, bringing it gradually into its normal line, and then an attempt made to lift it vertically upward into its socket. If this does not succeed, in spite of lateral movements to release the head and stretch the capsule out, rotation must be tried. The limb is flexed to a right angle, adducted, rotated inward and extended. The mechanism is the same as in the dorsal form, and if the degree of flexion or adduction is too great, the head of the bone sli]js round the lower margin of the acetabulum in a similar way (but in the opposite direc- tion), instead of rising over the edge. Pubic Dislocation. Dislocation on to the body of the pubes, not merely on to the front of the bone, is still more rare. It can only occur when the limb is extended and ab- ducted, and it may be caused either indirectly by this movement being carried too far, or directly by violence applied to the back of the hip. The head of the bone rests upon the point of junction of the ilium with the pubes, outside the femoral vessels, and under Poupart's ligament. The rent in the capsule is a little higher up than usual ; the round ligament, the pectineus, and the abductors are always more or less torn, and sometimes Poupart's ligament ; and the short external rotators, especially the obturator internus, are forcibly stretched and hold the limb down. The limb is everted, abducted, and nearly straight. The trochanter is. more sunken than in the thyroid form, the head of the bone can be felt distinctly in its new situation, and in most cases can be seen. There is shortening, generally to the extent of an inch. Flexion, without drawing the head of the bone down or abducting the limb first, is only allowed to a slight extent ; abduction is fairly free. The mechanism of reduction is the same as for thyroid dislocation ; only, because of the position of the head of the bone, the limb must be abducted while it is being flexed so as to bring it round the acetabulum. Vertical extension may fail, owing to the capsule being torn more on the inner side than below ; but rota- tion is nearly sure to succeed ; if it does not, extension, with direct pre.ssure upon the head and the upper part of the thigh, must be tried. Anomalous Dislocations. Besides these dislocations there are others, either intermediate in their char- acter or exaggerated, owing to the amount of laceration and to the distance that the head of the bone has been carried. Generally speaking, they may be grouped round the regular forms and classified, either by the attitude of the limb or the method of reduction. The head of the bone, for example, may rest upon the ischium immediately below the acetabulum, opposite the point from which it has escaped, without passing either forward or backward. Secondary displacement has been in some way prevented, and the limb is inverted and strongly flexed. (This maybe compared with the luxatio erecta of the humerus.) From this point the head of the bone may be carried toward the tuberosity, or on to some part of the margin of the great sacro-sciatic foramen, until it is fixed in one of the ordi- nary positions. In other cases the head of the bone is forced so far inward that it passes from the obturator foramen into the perineum, and the abduction, flexion, and eversion become extreme. I have seen, in a case of this kind, the thigh laid completely on its outer side and flexed to less than a right angle. Most of these irregular forms, however, belong to the pubic group ; the head of the bone may lie just internal to the anterior inferior spine, or it may be carried DISLOCATIONS OF THE HIP JOINT. 535 beyond it or even above it, until it rests in the notch between the two spines (the supraspinous variety). The attitude of the limb and the other symptoms are the same as in the pubic form, only much exaggerated, and reduction must be carried out in the same way, by abduction and flexion first, and then inversion, adduction, and extension. After-treatment. — It occasionally happens that, after reduction has been accomplished, the head of the bone slips out again as soon as the effects of the anaesthetic pass off. In old dislocations this may be due to the cotyloid cavity being partly filled up; in recent ones it is the result either of some portion of the capsule having fallen into the acetalnilum in front of the head of the bone, or to part of the rim being dragged away. In either case reduction must be effected again, and a long splint and weight extension applied before consciousness returns, in order to ensure the position being maintained. The limb should be kept quiet in such a case for at least four weeks. Under ordinary circumstances, where there is no tendency to redisplace- ment, it is sufficient to confine the limb between sand-bags, and passive motion may be commenced at the end of a week. Old Dislocations. If not of more than two months' standing, there is a fair prospect of success ; in one ca.se reduction was .accomplished at the end of a twelvemonth, but this Fig. 232.— Showing the Fashion of Applying Pulleys. (N B —The leg and thigh should be bandaged.) must be regarded as quite exceptional. Manipulation under an anesthetic affords a much better chance than extension, even with the aid of pulleys (Fig. 232). If the head of the bone is not reduced, the adhesions are broken down, the range of movement is much improved, and, especially in the sciatic form, the limb regains a great deal of its strength and activity, a new cavity gradually being developed for the head. Care, however, must be taken not to fracture the femur, which is very often atrophied from disuse, or to injure the sciatic nerve, which sometimes is wound around the neck of the bone. Both of these accidents have been met with in recent dislocations, but they are much more likely to happen in old ones. Excision of the head of the bone has been performed in several cases with a very satisfactory result, though the operation is a serious one. If the head is fairly movable, but the position of the limb faulty, subtrochanteric osteotomy may be tried instead. DISLOCATION OF THE PATELLA. This maybe dislocated to either side, or it may be twisted on its vertical axis so far that the articular and cutaneous surfaces are almost reversed. Displacement upward can only be regarded as a part of rupture of the ligamentum patellae. 536 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Outward dislocation is the most common, esi)ecially if there is any genu val- gum. It can only occur in extension; the patella then is so loosely held that it can be pushed from side to side, and can be dislocated either by muscular action, or by a sudden blow from its inner border, tilting it out over the external condyle ; in flexion it sinks in between the condyles and is held strapped down by the tension of the muscles. If the dislocation is complete, the articular surface rests against the outer. side of the external condyle ; if it is only jjartial, the bone is not carried so far and the margin looks forward. Laceration of the capsule is very general, but ai)ijarently not absolutely essential. Dislocation inward and rotation are both very rare; the latter has Ijeen produced by a violent l)low upon the inner side of the bone when the knee was bent to an acute angle. The deformity can usually be recognized at once ; the limb is extended or very slightly flexed ; the knee is flattened in front and broader than natural ; a hollow can be felt between the condyles; and the shajjc of the patella, with the ligamentum patellae and the tendon of the ciuadricei)s, both of which are very tense, can be seen standing out beneath the skin. Movement is very limited. Treatment. — Generally, if the hip is flexed, the knee extended, and direct pressure made ui)on the prominent border of the bone, it slii)s back into its posi- tion at once ; or, if this fails, the hip and the knee may be bent (under an anjes- thetic) and pre.ssure and extension tried together ; sometimes rotation of the leg has been found of assistance. But, while one or other of these nearly always suc- ceeds at once, instances are occasionally met with in which reduction is impossible in spite of every attempt. Nor is the cause clear. It may be due to the patella catching in the intercondyloid notch, or to its being in some way entangled in the capsule ; but, whatever it is, in a i^^ cases it has resisted everything, and the dis- location has remained unreduced in spite of section of the ligaments and the tendon of the quadriceps. In such circumstances it would be wiser to open the joint freely, with every antise])tic precaution, and divide the structures that retain the bone, than to trust to force and subcutaneous section, which on several occa- sions have ended in suppuration. As in all injuries involving the knee, the joint becomes filled with fluid even before the dislocation is reduced ; and partly for this reason, the capsule becoming stretched and softened by the effusion, partly because the dislocation is due in great measure to the shape of the bones, recurrence is very common. The limb must be placed upon a splint, in a position of moderate extension, carefully packed in cotton-wool, and firmly bandaged until the effusion is absori)ed. Afterward an apparatus must be worn to prevent any lateral movement of the patella. The simplest, perhaps, is a piece of chamois leather spread with lead plaster strained round the limb ; it should be large enough, when the knee is laid upon it, to over- lap well in front, and should extend a few inches above and below the joint. This answers better than ordinary strapping, unless it is applied exceedingly well. If, however, there is much laceration, or if the bone has been displaced more than once, some apparatus similar to that used to retain a displaced fibro-cartilage is advisable. In young people of rapid growth, when the bony prominences are poorly marked and the ligaments yielding, the i)atellacan be moved freely from one con- dyle to the other, and sometimes it gets caught upon the outer one. The capsule, however, is not torn ; the bone is easily replaced ; and there is a very slight amount of effusion afterward. DISLOCATIONS OF THE KNEE. The leg may be dislocated backward, forward, or to either side ; and a few cases are recorded in which the tibia has l)een displaced so far by rotation that the inner tuberosity was directed forward and the tubercle outward. DISLOCATION OF THE KNEE. 537 Lateral dislocations are the most common and are always incomplete, the tibia never being displaced entirely from the femur. This may be caused by a fall with the leg bent under the body, by sudden forcible twisting, or by extreme violence applied to one side of the limb ; and are always attended by very serious injury to the lateral and crucial ligaments and to the tendinous expansion of the vasti. The deformity is sufticiently conspicuous to be recognized at once, the internal condyle of the femur resting on the outer tuberosity of the tibia (or vice versa) and forming a distinct and easily recognized projection on the side. Reduction, owing to the extentof the injury, is easily accomplished by flexion and extension combined with lateral pressure. Afterward the knee must be placed upon a splint, raised, very carefully bandaged and covered with ice. Passive motion may be commenced in a fortnight or three weeks, but through a very small angle, so as not to throw any strain upon the ruptured parts ; and the patient should not be allowed to bend the joint himself for at least a month more. Afterward an apparatus must be worn restricting the movement of the joint, for fear of any sudden twist displacing the bones again. Aiitero-posterior Dislocation. — Dislocation of the knee forward may take place either by over-extension or by direct violence : dislocation backward, which is much more rare, only by the latter. The luxation may be complete, the tibia being carried altogether in front or behind the femur, and forced some distance up the thigh ; or more often incomplete, and the bones still to a great extent in contact. The ligaments are always torn, or wrench away portions of the bones ; the neigh- .boring tendons and muscles, such as the hamstrings and the gastrocnemius, are lacerated or stretched ; and the vessels either compressed, so that the circulation is stopped or actually torn across. The shape of the bones is easily made out, and the nature of the injury can hardly be mistaken. In the forward dislocation the limb is usually extended, and if it is complete, much shortened. The patella is freely movable ; sometimes the joint is fixed ; sometimes, owing to the extent of the laceration and the position of the bones, there is a wide range of passive move- ment. In the backward form the displacement is more variable ; generally the limb is in a position of extreme extension, but it may be completely flexed. Reduction, especially under an anaesthetic, is easy, and maybe accomplished either by traction in the axis of the limb, or by flexion and extension, according to the position of the bones. The condition of the vessels below should be ascertained at once ; even if the artery has only been compressed or stretched, a thrombus may form, and gangrene set in ; or later an aneurysm may develop ; if it has given way, immediate amputation should be performed. Usually this is required in com- pound dislocations ; only, perhaps, sometimes, when the skin is not so much torn, and the vessels are intact, and the patient is young and healthy, an attempt may be made to save the limb, either by washing the joint out and draining it thor- oughly, or by performing a primary excision. Dislocation of the Semilunar Cartilages. In this accident, which was first described by Hey under the name oi internal derangement of the knee joint, one of the semilunar cartilages is displaced and caught between the bones, so that the joint is locked and, so far as the patient is concerned, is entirely out of control. The external cartilage glides backward and forward freely over the upper surface of the tuberosity ; the internal is more fixed and follows the movements of the tibia ; but the latter appears to be the more frequently displaced. The nature of the injury probably differs a good deal. Sometimes the margin of the cartilage is detached, and the disc is rolled inward toward the centre of the joint ; the ex- ternal has been found by Godlee rolled up in the inter-condyloid notch. More often one of the ends is torn away from the bone, and the disc is squeezed out under the skin, either in front or to one side. The anterior part of the internal is 35 538 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the part that gives way the most freriuently ; and it has been found, as the result of football, so completely detached that it had to be removed as a foreign body. In many instances it is probable that the actual laceration is insignificant, the fibrous tissue by which they are attached being stretched, rather than torn, so that in certain positions of the joint the cartilages can be pushed backward or forward until they are caught between the bones. Such an accident may occur even in a healthy joint ; but it is much more likely to happen when the ligaments are already relaxed by chronic synovitis or rheumatoid arthritis; and, for this reason, recurrence of the displacement, when once it has occurred, is the rule rather than the exception. The joint always becomes filled with fluid after this accident ; the ends of the cartilage, if it is torn, are forced apart from each other, so that repair can only be carried out imperfectly, and all the ligaments are stretched and softened. For the same reason internal derangement is not uncom- mon in young, rapidly-growing subjects, in whom, owing to the weakness of the muscles and the poor development of the articular ends, the bones can often be made to assume abnormal jwsitions; but it may happen to the strongest and most athletic. The cause is always a trivial one ; crossing the legs, for example, while .seated ; catching the inner side of the great toe in walking; twisting round to take a ball at lawn-tennis ; or even suddenly turning over in bed. Nearly always it is caused by rotation while the leg is semi-flexed ; in eversion the internal one suffers ; in inversion, the external ; it may occur, how-ever, at the end of extension, if there is no weight on the limb to hold the bones together. Thus it is common at football when a kick is missed ; the posterior end of the internal cartilage is carried for- ward until it slips under the condyle ; if it slips back again, there is merely a sharp stab of pain, often followed by a slight amount of effusion ; but, if it is caught, there is genuine displacement and the limb becomes locked. Knott's and some of Hey's cases were probably similar. In Lucas's the external was displaced, the posterior end being carried forward in the same way until it was caught under the condyle ; there was a sudden jerk when the joint was flexed ; a projection made its appearance on the outer side of the patella and the limb became inverted ; in ex- tension this was reversed, the limb becoming straight and the projection vanish- ing. Several similar instances have been recorded by Marsh. It is not uncommon to find, after repeated accidents of this kind, that there is a certain amount of permanent thickening, generally on the inner side of the limb; and in one or two cases the disc appears to have become hypertrophied, from the effect of constant irritation. According to Kocher it may become con- verted into a mass of granulation tissue, and, unless it is excised, lead to suppura- tion in the joint. Symptoms. — In all the cases there is a strong family likeness, though there are many small points of difference, depending in all probability on the character and the direction of the disi)lacement. There is a sudden attack of the most in- tense pain ; the patient falls down almost in a fainting condition with the knee slightly bent ; and in severe ca.ses he is quite unable to stand. Voluntary move- ment is out of the question, but passive motion is free and almost painless ; if the patient sits on a table he can swing the leg backward and forward, but not to its full extent in either direction. In a few minutes the joint becomes filled with fluid ; by degrees the severity of the pain abates, and very slowly power returns until the patient can limp about ; but so long as the displacement persists, full flexion and extension are imjwssible. Sometimes a projection can be seen on the outer or the inner side of the limlj, corres])onding to one of the cartilages ; occa- sionally the skin is puckered in when the displacement is toward the interior; in most instances the only change visible is a slight relaxation of the ligamentum patellae when compared with the opposite side. Synovitis is invariable and as a rule very rapid. Slighter cases, in which the cartilage probably slips back of itself, are not uncommon. The patient generally complains of the joints locking or catching, DISLOCATION OF THE KNEE. 539 of a moment's sudden pain, and then, after a sensation of something slipping away, of l)eing able to move again, but with a certain degree of uneasiness. Diagnosis. — The history and symptoms closely resemble those of loose car- tilages in a joint, but the |)resence of a projection or a depression on a level with the head of the tibia, and the continual locking of the joint, generally make the diagnosis certain. If, however, before the case is seen the synovial cavity has alread)' become distended, the difficulty may be very considerable, and in all cases in which tlie history or symptoms suggest either of these conditions, it is advisable to make the most thorough examination, not only at once, but afterward when the effusion has in great measure subsided. Much discredit has arisen on more than one occasion, from the fact that this displacement has never been re- cognized. Treatment. — The first thing is to release the cartilage. In the slighter cases it often slips back of itself before the patient is seen, or is reduced by some almost involuntary action. Knott, for example, relates how, on the first occasion on which it happened to himself, he instinctively applied his hands upon each side of the joint and j^rcssed as firmly as he could to relieve the pain ; suddenly he felt something slip and the limb could be moved again at once. Where the displace- ment has repeatedly occurred this is frequently the case and the patients learn either to do it for themselves or to direct others in the manipulation required. An anaesthetic is not absolutely needed, but in most cases it is advisable; the manipulation is so much more easy, and the condition of the joint can be exam- ined so much more thoroughly. Hey recommended that the patient should be seated on a high chair facing the surgeon, who should grasp the limb firmly, extend it, until it was as straight as circumstances would allow, and then rapidly flex it. Modern surgeons have reversed this proceeding with advantage, as preliminary extension is much more painful than flexion, and in the second step rapid flexion is somewhat difficult to carry out. Whichever plan is adopted, firm pressure must be made with the thumb over any projection that can be felt. If this fails the limb may be flexed to its full extent, rotated inward or outward as far as it can be, and then rapidly ex- tended, or abduction and adduction may be tried in the same way. Sometimes it suddenly slips into position almost of itself; in a few cases it has never been reduced at all, although repeated attempts have been made, not only at -first, but afterward, when the effusion into the joint had been absorbed. In such cases, or if the displacement takes place so frequently that the joint is practically useless, and is in serious danger of becoming disorganized from repeated attacks of syno- vitis, there is no doubt the cartilage should either be removed, or be reduced and stitched into position with catgut. As soon as reduction has been accomplished, means must be taken to get rid of the effusion. Recurrence cannot always be prevented, especially if one end of the cartilage has been torn off the bone ; but there is no doubt the tendency to it is greatly increased by the amount and persistence of the effusion. The limb must be carefully packed in cotton-wool and bandaged as firmly as possible ; and if the pain and tension are very severe, it should be placed upon a splint and the patient kept in the recumbent position for a few days. Passive motion may be commenced after forty-eight hours, so that there may be no after-stiffness or wasting of the muscles ; but the extremes of flexion and extension should be avoided, and care should be taken to keep the foot perfectly straight. After the effusion has been absorbed an apparatus must be worn for some months, especially when indulging in any exertion which, like lawn-tennis, has a particular tendency to produce this displacement. If it has happened only once, an elastic knee-cap, strengthened and padded opposite the cartilage, whichever it is, may suffice, but this must only be worn during exercise, never at night ; and the knee, every time it is removed, must be thoroughly rubbed and shampooed, or more harm than good may result. In older cases this is not enough, and a metal apparatus must be fitted on. A very good arrangement consists of two 540 DISEASES AND INJURIES OF SPECIAL STRUCTURES. \vc'll-])a(l(led metal plates, accurately fitted roiiml the knee-cap, one on either side, and held together above and below by short strajjs. These plates are connected together by a steel spring passing horizontally across l)ehind the joint, so that when the splint is in position they press firmly upon the unprotected })ortion of the capsule where the displacement is most likely to take place. If this does not answer, or if, as not unfrequently happens when the internal lateral ligament of the knee joint has been injured, rotation of the tibia is a marked feature in the displacement, the best kind of apparatus is formed on the principle of two lateral bars, jointed opposite the knee and connected together above and below by a circle round the limb, formed partly of metal, ])artly of leather. An additional strap across the joint above and below the i)atella is of service. This is heavier and more cumbersome, but much more efficient than the former in checking irregular movements of rotation. In any case the patient should learn to keep the foot as constantly as possible turned in the direction of the displacement — inverted, that is to say, when the internal cartilage is affected, and vice versd. DISLOCATION OF THE ANKLE. The foot may be detached from the tibia and fibula, and driven either back- ward, forward, inward, or outward ; but the displacement is rarely complete. A few cases are recorded in which the bones of the leg have been separated from each other, and the astragalus driven up between them. Lateral Dislocation. This is caused by the foot being forcibly twisted on an antero-posterior axis, and it can scarcely take place without fracture of one or both malleoli. Dislocation outward, with frac- ture of the fibula, is the more com- mon, and is known as Pott's fracture (Fig. 233) : the foot is forcibly everted, the strain falls upon the in- ternal lateral ligament or the in- ternal malleolus ; one or other of them gives way, the fibula breaks inward toward the tibia a short distance above the joint, and, if the force continues, the astragalus is twisted round in its socket, carrying with it the bones of the foot. When the violence is very great, there is, in addition, a vertical fracture through F.c;. 233.-Potfs Fracture. the tibia, a portion of the bOHC being dragged away by the interosse- ous ligament. If the separation is only slight, the deformity is not serious, though, unless care is taken to prevent it, the socket in which the astragalus is fixed may be widened, and the security of the joint permanently impaired; but, if it is ex- tensive, the whole of the foot and the external malleolus may be carried upward on to the outer side of the leg, until the articular surfaces are completely dis- placed. This, which is known as Dupuytren's fracture, is very rare but very serious. It sometimes happens, when both malleoli have given way, that the astra- galus, with the foot, is carried boldly outward or inward on the leg without any twisting. Dislocation inward is not so often met with. It can only be produced by extreme inversion ; the internal malleolus or the portion of the tibia carrying it DISLOCATION OF THE ANKLE. 541 is prized off by the rotation of the foot, and either the external lateral ligament is torn, or, more commonly, tlie fibula is broken outward, from the traction upon its inferior extremity. Sometimes the astragalus itself is crushed as well. Fig. 234. — Dislocation of Foot, Backward. Antero-posterior Dislocation. In spite of the width of the astragalus in front, and the strength of the lateral ligaments, the foot is occasionally displaced backward ; displacement forward is very rare. In either case the lateral ligaments give way ; or the fibula, or the internal malleolus, is broken off instead, and carried forward or backward with the bones of the foot. Dislocation backward may be either complete or incomplete (Fig. 234). It is caused by forced plantar flexion, the point of the foot being depressed until either the bones or the anterior part of the lateral ligaments give way ; then if any force is applied to the leg from behind (such, for example, as the im- petus of the body in falling from a carriage in motion) the tibia and fibula are driven over the front of the astragalus. As soon as the force is spent, the foot is straightened by the action of the muscles. Forward displacement may be produced by ex- treme dorsal flexion : if, for example, while the foot is fixed and the knee and ankle are completely bent, a violent blow is delivered on the front of the thigh, driving the bones of the leg backward ; but only six cases are on record. In dislocation nptuard the fibula is wrenched off from the tibia, the inter- osseous ligament either giving way or tearing off a portion of the bone ; the lateral ligaments are torn, and the astragalus is forced vertically upward into the inter-space. This can only arise from an extreme degree of violence applied to the sole of the foot, the bones first being separated and then the astragalus driven upward by a continuance of the force. In one case it was bilateral, caused by jumping down from some great height. Diagnosis. — Immediately after the accident, there is rarely any difficulty, owing to the way in which the bony prominences stand out beneath the skin ; but the outlines soon become fainter as the depressions are filled up by the extrava- sation and swelling, and, in a little while, nothing can be seen but general dis- tortion. The position of the foot with regard to the rest of the limb, whether it is inverted or everted, shortened or lengthened, always gives a clue to the nature of the injury ; and then deep pressure may be used to determine the particular character of the displacement and the amount of damage done to the bones and ligaments, every bony projection being compared, one by one, with the corres- ponding ones in the opposite foot. Finally, passive motion must be tried, not only to assist in identifying the bones by the way in which they move, but to ascertain the presence of abnormal mobility (lateral flexion, for example), or of crepitus. Treatment. — The method of reduction is essentially the same in them all. The patient must be placed under an anaesthetic, to relax the muscles ; the knee must be flexed, and then the foot must be slowly but firmly brought round to its right position. If the displacement is lateral, this is generally easy ; when it is backward, it may usually be managed by extreme plantar flexion, drawing the foot downward, away from the leg, at the same time, and rocking it from side to side so as to disentangle it ; but in dislocation of the foot forward the difficulty is very great. Dorsal flexion appears to offer the best prospect, and the tendo- 542 DISEASES AND INJURIES OF SPECIAL STRUCTURES, Achillis or any other that gets in the way between the bones, may be divided ; but even then the attempt has not always been successful. Upward dislocation, the diagnosis of which is easy, from the enormous breadth of the lower part of the leg and the approximation of the sole of the malleoli, can only be reduced by extension on the foot. If the attempt fails, the liml) ultimately becomes very useful, although the joint itself always remains stiff. In all dislocations of the ankle, some form of apparatus is re(]uired after re- duction has been accomplished, to prevent the surfaces being displaced again. In the slighter cases, in which the tendency to return is not very marked, and the injury is seen a short time after the accident, so that the extravasation is not ex- treme or the skin in danger of giving way, a fixed apparatus may be apjjlied at once, only it must be formed in two parts, laced, or fastened together in some other way; and it must be thickly padded with cotton-wool opijosite the seat of injury. Afterward the limb must be raised for twenty-four hours, and the knee joint kept flexed until the tendency to spasmodic contraction on the part of the muscles has disappeared. Passive motion and ma.ssage may be commenced at the end of ten days, but the limb in the meantime must be incased in a starch bandage, and the patient must not be allowed to rest any weight upon it for at least six weeks. The greatest care is necessary during the whole course of treat- ment to prevent any drooping of the toes or version of the foot. If either of these is present, the limb becomes almost useless. When the injury is more severe, and in all cases of antero-posterior displace- ment, it is better to make use feither of back and side splints, swinging the leg from a cradle (as already described in speaking of fractures), or of a single side splint with a foot and sole piece, the limb resting upon its outer surface. In either case the knee must be kept well bent, the foot must be exactly at right angles to the leg, and the pads must be so arranged on the splints as to correct as far as possible any tendency to eversion or inversion. If a side splint is used, it is of great advantage to pack the ankle well with several layers of cotton-wool and bandage it firmly over all. Very often, unless this is done, it is difficult to be certain whether the displacement is rectified or not, owing to the amount and the persistence of the oedema and extravasation. The limb may be placed in a fixed apparatus at the end of a fortnight, but this must be so arranged that it can be removed for the purpose of carrying out j^assive exercise every two or three days. If this is neglected, the joint is liable to become exceedingly stiff and painful. Covipound {opeii) dislocation of the anklc-Joinf is a most serious injury, and, especially if the patient is broken down in health, may require immediate amputation. Age is not of so much importance in this respect as the condition of the kidneys, though of course the risk increases with advancing years. Much depends upon the way in which the accident happens. If it is the result of in- direct violence, so that the skin on one side of the joint is torn, and the interior exposed, without the bones being crushed or the soft parts bruised, the limb may be saved, though it can only be done by the most perfect drainage. Even if suppuration and ankylosis occur, it may prove exceedingly usefiil, the mid-tarsal joint replacing the one that is lost. The bleeding must be stopped ; detached fragments of bone or cartilage removed ; the wound thoroughly wa.shed out (it is a very good plan to immerse the part bodily in a corrosive sublimate bath for some hours) and so arranged that it can drain perfectly, counter-open- ings being made, if need be, to ensure this. If the wound is very small, it may be sealed and closed at once ; as a rule, it is better to leave it open, so that the cavity can be constantly washed out and there may be no accumulation in the interior. Then the ankle must be covered with a thoroughly absorbent dressing and fixed upon a splint, interrupted so that the wound may be exposed without disturbing the bandages. Parafiin is very usefiil for this, as it is waterproof. In man V cases the wound heals up at once; sometimes there is a certain DISLOCATION OF THE ASTRAGALUS. 543 amount of dischari^'c ; granulations spring \\\) round the orifice, the synovial lining becomes unduly thickened and vascular, and the joint is stiffened from the forma- tion of extra-articular adhesions ; but the cartilages remain intact and the cavity is preserved. If, however, the drainage is not perfect, or if the discharge is allowed to decompose inside, acute suppurative arthritis is sure to set in ; the car- tilages necrose ; the ligaments are destroyed ; the surface of the bones becomes carious ; and abscesses form in the loose cellular tissue around. Even then, if free exit is provided, and the cavity is kept constantly clear, granulations may spring up and fill the cavity, until the oi)posite surfaces fuse together ; but secondary amputation may at any moment become necessary. The patient's health and strength may fail from the intensity of the fever and the profuse supi)uration ; or the inflammation may spread along the tendon-sheaths or the planes of cellular tissue ; or the bones may become extensively necrosed ; and finally, even when ankylosis has set in, it may be required, owing to the useless condition of the limb. When the injury is more severe, the same general plan of treatment may be followed ; but if it is the result of direct violence the prospect of success is very small. The tendons may be sutured ; the ends of the bones resected (removal of one malleolus has some advantage, as it gives more room for drainage), and even the posterior tibial has been divided and tied, with a good result ; but if the skin is badly bruised and strii)ped off the adjacent tissues, or if it is torn a considerable way round the limb, recovery with a useful foot is almost hopeless. Dislocation of the Astragalus. This must be distinguished, on the one hand, from dislocation at the ankle- joint, in which the whole foot is detached from the leg; and, on the other, from the subastragalar form, in which the rest of the tarsus is separated from the astrag- alus. In this injury the astragalus is dislocated both from the foot and from the leg ; and is thrown out from its socket, sometimes so thoroughly that it has been shot out of the foot altogether. The displacement may be either forward or backward, the bone generally being forced to one side or the other at the same time. True lateral displace- ment without fracture of the malleoli is scarcely possible ; most of the instances, in all probability, having been really dislocations forward first. In a few very rare cases the astragalus has undergone a process of version without leaving its bed ; the bone has been twisted round in its socket by some violent wrench, so that the lateral surfaces look upward or downward, or its head faces one of the malleoli. Dislocation forward is produced by over-extension ; the foot is first detached from the astragalus ; the head of this bone is twisted out from the scaphoid ; and then, if the force continues, the lateral ligaments give way, and it is shot out from underneath the tibia. As soon as the force is spent the muscles pull the foot into position again. The dislocation may be either complete or incomplete; the as- tragalus, that is to say, may be forced altogether out of its socket, until it rests either on the cuboid, or on the scaphoid and cuneiform bones, according to the side, while the tibia rests upon the os calcis ; or it may be merely detached from its connection, and lie still partly under the bones of the leg (Fig. 235). In either case the neck of the bone is not unfrequently broken. The prominence caused by the peculiar shape of the bone can be recognized at once ; the foot is turned inward or outward, in the opposite direction to the displacement ; the sole, especially in the complete form, is brought nearer to the leg ; one malleolus stands out while the other is deeply sunken ; and all move- ment is abolished. Dislocation backward is much more rare, and, owing to the space in front of the tendo-Achillis,-is not so conspicuous. It can only be produced by extreme 544 DISEASES AND INJURIES OF SPECIAL STRUCTURES. flexion ; in one instance, for example, the foot was fixed, the heel driven down into a depression, and the leg crushed down upon the foot. In most it is incom- plete, and generally it is rather to one side, but it may be nearly straight. The foot is neither inverted nor everted : in front there is a dei)ression over which the edge of the tibia can be felt, and the great toe is strongly flexed, owing to the tension on the tendon of the flexor longus pollicis ; behind, the tendo-Achillis is forced back, a hardness can be felt in front of it, and in some cases, where the displacement is lateral, the shape of the bone can be made out to one side or the other. Treatment. — In the incomplete form of dislocation forward (which is the most common) reduction may be accomplished by placing the patient under an anaesthetic, bending the knee, and making traction on the foot away from the leg while in the position of plantar flexion, direct pressure meantime being exerted on the anterior surface of the bone. If this fails the tendo-Achillis may be divided, and any other bands that are plainly in the way ; but, especially if the dislocation is complete, the attempt is very likely to fail. The space between the \ \* V 9ii;o ii^ic? KiG. 235. — Subastragalar Dislocation, with Partial Luxation of Astragalus from Leg. bones is so much reduced ; the astragalus it.self is often twisted ; there is very little hold ; and sometimes the bone is so caught and entangled that it cannot be released. If it does fail, the astragalus should be left in situ ; the foot, especially when the dislocation is backward, regains a wonderful amount of power. Subsequently, if the skin over it sloughs, or if it is seriously in the way, it may be excised. The operation should not be performed at once, as the parts are so badly bruised that suppuration would almost certainly occur. In compound dislocations, if the skin and the vessels are not much injured, the astragalus may be freed from its remaining attachments and excised ; but in many cases amputation is necessary. Subastragalar Dislocation. This is produced in the same way as the former, but by a less degree of force ; the bones of the tarsus only are separated from the astragalus ; this is often partially displaced from under the tibial arch, but is not dislocated from it (Fig. 235). DISEASES OF JOINTS. 545 Dislocations forward, and to one side, have Ijcen descril)ed, hut the displace- ment is nearly always backward, with a certain amount of lateral deviation. It is generally complete so far as the scaphoid is concerned, but it is seldom that the astragalus is entirely detached from the os calcis. The foot is in the position of plantar flexion, everted or inverted, in the direction of the displacement, and carried backward. The head of the astragalus forms a rounded projection on the dorsum under the skin ; one malleolus is prominent, the other buried ; but they still retain their relation to the astragalus ; there is no shortening, as in the former dislocation, antl a certain amount of movement is permitted at the ankle-joint itself. Reduction may be accomplished by drawing the foot forward, while in extreme plantar flexion, and pre.ssing from behind upon the heel. If this does not succeed, any tendon that is clearly in the way may be divided, and a further attempt made ; but not unfrequently it fails, either because the under surface of the astragalus is caught against the groove of the os calcis or the dorsum of the scaphoid, or because the neck of the bone is entangled in the tibial tendons. Dislocations of the other tarsal bones are very rare ; the internal cuneiform and the scaphoid have been displaced separately, and the scaphoid and cuboid, carrying with them the anterior part of the foot, together. There are more instances known in which the metatarsus has been dislocated from the tarsus ; sometimes all the bones together (in one case carrying with them the internal cuneiform) ; more often separately or in groups of two or three. Dislocation of the toes, both at the metatarsal and phalangeal articulations, are not uncommon ; in the case of the great toe the same difficulty occurs as that already described in the thumb, probably for the same reason. SECTION v.— DISEASES OF JOINTS. Inflammation of a joint nearly always begins in the most vascular part, that is to say, either the synovial membrane or the growing portion of the bone, and spreads from there to the rest of the tissues. Osteo-arthritis is an exception ; whether it is acute or chronic, inflammatory or degenerative, it is general from the first, and affects all the structures, though not always to the same extent. Pathology. I. The Synovial Meinbrane and the Capsule. — The immediate effect is the same, whether the inflammation begins in the cavity or extends into it from the bones or other structures near. The vessels dilate ; the amount of blood flowing through the part increases ; lymph is poured out in excess ; the cellular tissue becomes soft and spongy ; the interstitial spaces are enlarged and filled with exudation ; the endothelium is detached ; and the interior loses its polished appearance, and becomes rough, velvety, and granular. In severe cases stasis and extravasations of blood occur as well. This is most marked where the tissues are soft and vascular ; the fibrous capsule at first is scarcely affected ; on the other hand, the folds at the margins of the joint, and the pads of loose cellular tissue and fat which fill up the inequalities between the bones as the position of the limb changes, become more and more swollen, until the whole available space is occupied. The exudation collects in the synovial cavity even more freely than it does 546 DISEASES AND INJURIES OF SPECIAL STRUCTURES. in the tissues. 'Hie amount of fluid is increased ; the peculiar character of the synovia is lost ; and the joint is filled with a turbid and blood-stained fluid, mixed with detached endothelial cells, flakes of fibrin, small blood-clots, and masses of lymph-corpuscles. The ligaments and the capsule, owing to the density of their structure and the scanty distribution of vessels, for a long time show but little change. If, however, the inflammation continues, at length they share the same fate ; hyi)ernemia begins to show itself; the fibres soften; the interfibrillar substance becomes more abundant and more fluid ; the exudation increases in amount ; new vessels grow in from around ; and by degrees the natural structure is replaced by a mass of soft vascular granulation tissue, in which a few traces of the old bundles of fibres can be found here and there, more or less softened. The subsequent changes dei^end ui)on the nature and persistence of the cause. If it cea.ses to act, resolution begins, the hyperemia disappears, the exudation is absorbed, and the fibrous tissue becomes firm again. If it continues, the effect depends whether it is {a) merely a mechanical or chemical irritant or {b) a living organism. {a) In the first case the synovial membrane may continue to pour out an enormous quantity of a clear watery fluid (Jiydrops articu/i) ; or a kind of false membrane may form upon the inner surface {fibrinous synovitis) ; or the secretion may grow thicker and thicker until, without there being any destruction of the cartilages, or suppuration outside the joint, the interior is filled with a fluid appar- ently similar to pus (^purulent synovitis') ; or (especially when it is due to rheuma- tism) organization may be the prominent feature, the synovial lining becoming thickened and opaque, the .soft tissues condensed and hard, and the interior covered with outgrowths, synovial folds, and fringes, sometimes uniform in shape and size, and springing from every part of the sac {papillary synovitis) (Fig. 243), sometimes few in number and very large. {b) In the second, when the irritant is a living organism, the effect depends upon its mode of action. In tubercle, for example, the synovial membrane and the structures around are converted into a mass of granulation tissue, which slowly undergoes caseation and liquefaction ; in syphilis, gummata form ; and when the micrococci of suppuration enter, all the tissues melt away and form pus ; the whole joint is converted into an abscess, and, unless the tension is relieved at once, even the cartilage and the bone perish. • 2. The Bone and Cartilage. — {a) If the irritant is a very intense one, the bone and cartilage, like other dense and almost non-vascular structures, simply undergo necrosis. Sometimes the sequestra are wedge-shaped (Fig. 252), with their base toward the joint and covered with cartilage, as if caused by embolism. A mass of some material (caseous and full of bacilli if it is tubercular ; broken- down blood-clot with micrococci in pyaemia) is carried along by the blood-stream until it is impacted in one of the small arteries at the cancellous end of a long bone ; and the corresponding area of tissue perishes, partly from the blood-supply being cut off, partly from the inflammation caused by the embolus. Sometimes, on the other hand, when the attack starts from the synovial cavity, the surface is the first part to feel the effect, and either the whole of the cartilage is separated from the bone beneath (Fig. 238), or, more frcfjuently, only those parts upon which the pressure falls, where, for example, the patella and the upper surface of the tibia are in contact with the condyles of the femur. When this occurs the articular lamella of the bone usually comes away as well, leaving the cancellous tissue beneath exposed and carious. (b) If the exciting cause is not sufficiently intense to cause necrosis, the bone and cartilage undergo the same changes as the other tissues, only more slowly and with certain peculiarities of their own. In the bone the inflammation begins as rarefying osteitis ; the cancellous tissue becomes softer and more vascular ; the trabecule are absorbed ; and the cancelli filled with inflammatory exudation. What happens next depends upon the excit- DISEASES OE JOINTS. 547 ing cause. Resolution takes place in a large proportion of cases. Of the rest, in some the e.xiitiation simply continues to spread (fungating caries), without undergoing any further change, until it invades the articular lamella (Fig. 251), and either detaches the cartilage from beneath or perforates it ; in others it breaks down into pus, and bursts through everything into the synovial cavity ; and in others again it undergoes organization and leads to sclerosis and condensation (Fig. 242). The effect on the cartilage is very similar. The matrix becomes softened (in osteo-arthritis it splits up into fibrils arranged vertically to the surface (Fig. 239), the plasmatic canals dilate so as to allow the entry of a larger (juantity of lymph, and the corpuscles increase in number. In the centre, where there is pressure, the inflamed cartilage becomes absorbed ; around the margins it becomes vascular, the blood-vessels growing into it from the synovial membrane, so that it is either gradually replaced by granulation tissue, as in tubercu- lar disease, or is heaped up into thickened and hyper- ,,. trophied lips, as in osteo-arthritis. So slowly, however, ^V ' '^ does this take place that, in many forms of joint dis- ■■;f- ease, the cartilage is removed by simple atrophy and ^• fatty degeneration, or by the erosion of granulations -r that spring from the opposite bone or the surrounding j|, V. tissues. In the former case the whole covering of car- p ■. V. tilage is thinned, the surface is smooth and rounded for the most part, but marked here and there with broad flat depressions, where the pressure of the opposing sur- face has caused absorption to progress more rapidly, f and the microscopic character is unaltered except for -■ the presence of fatty molecules in some of the corpus- cles. In the latter it is eaten out all over into little > circular pits, some quite superficial, others so deep that the bone beneath is exposed (Fig. 236). Fig. 236. — Lower End of Femur of an Infant, from a case of suppur- F'rTnTr>r\- ative arthritis, showing the way JLxlULUU\. in w'hich the cartilage is eaten _ _ . r • • • ... out in little circular pits, some Inflammation of joints may be primary, originating penetrating down to the bone, in the synovial lining or some other component part ; or consecutive, due to extension from a focus of disease in other structures near. I. Fri/nary inflammaflon\s duQ either to the persistent action of a mechanical or chemical irritant, or to a living organism. (a) Mechanical Injury. — A single strain merely causes a certain degree of damage, which, if the tissues are healthy, is repaired forthwith. If, however, it is repeated, or if before its effects have died away a second irritation of any description makes its appearance, nutrition is impaired and inflammation follows. Thus a neglected loose cartilage gives rise to synovitis and ultimately arthritis ; and want of rest or undue tension may cause an acute attack after a simple sprain. {h) Chemical Irritants. — In gouty synovitis urate of soda is always present in the fluid and sometimes in the tissues. It may be itself the exciting cause; but, as it is not unusual to find a considerable deposit in joints that have never shown a sign of inflammation, it may, on the other hand, merely be an evidence that the vitality of the tissues is impaired, so that they are unable to withstand the slightest irritation. Of all chemical poisons the most intense is that produced by septic decomposition, breaking out in a foul and ill-drained wound. {/) living Organisms. — These may be pyogenic or specific. In either case the irritated tissues around strive to protect themselves and repair the injury by throwing out masses of lymph ; in the former (acute suppurative arthritis) this melts away as pus, the fully developed tissues perishing, too, so long as the germs are the stronger ; in the latter either caseation and liquefaction set in (tubercle) or absorption and organization (syphilis). 54S DISEASES AND INJURIES OF SPECIAL STRUCTURES. In addition to these there are, as in the case of osteitis, other agencies which, perhaps, should rather be regarded as predis])osing than exciting causes. Of these the most important are the action of cold and damj) and the influence of the cen- tral nervous system. {a) Exposure to cold and damp may be followed either by acute inflammation (the resisting power of the tissues is so depressed that the least irritation is suffi- cient to cause a very severe attack) ; or when, without being intense at any one time, they exercise their influence for years together, by a kind of degeneration or very chronic inflammation, characterized by changes similar to those that occur in old age after prolonged disuse, but more severe. {b) Diseases of the Nervous System. — It is believed by many that certain very rapid forms of degeneration, attended with more or less inflammation, may be caused by diseases of the central nervous system or the peripheral nerves. The pathological changes belong to the same class as those that follow prolonged exposure to cold and damp and other depressing agencies, though they present certain differences in degree ; the clinical symptoms, however, in most cases enable a distinction to be drawn at once. How causes of this kind act is uncertain. It must be admitted, if they are merely predisposing ones, their influence is so strong that an almost imperceptible irritant is able to produce an entirely disproportionate result. All that can be said is that the impairment of nutrition, known as inflammation, may be induced either by continued irritation (mechanical or otherwise) ; or by a depressed condition of vital energy, general or local (exposure to cold and wet, and certain affections of the nervous system) ; or with much greater effect by both together. 2. Consecutive inflammation may extend into the joint from any of the tissues near ; the bones the most frequently, the bursae, tendon sheaths, and cellular tissue less often. So long as the original focus of disease is at some distance, whatever its character may be, whether it is traumatic, tubercular, or suppurative, only the synovial membrane shows any effect, and the inflammation is not specific. A tubercular focus, for example, in the end of one of the long bones merely causes synovitis so long as the bacilli are limited to the bone ; and after evacuation of the caseous focus (if it can be cleared out without involving the joint), the secondary affection disappears of itself; but, if left, the micro-organisms are almost sure to work their way in at last, and then the inflammation of the joint becomes tubercular and specific. The same is true of the pyogenic and probably of all other organisms; simple inflammation precedes the specific and prepares the way for it. Mode of Examination. Examination in a case of suspected joint disease must be systematic and thorough, conducted with a definite object, taking care not to alarm the patient, and putting off to the last everything that might give pain. Children in particular are nervous and often exceedingly afraid of being hurt, and an incautious move- ment at the first may throw all the muscles around the articulation into a state of perfect rigidity, and obscure some of the most valuable signs. Unless it is wished to explore sinuses with a probe, or to ascertain the existence or the extent of fibrous adhesions, an anaesthetic is inadmissible, as many of the most important symj)toms depend upon contraction of the muscles, which, of course, disappears at once. The history, family as well as personal, and any evidence of a constitutional diathesis that may be present, must be carefully noted, and then the patient's own account of the commencement of the disease, the supposed cause, the time of its first appearance, the progress it has made, the kind, severity, and locality of the pain, and whether it is made worse by any particular movement. In the case of the lower extremity, if the inflammation is not acute, the amount of impairment can be fairly well estimated by seeing the patient walk. It is an absolute rule that the two sides of the body must be compared together under the same conditions. DISEASES OE JO/NTS- SYNOVITIS. 549 Inspection and measuremeiit come first. If it is the hip joint, the patient should lie upon a firm couch with the legs parallel and the knees extended ; for the shoulders he should be seated facing the light. The condition of the skin, whether it is reddened or not, the shape of the joint, the j^resence of any enlarge- ment, the wasting of the limb, or of one particular muscle, and any malposition — abduction or adduction, flexion or displacement — can be detected at once. The difficulty is greatest in the case of the hip, as by arching the back and tilting the ])elvis an appearance of parallelism and extension is produced, while the reality is very different. These results can then be verified by measurement. The rod should be used to ascertain any alteration in length, a tape to take the circumfer- ence, and callipers, or the hand, which after a little practice can appreciate the most minute change, to make certain as to the difference in shape. Further information may be obtained by touch, proceeding very carefully at first, as sometimes there is great tenderness on pressure. The enlargement may be hard and firm, like the bone upon which it rests ; or soft and fluctuating if it is due to an effusion of fluid ; or it may have a peculiar elastic resistance, as when the synovial membrane and the tissues around are converted into a pulpy gela- tinous mass ; or it may vary very greatly in consistence, especially if suppuration has occurred and the pus is working its way near the surface. The tejnperature may be ascertained in the same way with great exactness, taking care always to compare identical spots on the two limbs ; the loss of muscular tone can be felt, even when no wasting can be detected with the eye ; and the finger often finds out that some parts of the skin are usually tender or cedematous. Finally, when all this is clear, an attempt maybe made to ascertain the range of movement, whether it is limited in any direction or attended with pain ; if there is any grating, as of two bony surfaces rubbing against each other, or crepitation, as when the cartilages have lost their polish and the synovial fringes are enlarged and hardened ; and whether there is any abnormal mobility and displacement or dislocation of the ends of the bones. Greater care than ever must be taken in investigating this, as the least rough movement, or even sometimes the approach of the hand, scares the muscles into activity, so that the joint is held perfectly rigid. Such tests as jarring the heel or the knee in hip disease, which depend solely upon the pain they cause, should never be employed, unless from other evidence it is practically certain that the joint is not inflamed. INFLAMMATION OF THE SYNOVIAL LINING. I. Simple Acute Synovitis. In most cases synovitis is merely a symptom of arthritis : and whatever the cause, unless the attack subsides at once, the inflammation is never really restricted to the lining membrane. Still, for the sake of convenience, and because the changes, although they are not absolutely confined to that structure, are very much more extensively shown by it than they are by the rest, it is usual to describe some forms at least as if the affection were a distinct one. Causes. — These maybe local or constitutional. Injury, extension from the bone or from some other structure near, or cold and wet, may cause it ; or, on the other hand, it may be merely a sign of some constitutional ailment, such as gout or rheumatism. These varieties, however, as they are specific, must be described by themselves. T\\& pathological appearances oi ?,\vi\vi\q synovitis have been described already. The joint is distended with fluid, the endothelial lining is detached, the interior is roughened and has lost its polish, all the folds are bright red or purple with extrava- sations, and so swollen that they overlap the margins of the cartilages ; and all the loose tissues round are softened, thickened, and filled with lymph. The fluid 550 DISEASES AND INJURIES OF SPECIAL STRUCTURES. varies much in character. In cases of injury in which the hemorrhage is often considerable and the swelling immediate, it may be almost jnire blood {hnnar- throsis) ; more often it is a mixture of synovia, blood, and lymph in varying pro- portions. It many cases it is thin and watery, as if it were mixed \sith serum ; not unfrequently, when the inflammation is severe and the tension high, the number of leucocytes and the amount of fibrin increase to such an extent that it becomes milky and even purulent. This is known as catarrhal suppuration ; it may occur after injury, but it is much more common when, as in urethral rheumatism, the irritant is of greater intensity without being so .severe as to cause suppuration. The distinguishing feature between it and true sujjpurative synovitis is the jjreser- vation of the synovial membrane ; the secretion comes merely from the surface and does not involve the deeper strata. Symptoms. — The /^.f///^« of the limb is characteristic. The affected joint is fixed rigidly by the muscles in the position of greatest ease. The hip is flexed, abducted, and everted, the knee held at an angle of 140°, the ankle slightly extended, the arm hangs by the side, and the elbow and wrist are somewhat bent. As a rule, the patient can flex the limb further still, but complete extension is out of the question. Not only does it diminish the capacity of the sac and increase the pressure upon its inner surface, but, by the traction it exerts upon some parts of the inflamed and tender capsule, it makes the pain tenfold worse. Later, when arthritis sets in, and the bone and cartilage are involved, this position is exagger- ated, and more serious displacement caused by the persistent contraction of the flexor muscles. The shape assumed by the distended synovial sac is equally important. In acute traumatic synovitis it is often filled to its utmost, but the general outline is scarcely altered ; there is little or no oedema of the cellular tissue around, as in some forms of inflammation, and the weaker parts have not had time to yield and stretch, as when the attack is more chronic. In the knee the patella is pushed forward ; the depressions on either side of it, extending down by the ligamentum patellce, are filled ujj, so that the front of the joint is evenly convex ; and the pouch under the quadriceps is distended, though it is not stretched ui)ward as in chronic synovitis. Fluctuation can be distinctly felt on either side of the knee-cap, the hands being placed across the joint, one above and one below, so that the synovial pouch is grasped between the fingers and the thumbs ; and the patella itself can be made to float. This is the most valuable sign of all. If the synovial sac is full there is no difficulty ; the limb must be gently extended and supported so as to relax the quadriceps, and then the bone can be pressed back at once against the articular surface of the femur. More care is required if the distention is only moderate ; the upper ]jart of the sac above the patella must be emptied by scjueezing the fluid out of it into the lower s])ace ; and the pressure must be made directly upon the centre of the bone, not upon its lower end. If the quadriceps is relaxed and the patella drawn down, the lower end rests upon a soft cellular pad of fat, and even when there is only the normal amount of fluid in the joint the sensation of floating is easily produced if pressure is made on the apex. In the ankle the chief swelling is behind, on either side, between the malleoli and the tendo-.'Vchillis, and in front lifting up the extensor tendons. In the elbow it lies on either side of the tendon of the triceps and over the head of the radius. In the hip and shoulder there is, on the other hand, only an ill-defined fullness — most marked in the former beneath Poupart's ligament, in Scarpa's triangle, and shown particularly when the limb is abducted, flexed, and everted ; in the latter, raising the whole of the deltoid. Fain is always present ; sometimes it is very severe and of a tense throbbing character ; often it is worse at night, and always if an attempt is made to use the part or press the two bones together. The skin is freely movable over the deeper structures ; there is no redness or oedema, but it is excessively tender, and at times even the weight of the bed-clothes can scarcely be borne. Usually there are cer- DISEASES OF THE JO/NTS— SYNOVITIS. 551 tain spots, i)eculiar to each joint, much worse than the rest. On the inner side of the knee, for example, there is one on a level with the upper border of the artic- ular surtice of the tibia ; in the hip it lies behind the trochanter, and in the ankle in front of the external malleolus. The flexor muscles are in a state of to7tic contraction, so as to limit the amount of movement as much as possible ; the exten- sors, on the other hand, waste, and, especially in the case of purulent synovitis and that form which ultimately merges into osteoarthritis, distinct flabbiness and loss of tone may be present by the end of a week. When the joint is superficial the temperature of the skin is distinctly raised ; and, if it is large, or if several are involved together, slight chills are not uncommon with a certain degree of fever. In some of the constitutional forms of synovitis it may be very severe. Course and Termination.— The subseciuent course depends partly upon the exciting cause, partly upon the condition of the patient. In simple traumatic synovitis, the extravasated blood, if there is any (juantity, coagulates in the interior ; the hyperjemia and exudation continue to increase for a few hours, or perhaps two or three days, according to the severity of the injury and the success of the treatment, and then, if the part is kept at rest, resolution sets in. The coagula break down and liquefy ; the blood-vessels contract again ; the endothelial lining is restored ; and the synovial fluid, though it remains col- ored for some little ttme, gradually resumes its normal consistence. Occasionally, when there is a high degree of tension, or when the injury is repeated time after time, the inflammation becomes chronic, and either the synovial cavity remains distended or the walls become thick and rigid and covered over with fringes. Very rarely (unless there is an open wound) suppuration follows. The same may be said of that form of acute synovitis which results from ex- posure to cold and wet ; only, as the attack is rarely an isolated one, the tendency for the inflammation to become chronic is much greater. When, on the other hand, it is due to extension from neighboring structures, or when it is a symptom of some constitutional disorder, whether it is tubercle, gonorrhoea, or one of the acute exanthemata, the termination is naturally dependent upon the exciting cause ; it may subside without any further evidence of arthritis ; or it may extend from one part to another until the whole joint is inflamed. Treatment. — If there is an external wound, this must be dealt with first, according to its condition. Either it should be closed at once, sutures being used if required to draw the deeper parts together ; or enlarged, explored, washed out and drained. The chief treatment must be local ; the bowels should be well opened, and the diet light and unstimulating, especially if there is any tendency to gout or rheumatism ; but, unless there is a high degree of fever or a well-marked diathesis, internal remedies are of little avail. Rest is of the first importance. Every movement causes pam and makes the inflammation worse by increasing the amount of blood flowing through. Unless the attack is very slight, and aff"ects one of the smaller joints only, the limb should be placed upon a splint, or fixed by means of a sling or a triangular bandage and raised. The position varies with each joint, and is not by any means that which the patient assumes of himself. The elbow should be flexed to a little less than a right angle ; the hip should be straight, the knee bent ever so little, and the foot. in the case of the ankle, exactly perpendicular to the leg. Heat, cold, and pressure are the most eff'ectual means for checking the exuda- tion and preventing tension. Of these the first is limited in its application, and is chiefly of service in traumatic synovitis, when the joint, like the ankle, is super- ficial, and the limb can be plunged for a moment immediately after the accident into water as hot as can be borne. Cold is of more general use, and can be kept up for a longer time ; but after the first few hours its utility diminishes very rapidly. The immediate eff"ect is a contraction of the arterioles ; but if it is continued, the walls of the vessels lose their tone and passive congestion follows. A rubber bag, filled with ice, or Leiter's tubing with ice-cold water, is easily arranged in the case of most joints ; or, if it is the lower limb, and the patient is confined to bed, 552 DISEASES AND INJURIES OF SPECIAL STRUCTURES. lead and spirit may be allowed to drip from a vessel over the joint. Pressure, if it is properly applied, is by far the best. It must be perfectly uniform, falling on the soft parts as well as on the bones, gentle, and elastic, so that it does not slacken off as the blood-vessels become empty and the part diminishes in size. Absorbent cotton-wool answers all requirements. All the hollows of the limb should be packed with ixids until the bones appear buried ; then several thick- nesses should be placed round the whole, and over all a moderately tight bandage. In the course of a few hours the extreme tension disappears and the bandage can be replaced by a firmer one. Nothing is equal to this for checking hyperoemia and exudation, causing the absorption of extravasated blood, and preventing the distention of the capsule, which is not only the chief cause of the pain (after the immediate effects of the accident have subsided), but, from the weakness it leaves behind it, a source of very grave inconvenience afterward. Pain, if it is very severe, may be relieved by placing a few leeches over the joint, or by giving a hypodermic injection of morphia. Aspiration is seldom recjuired in cases of simple acute synovitis, though it may be advisal)le when there is a large extravasation into the synovial cavity, as in fracture of the patella, and it is of importance to empty the joint at once, or when, from the persistence of the swelling and the continued heat, there is reason to fear that the exudation is becoming purulent. Great care of course is necessary ; the cannula should be cleaned by boiling in liquid potassce, so as to make sure that no greasy substance is retained inside ; [it should also be made aseptic by passing through a flame, or l)lunging in absolute alcohol just previous to its use,] and the opening should be valvular and well secured. Very often marked relief is ol^tained, even if only a few drachms are withdrawn ; the tension is lowered ; the pain and hyperemia diminish, and absorption commences at once. Passive motion should not be delayed too long. As a general rule, it should be commenced as soon as the temperature of the part is normal. Moving the joint once each day, through its whole range, quietly and steadily, cannot excite inflammation or cause severe pain, while it effectually prevents the formation of adhesions and contractions in the synovial wall. 2. Chronic Synovitis. Chronic synovitis occurs either by itself or as part of a general arthritis ; but even when it is local at the first, the inflammation always involves the other tissues sooner or later. Sometimes it begins as such, quietly and insidiously ; in most instances, however, it follows an acute attack, which, from want of rest or other causes, gradually becomes chronic. The pathological appearances are very variable. The fluid is usually increased in quantity ; sometimes there is an immense excess. Generally it is thinner and more watery than normal ; sometimes it is almost serous, and straw-yellow in color, and occasionally it is turbid ; but it usually retains its lubricating feeling. The surface of the lining membrane is dull and opaque. In places it is rough and velvety ; and around the margins where it is thrown into folds it may be covered with fringes and villous processes as thickly as in chronic osteo- arthritis. The fibrous capsule is softened and weakened at some parts ; thickened and rigid from the organization of the exudation at others. In some cases the weaker portions are stretched to such an extent that the shape of the sac is com- pletely altered ; hernial pouches form between the fasciculi, owing to the continued I)ressure ; or the walls are gradually absorbed until a communication is established with neighboring burs?e. In others the flexibility is lost ; the soft cellular pads, which should yield at once to the pressure of the bones, are hard and dense ; the delicate peri-synovial tissue is thickened and contracted ; and the folds of the synovial membrane, especially where they are pressed together and kept at rest for any length of time, as on the inner side of the shoulder joint, become adherent to each other, so that they cannot open out as the bones sejjarate. In rarer DISEASES OF JOINTS— SYNOVITIS. 553 cases the exudation in the interior becomes organized, and long slender adhesions are left, i)assing from one surface to another. They form during the acute stage of the inflammation, while the endothelium is detached and the walls are covered with lymj)h ; and while still soft they are gradually stretched by some change in the position of the joint. Symptoms. — The signs of inflammation are much less marked than in the acute form ; the temperature of the part, for example, is scarcely raised, the pain is not so severe, and there is no constitutional disturbance ; but there is evidence of much greater changes in the tissues ; the muscles, especially the extensors, are atrophied ; the outline of the joint is altered ; sometimes the bones stand out too prominently, from the wasting of all the tissues over them, more often they are concealed by the distention of the synovial cavity. The shape of the synovial sac is not the same ; the weaker parts of the capsule yield more than the rest ; the pouch under the quadriceps, for instance, in the case of the knee is enormously increased in size, while the tough fibrous capsule on either side of the patella is scarcely affected. The joint is stiff and weak, with a feeling of insecurity and helplessness ; the range of movement is limited, full extension in particular being impossible. There is crackling or grating, as one surface moves upon the other; sometimes it is the soft silken crepitus of cartilage that has lost its polish, more frequently the rough sensation produced by the synovial fringes as they are squeezed between the capsule and the bone ; and there is always tenderness on pressure, not only at the usual points, but at others where the capsule is thickened from the organization of lymph, or where it has grown out into little pedunculated masses which are caught between the finger and the bone. Prognosis. — In most instances, tubercular disease for example, the syno- vitis is merely part of a general arthritis, or is associated with some diathesis, and requires special description. Sometimes, however, it is local and exists by itself. In the early stages, while the exudation is still cellular and to a great extent fluid, resolution is usually complete if the cause is removed. Later, when organi- zation has set in and the wall has undergone a definite alteration in structure, the prospect is not so favorable. When part of the capsule is hard and rigid, or incorporated with the tissues around, or when the folds are hypertrophied and covered over with fringes, recovery is rarely perfect ; the joint never moves easily, it remains weak and insecure ; one spot in particular is painful, or one special action ; the amount of fluid is too great, though it varies from time to time, and there is always the chance that a sudden strain, or the slipping of one of the pedunculated outgrowths between the bones, may give rise to an acute attack. Treatment. — The sooner the exudation is absorbed the less the risk. If it is left for any time the capsule becomes stretched, and for want of proper tension the fluid collects again as soon as it is removed. Gentle uniform pressure — an elastic bandage, for example, over properly arranged pads — is most successful, especially in the early period, while there is still a certain degree of hyperaemia. As this disappears, friction and massage may be used for a few minutes each day to prevent the wasting of the tissues and increase the flow of lymph in the vessels. Then, as the fluid disappears and only thickened bands and fringes are left, douching with a jet of warm water under moderate pressure, steaming, shampooing, and other more vigorous remedies may be tried. Very great relief is often obtained by the use of counter-irritants : oleate of mercury of various degrees of strength, Avith morphia, painted on the skin ; iodine applied every day until there is very distinct tenderness ; or, especially where there is an unusually sensitive spot, light flying blisters repeated at frequent intervals. Scott's dressing is invaluable when the fluid persistently re-collects. The joint is covered over with strips of lint, on which is spread camphorated mercurial ointment (an ounce of strong mercurial ointment to a drachm of camphor) ; over this are placed two or three layers of firm adhesive plaster ; and then the whole is fixed and rendered secure by means of a starch bandage. This should be removed at the end of a 36 554 DISEASES AND INJURIES OF SPECIAL STRUCTURES. week at the latest ; by that time the strapping is too loose to exert any pressure, and very often a sufficient effect has been produced upon the skin. Not unfre- quently it is advisable to vary the treatment, i)rotecting the joint in the mean- while from cold and overwork, without, unless the temperature is distinctly raised, laying it up completely. In some cases, in which the effusion persistently returns again and again with- out any other sign of inllammation, aspiration and injection with a stinuilating fluid may be tried. A one per cent, watery solution of carbolic acid or tincture of iodine and water (one part in ten) is usually employed. The fluid is injected into the joint, brought into contact as far as possible with all parts of the synovial cavity, and then allowed to escape again, the aperture being closed at once. The limb should be thoroughly packed with cotton-wool and kejit upon a splint until the reaction that follows has subsided. Afterward a certain amount of sujjport (an elastic bandage for example) must be worn to prevent any further accumu- lation. This treatment, however, is by no means devoid of risk : the reaction may be very much greater than is wished, and it must not be forgotten that this passive collection of fluid {liydrops articuli or hydrarthrosis) is in many cases rather a sign of incipient osteoarthritis, or of that form of arthropathy associated with locomotor ataxy, than of simple chronic synovitis. [The injection of iodo- form emulsion is very valuable, and is seldom attended by any troublesome complication.] In others again the joint continues stiff and painful without any increase in the amount of fluid, and without any rise of temjjerature, every attempt at using it bringing back an acute attack, although the skin in the intervals is cold, blue, and congested. This may be due to the presence of bands or adhesions in the interior of the joint or in the loose tissue around the capsule; but much more frequently it arises from simple disuse and defective circulation. The appearance of the part is characteristic ; it has a helpless, withered look about it, the skin does not fall into its natural folds, or move easily and freely over the prominences beneath ; it seems as if it were shrunken on, and it is always cold, though the patient may complain of a constant burning pain. Movement is generally exceedingly limited and very painful, especially at one particular spot, and in many cases the least attempt at carrying it beyond a certain point is followed by a return of the acute symptoms. Such cases as these may generally be cured at once by massage, douching, and friction ; the circulation improves, the skin becomes warm again, and the synovial folds, which are, as it were, glued together from having been kept at rest too long while softened by inflammation, gradually open out and allow the proper movements to take place freely. Sometimes, how- ever, this fails ; instead of recovering, the joint continues tender, i)articularly at one spot ; or, while other movements can be performed with ease, one remains ■ impossible, from the pain it causes. In this case it is probable that the synovitis is kept up by the stretching of an adhesion, and it may be brought to an end at once by suddenly rupturing it. The action and the spot must be noted carefully, the muscles thoroughly relaxed, preferably by an anaesthetic, the i)roximal segment fixed, and then the band torn across once for all by suitable manipulation. This condition, however, is much more rare than the former. ARTHRITIS. Simple Inflammation. This may either begin in the synovial cavity and spread to the rest of the joint (primary), or follow disease of the articular ends of tlie bones or other adjacent structures (consecutive). It may be acute or chronic, and according to the nature and persistence of the cause it may subside or end in disorganization. Suppuration is a complication and does not occur unless the vitality of the DISEASES OF JOINTS-ARTHRITIS. 555 tissues is impaired and the pyogenic organisms gain entrance in sufficient numbers. Causes. — Traumatic inllammation of the synovial Hning is of common occurrence ; but, except in the case of a neglected loose cartilage or frequently repeated sprains, it seldom happens that mere mechanical injury is sufficiently intense or prolonged to affect the other tissues of the joint. Chemical irritants either give rise to a specific form (gouty arthritis, for instance), or, as in the case of septic decomposition, are so severe that suppuration follows almost as a matter of course. A typical example of simple inflammation is sometimes met with when there is a neighboring focus of inflammation (consecutive arthritis) ; the knee-joint, for instance, may be more slowly disorganized, as a result of chronic osteitis of the lower end of the femur, without pus ever making its appearance in the articulation. Pathological Appearances. — The earliest changes take place in the most vascular parts. The synovial meml)rane is swollen, softened, and reddened with extravasations ; the cavity filled with a turbid blood-stained fluid, and the articular ends of the bones and the soft structures around deeply congested. The cartilages, as they contain no vessels, undergo no active change, and the same is true, although to a less extent, of the ligaments and capsule. If the irritant continues, this becomes more marked. The amount of exuda- tion increases, the fluid in the interior becomes thick, the ligaments soften, their fibres separate from each other, and all the interstices are filled with lymph. The synovial membrane and the capsule are so swollen and thickened that they can scarcely be recognized. The cartilages lose their lustre and become opaque ; they melt away on the surface and grow thinner and thinner, while around at the edges they are eaten out in little pits by the granulations that spring from the vas- cular circle around the bone ; the periosteum is thicker than natural ; it can be stripped off" with ease from the surface beneath, and the bones themselves are deeply congested and so soft that they can be cut with a knife. These extreme changes are only seen when the irritant is an intense one and suppuration impending. When the cause is a loose cartilage or a neighboring focus of inflammation, they are much less marked ; and as in these cases there is rather a succession of slight attacks at frequent intervals, than a single very severe one, at one time all the tissues may be swollen, softened, and filled with exudation, at another they may be dense and hard from organization and repair ; but, inevitably, if the irritant is continued sufficiently long, all the tissues of the joint lose their natural texture and it becomes more or less crippled and ankylosed. Repair. — The destruction may be arrested at any point ; the irritant ceases to act, the hyperemia subsides, and the exudation partly becomes absorbed, partly organized. In most traumatic cases this takes place before the synovial membrane is destroyed or any very serious changes are produced in the ligaments or cartilages ; and then, although the capsule is left thickened and somewhat rigid, a very fair range of movement is regained. Even when the surface of the cartilage has been eaten away and the ligaments softened this is still possible, especially in children, so long as there is no displacement. The fibrous tissue that fills up the deficiency presents a sufficiently smooth and even surface, and the ligaments soon become firm again. If, however, the irritant persists (as in chronic osteomyelitis of the lower end of the femur when the sequestrum is locked in), the joint may become so rigid and painful that the patient is driven at last to seek relief in operation. Symptoms and Course. — Acute arthritis presents the same class of symp- toms as acute synovitis, but they are very different in degree. The pain is more severe. The limb is flexed and held perfectly rigid. The skin feels burning hot, and, though it may be white at first and in the more chronic cases, reddened patches may show themselves over the part where the capsule is thin and superficial. The whole of the joint is swollen, not the synovial sac only ; the shape is different ; it is more rounded and uniform, spreading upward and downward over the bones. 556 DISEASES AND INJURIES OF SPECIAL STRUCTURES. and not following the outline of the cavity. The consistence of the swelling is firmer ; the tenderness on pressure is greater, and, though one or two spots may be worse than the rest, it is not confined to any part in jjarticular. The extensor muscles waste even more quickly; the flexor ones maintain a state of rigid con- traction, broken only by sharp spasms, especially at night, and the constitutional disturbance is much more severe. These symptoms are followed by the others which do not occur in synovitis. As the ligaments become soft and yield, undue mobility is allowed. Displacement of the articular ends and even dislocation may follow, the weight of the lower seg- ment of the limb and the persistent spasm of the flexor muscles drawing the bones away from each other. Friction is felt when the joint is moved, owing to the car- tilages having lost their smoothness of surface. At the same time, or even before this, peculiar starting-pains make their appearance. These rarely hapi)en in the daytime or at night, when the patient is sound asleep ; but as he is losing con- sciousness and the muscles are relaxing their vigilance there is a sudden violent jerk of the limb and the two bones are driven together with the most excruciating pain. This may happen time after time and night after night, until the patient dreads going to sleep, and keeps himself awake as long as he possibly can. It always means that the bones are inflamed, and often that the cartilages are eroded. The start is due to the sudden reflex contraction of the muscles. As they relax in sleep, one part of the joint moves ever so little upon the other, the stimulus is car- ried up to the nerve-centres, there is a sudden sj^asm in response, and the two bones are brought forcibly into contact. It is not uncommon for them to be present when no grating can be detected, either because the surface of the bones is covered with granulations, or because the cartilage is not yet removed. If the irritant is very intense (such as the poison of septic decomposition) and the inflammation continues to spread, the periarticular ti-ssues become involved, the skin becomes red and oedematous, especially along the inner side of the limb ; the swelling increases rapidly in size and becomes more diffuse; the pain grows more severe and continuous ; the constitutional disturbance becomes worse and worse, and at length the pyogenic organisms gain the ui)per hand and suppuration sets in, sometimes in the joint itself, sometimes in the tissue around. Diagnosis. — Occasionally there is some difiiculty in determining whether the inflammation involves the joint or some of the structures around it. This usually occurs in connection with bnrs?e (under the deltoid in the case of the shoulders, between the iliopsoas and the front part of the capsule in the hip ; and in children under the crureus, between the quadriceps and the femur) ; but a careful examination nearly always settles the point at once. The shape of this swelling is different ; movement in some directions is much more free than when the joint is involved, pain is less severe, and the constitutional symptoms are much less marked. Treatment. — i. Primary Arthritis. — {a) Acute. In this, as in synovitis, local treatment is the most important. If the fever is high and the constitutional symptoms severe, small doses of aconite (one minim of the tincture), or of anti- mony, may be given at frequent intervals ; the bowels must be kept ojjen, the diet strictly limited, and antipyrin or quinine may be tried ; but unless there is evidence of some definite diathesis, such as gout or rheumatism, constitutional remedies by themselves are of little avail. Rest is the first consitleration. Every movement of the joint not only causes intolerable pain, but makes the inflammation worse. At the very earliest sign, whether it is due to a wound or not, the limb should be placed upon a suitable splint. This varies, of course, with the nature and situation of the joint ; it must fix both segments, the one al)ove and the one below ; it must hold the limb in the most convenient position, supposing it should become stiff; it must enable con- tinuous extension to be made if it is required, and it must be arranged so that the cold, compression, or counter-irritation may be applied without its being necessary to move it. For the hip, either Bryant's or Thomas's splint maybe used, accord- DISEASES OF JO/NTS -ARTHRITIS. 557 ing to the position of the joint, which is certain to l)e flexed, and which may not come straight for days; in the case of the knee, either Thomas's or Mclntyre's. The anterior ones do not give sufficient immobility, or prevent the eversion which always takes place if the ligaments are softened and the limb is left to itself; but, both for this, the foot, and the joints of the upper extremity, nothing answers better than one of the various forms of plaster splints (especially Gamgee's absorb- ent cotton-wool dipped in i)laster cream) or poroplastic felt. Extt-itsion is part of rest, and, especially in the case of the hip and knee, is almost intlispensable. It i)revents muscular spasm and stops the starting-pains at once and in a fashion which nothing else can ; it prevents the two bones being jammed against each other, and saves the articular cartilage from absorption ; it helps to steady the limb and bring it into the right line, and it checks the tend- ency to displacement. It is managed most easily by means of a weight attached to a stirrup, the amount being proportioned to the size of the limb. Elevation, cold, and compression are invaluable for checking the hyperemia and reducing the tension of the part. With regard to the first, Lister has shown that not only does the venous blood return more freely when a limb is raised, but that there is as well a contraction of the artery under the influence of the vasomo- tor nerves. Of cold it is unnecessary to say anything, the only point is that it must be continuous and not intermittent. Ice-bags may be placed over the joint, or Letter's coils wound around it ; or, what is perhaps more effectual when the affected joint is covered thickly up, an ice-bag may be laid along the main artery supplying the limb. It has been proved that this has a very decided influence upon the temperature of the parts below. Compression is even more important, but it must be carried out thoroughly and carefully, or it may make the congestion worse. The whole limb, from its extremity to well above the affected joint, must be evenly packed with layer upon layer of absorbent cotton-wool. On the outside of this longitudinal strips of torn mill-board soaked in plaster cream are placed to give firmness and resistance ; and then over all a bandage carried evenly upward, diminishing the pressure ever so little toward the end. Other remedies are occasionally of service. If the inflammation is very acute, ten or a dozen leeches may be placed over the joint. The skin may be covered over with a mixture of equal parts of extract of belladonna and glycerine. Morphia may be given hypodermically to relieve the pain and restlessness and procure sleep ; and if the joint is very much distended, aspiration may be used to draw off some of the fluid. (J)) Chronic. — If this treatment is successful, the severity of the symptoms diminishes, the fever subsides, the hyperaemia disappears, and the exudation is in great measure absorbed. Very often, however, more or less organization takes place, repair is incomplete, and a certain amount of chronic inflammation persists. The muscles are wasted; the joint is swollen and stiff; movement is painful; the temperature of the part continues higher than normal ; there is tenderness on pressure ; and every attempt at using the limb threatens to bring back an acute attack. When this occurs rest is still essential ; it must be rigidly enforced so long as the temperature is raised, although it may not be necessary to confine the patient absolutely to bed. With the aid of Thomas's splints and a patten under the oppo- site foot in the case of the hip and knee, and gum and chalk, leather, or poro- plastic, for other joints, patients may be allowed to get about to a certain extent upon crutches as soon as the acute period is passed, very often with great benefit to their general health. Compression is not of so much service unless there is a large amount of exudation still ; but a great deal of good may follow the judicious use of counter-irritants. Blisters, iodine, and the oleate of mercury are of Service in the slighter cases only ; Scott's dressing is of greater use, as it may be applied as a splint as well ; but when there is evidence, from the shape of the swelling and the severity of the pain at night, that the bone is in a state of chronic inflamma- tion, and even in some cases of starting pains, nothing succeeds like the actual 55 S DISEASES AND INJURIES OF SPECIAL STRUCTURES. cautery. The broad, flat platinum jjoint of Paquelin's cautery answers best. It should be of a black-red heat, and should be drawn slowly over the skin in parallel lines, not destroying the whole thickness, l^ven in disea.se of the spine I have known great benefit follow from this : the i)ain is not great ; if the patient is under an anresthetic, and the part is covered up from the air before consciousness returns, it is scarcely felt ; very slight suppuration, only of a superficial character, may follow; but the tension, and the constant gnawing pain in the deeper structures, are materially relieved ; and a great deal of the exudation disappears. In Pott's disease, with paraple'gia of not too long standing, the spinal cord sometimes recovers its power within a short time of the application. Later, when the inflammation has subsided, and stiffness or ankylosis only is left, proper means must be taken to restore the power of the muscles and the mobility of the joint. 2. Consecutive Arthritis. — The diagnosis of consecutive inflammation from primary arthritis is of especial importance. If, for example, it starts from an abscess in the bone, and this can be opened so that the pus has free exit before the joint is too seriously involved, complete recovery may be hoped for ; and even when there is a sequestrum, and it involves the articular surface, it is sometimes possible to remove it and leave a comparatively useful joint. Where this cannot be done, as in many cases of chronic osetitis of the lower end of the femur, either the joint gradually becomes stiff and almost useless from the repeated attacks of inflammation, or, worse still, the abscess finds its way into the interior and sets up acute suppurative arthritis. The shape of the swelling is entirely different from that of a primary inflam- mation of the joint, at least in chronic cases ; acute ones run their course too quickly. In the knee, for instance, instead of its following uniformly the outline of the synovial sac, it is very much larger on one side than on the other (Figs. 270 and 271), and it begins upon the bone, caused by the swelling and infiltration into the periosteum and the soft tissues lying over it. Tenderness is much greater, particularly over the swelling ; sometimes it is definitely limited to one spot, the skin over which is slightly puffy and oedematous. The pain is more severe and of a different character ; there is a constant, deep-seated aching in one of the bones, worse at night and after any evcertion, and severe in proportion to the acuteness of the inflammation. In traumatic cases this is usually very distinct ; in tubercular ones, on the other hand, owing to the peculiarly slow and insidious manner in which the affection advances, it is much less clear. Starting pains occur more early ; in synovial arthritis they do not begin until the cartilage is detached and the soft, cancellous tissue at the end of the bone exposed ; in the consecutive form they commence as soon as the inflammation approaches the articular lamella. For the same reason intra-articular pressure, as when one bone is driven smartly against the other, is a great deal more painful. Finally, muscular wasting is a more prom- inent feature. The first object is to check the progress of. the inflammation in the bone. For this appropriate constitutional and local measures must be adopted, as already described under osteitis. In tubercular disease an attempt must be made to strengthen the resisting power of the tissues by good food, fresh air, especially at the seaside, iron, cod-liver oil, and other tonics. If it is syphilitic, iodide of potash and mercury in small doses should be tried. The liml) should be placed upon a splint, and so long as the inflammation is acute the patient should be con- fined to bed. Cold may be aj^plied, partly to check the hyper.-emia and diminish the amount of exudation, partly, in the tubercular form at least, because there is some evidence that it possesses the power of checking the growth of the bacilli ; but care must be taken not to lower the vitality of the tissues too much. Leeches are of use when the pain is very severe ; in other cases more benefit follows the use of counter-irritants : the actual cautery, if there are starting-pains, iodine, blisters frequently repeated, or, particularly in the case of syphilis, the oleate of mercury with morphia. ^ UPP URA TIVE A R THRl TIS. 559 In many instances, however, in spite of transient improvement, the pain persists, the swelling refuses to clisai)i)ear, the effusion in the joint continues, and the local tenderness becomes more and more distinct. When this occurs there must be no further delay, an attempt must be made to reach the seat of the disease by incision in the bone, with- out, if it can jjossibly be avoided, implicating the joint. Even if no pus is found, the operation gives relief by dimin- ishing the hyperemia, with, so long as the synovial cavity is not opened, the least amount of risk. Sometimes the periosteum is thickened or detached from the surface of the compact tissue beneath ; occasionally a small sinus can be found, or the bone is altered in texture. In other cases everything appears to be normal ; but even then, so great is the risk of leaving a caseous or suppurating focus in the centre of one of the articular ends, that if, before the ope- ration, one spot w^as definitely tender or oedematous, a circle of bone should be removed with the trephine and the inte- rior explored with a small gouge, or, what answers better, a steel director set in a rounded wooden handle. With this the difference in the resistance offered by healthy bone and by that which is inflamed and softened can be api)reciated at once, even when there is ho actual cavity. If an abscess is found it should be opened freely, any loose fragments of bone that lie in it removed, and the cavity thoroughly scraped so as to destroy all the soft granulation tissue, washed out with a solution of perchloride of mercury (one part in looo), and plugged with iodoform gauze. This may be removed at the end of twenty-four or forty-eight hours, and a large drainage- tube inserted. If the disease has not yet broken through the articular cartilage an excellent result may be obtained by this ; the whole of the os calcis, for example, may be erased, leaving merely a periosteal shell, without the neighboring synovial mem- branes being lost. If, unhappily, the disease has spread too far, and suppurative arthritis or pulpy degeneration of the synovial membrane has occurred already, further measures, drainage, arthrectomy, or excision will be necessary, according to the condition of the parts. Fig. 237, — Osteitis of Upper End of Diaphysis of Tibia, ending in suppuration. Pro- bably it was tuljercular in origin ; on tbe outside is a layer of sub-periosteal new bone, but notwithstanding this it made its way as well outside as into the joint. Suppurative Arthritis. This, like the former, may either begin in the joint or spread to it from the adjacent structures. It never arises without the presence of pyogenic organisms, acting on tissues the vitality of which is already impaired by other irritants. If these are of but slight intensity and the general nutrition is good, the destruction is limited ; if, on the other hand, they are severe (as in septic decomposition), or if the tissues are badly nourished (whether from prolonged intemperance, excesses, kidney disease, or other causes), the destruction is widespread and complete. Causes. — The primary form very seldom originates without a wound ; excep- tionally in those whose health is impaired by intemperance and renal disease, a simple synovitis steadily progresses from bad to worse, until at length the tissues yield and give way and suppuration sets in. The consecutive one is nearly always the result of suppurative osteitis. In acute necrosis the inflammation may spread along the periosteum until it gains the capsule, or work its way between the epiphysis and the shaft, and then turn upward through the soft tissue of the former until it reaches and undermines the articular lamella. Acute epiphysitis of infants is sometimes known as suppurative arthritis, from the certainty with which the articulation is destroyed. In chronic osteitis. 56o DISEASES AND INJURIES OF SPECIAL STRUCTURES. whether tubercular, syphilitic, or traumatic in origin, the joint, if one is near, is always involved : at first, while the focus of disease is still some distance off, the inflammation is simple in character ; then, at least in the tubercular form, as the bacilli gain the synovial membrane, it becomes specific ; and finally, when either an external opening forms or the pyogenic organisms gain the upj^r hand, suppuration sets in. In other cases the starting-point of the disease is in some neighboring bursa or tendon -sheath, or even in the cellular tissue. Pathological Appearances. — The earlier changes are those of acute arthritis ; then, as the tissues melt away l)efore the pyogenic micrococci, the destruc- tion becomes more rapid. The synovial membrane grows thicker and thicker, until it simply becomes a mass of inflammatory e.xudation with scarcely a trace of its original texture left ; the loose cellular tissue around swells up and becomes gelatinous ; and the interior of the joint is covered with flakes of fibrin and sloughing shreds of tissue and filled with a turbid mixture of pus, synovia, and debris from its walls. Soon the cartilages lose their pearly-white color and become opaque. Sometimes, when the tension is not very high, they gradually melt away ; more often the central portions, which are pressed together when the bones are in contact, and which are furthest from the vascular circle, perish and drop off as sloughs, bringing with them the articular lamella on which they rest (Fig. 238), while around the margin and where the inflammation is less acute, they are gradually eaten out by the granulations in the form of little circular pits (Fig. 236). The den.se fibrous capsule and the ligaments resist the longest ; but in a little while the inflamma- tory exudation works its way into the inter- jr .j:_ ^"'^^ 'W t slices; the fibres soften and melt away; *-■ f^' ' vi yellow foci of suppuration appear in the tis- sues outside the joint ; and the bones become so movable that displacement and even dis- location occur. Finally the muscles waste away and undergo fibroid degeneration ; the periosteum is destroyed ; the capsule disap- pears ; the pus spreads far and wide in the softened structures around ; the skin be- comes undermined ; and nothing is left but l''r::^%^:!:i':^\'io^^^^^^ the articular ends of the bones, roughened, softened, and carious, loathed in pus and surrounded by suppurating tissues. In the most acute form of suppurative arthritis (that which follows a poisoned wound or complicates acute necrosis) the joint may be completely destroyed within a few days : if the irritant is less intense, the changes take place more slowly ; and they may be arrested at any stage ; but they are always the same. The difference in appearance arises from the size of the fragments that perish : in the most acute form necrosis is the prominent feature, and the cartil- ages and the ends of the bones are thrown off in great flakes ; in the less acute these are much smaller, and only come from the s])Ots where there is pressure ; and in those that are less so still, they are only molecular, the surface imperceptibly melting away. Repair. — The extent to which this is pos.sible depends upon the amount of destruction. So long as only the synovial and perisynovial tissues are involved, and the cartilages are fairly intact, recovery is possible, though with a considerable degree of rigidity ; the joint-cavity is preserved, although the bones are tied together by bands of organized lymph lying in the substance of the capsule and springing from the summits of the osteophytes formed round the articular ends. But if, as is usually the case, the cartilages have sloughed, bringing away with them the articular lamella, and the granulations spring from the ends of the bones Fig. 238.- tive Arthr cartilage, except at the margin. SUPPURATIVE ARTHRITIS. 561 as well as from the tissues around, when the discharge of pus ceases and organiza- tion begins, the opposing surfaces grow together, the cavity is ol)literated, and eitlier dense bands of cicatricial tissue form between the ends, or osseous union, true boiiv ankylosis, takes place. Symptoms.— 'I'hese are the same, both constitutional and local, as those ot acute arthritis, but infinitely more severe. When the joint is a large one and the attack acute, death may follow from septic absorption within the first few days. There is a rigor or a succession of chills ; the temperature rises rapidly to 105° or even 106° F. ; the pulse at first is full and bounding, but in a very short time it becomes weak and feeble ; the tongue is dry and brown ; sordes appears upon the lips and teeth ; delirium sets in ; and the patient sinks from acute blood-poisoning without the symptoms abating in the least. In other cases the constitutional symptoms are less severe ; the temi>erature is exceedingly high, with occasional rigors ; at first it is continuous ; after a time it falls of a morning, until, when suppuration has become free, it assumes the hectic type. The pulse is soft and compressible without losing its frequency ; the appe- tite is comjjletely lost ; the tongue continues dry and brown ; the emaciation is extreme, the cheeks become hollow, the eyes dark and sunken, and if the patient escapes pyaemia and other acute infectious disorders, amputation is frequently re(iuired, either because the joint is hopelessly disorganized and the limb useless, or to prevent the patient sinking from exhaustion. In others again, wheir the suppuration is not assisted by decomposition, or when the joint is a small one— in one of the fingers, for example— the effect is very much less, but in acute suppurative arthritis it is always severe. The local signs are equally grave. If the joint is a large one the whole limb is swollen ; the outline of the synovial cavity disappears ; the skin is burning hot and duskv'red, either in patches or all over ; and the inflammatory cfidema spreads up the whole of the inner side. The pain is most intense, the patient screaming out if the bed is touched, and the limb is flexed and held perfectly rigid, often grasped with both hands so as to prevent the slightest movement. Displacement, if it has not occurred already, very soon follows. The ends of the bones grate upon each other, owing to the cartilages having sloughed. The startmg-pams at night become simply agonizing ; and then, if the patient survives, the skin becomes thinned at some spot, fluctuation makes its appearance, and the pus discharges itself externally. 1 >.i,- In acute suppurative arthritis of the knee, it occasionally happens, when this stage is reached, that there is a sudden and most deceptive appearance of improve- ment ; the capsule of the joint gives way at its weakest part, under the tendon of the (piadriceps ; the pus escapes and spreads along the femur, until it is turned aside by an aponeurosis ; the joint diminishes in size ; the tension becomes less ; and the constitutional symptoms are decidedly improved. Unhappily this does not last long ; the swelling soon shows itself high upon the outer side of the thigh, and if the abscess is not opened and drained at once, the symptoms become even worse than they were before. Diagnosis.— In the acute form, especially that which follows a wound ot the joint, there is seldom any difficulty; sometimes, however, when suppurative arthritis sets in as a result of constitutional infection, and it is a question between this and purulent synovitis, the signs are at first far from obvious. The occurrence of a rigor ; a rapid rise of temperature ; the shape of the swelling, which is no longer that of the synovial sac ; the presence of cedema and of a peculiar dusky redness of the skin, and the intense character of the pain, are most significant In any case of doubt there should be no hesitation in using the aspirator and withdrawing some of the fluid from the interior, with the precautions already described. If the contents are still thin and serous, the product of catarrhal sup- puration, removing a certain quantity relieves the tension and the hypersemia, and then absorption may commence of itself. If, on the other hand, they are 562 DISEASES AND INJURIES OF SPECIAL STRUCTURES. thick and curdy, the sooner the contents are evacuated and the tension lowered the better the prospect of preserving the cartilages and saving the joint. Treatment.— Suppurative arthritis must he dealt with at once. The syno- vial cavity must be thoroughly drained ; the poison that clings to its walls destroyed or washed away ; and all further source of irritation, whether it is septic decom- position, tension, movement, or pain, absolutely prevented. If there is any doubt as to the presence of pus; or if, as in some cases of constitutional infection, there is a suspicion that it is really a purulent catarrh, kept up to a great e.xtent by tension, without the cartilages or the surrounding tissues being seriously concerned, aspiration may be tried. On the other hand, if the skin is red and oedematous, if the shape of the swelling is no longer that of the synovial sac, or if the arthritis is due to a wound, or an abscess that has formed in connection with the bone or one of the surrounding structures and has burst into the joint, the only \\o\>q lies in free incision and thorough drainage. The earlier this is accomplished the better. If the patient is not already jjoisoned by septic absorption, and the synovial membrane is not yet destroyed, a fair amount of movement may be regained ; if it is not done in time, either the patient will sink from acute septicaemia or exhaustion, or if he recovers the joint will be hope- lessly disorganized. The limb must be fixed upon a splint, protected with waterproof pads, so that there can be no displacement or spasm, and every part of the joint laid open ; the difficulty of accomplishing this, in the larger and more complicated ones, is chiefly responsible for the ill results that follow. In the case of the knee a free incision must be made down each side of the patella, slanting rather backward; and a pair of dressing-forceps pushed through the back of the joint into the popliteal space on the outer side of the middle line, until the point is felt beneath the skin. Then a small cut must be made, the forceps driven through, and a drainage-tube drawn back. Even with these three openings, however, drainage is not sufficiently thorough, and the joint must be kept free from any accumulation by some other means. In the early stages con- tinuous irrigation answers admirably, pure water being allowed to flow into the joint at one side, and out again at the other, carrying aw^ay with it all the secre- tion ; decomposition cannot occur, as none of the pus is left. But when the smooth synovial surface is destroyed, and abscesses are forming, it is very difficult to make the fluid (which will follow the line of least resistance) circulate suffi- ciently to wash out all the recesses. More may be done in this case by the intro- duction of large and firm-walled drainage-tubes at every available spot, syringing out thoroughly with a solution of bichloride of mercury (one part in 2000), and then covering the whole with a thick layer of absorbent moss or wood-wool. The poison is partly washed away — partly, so far as it lies upon the surface, destroyed by the action of the antiseptic; tension is impossible; decomjjosition cannot occur without fluid ; absolute rest is ensured ; and the gentle, elastic compression effectually prevents hyperaemia and limits the amount of exudation. In the case of the ankle, elbow, wrist, and the smaller joints, the same plan may be followed, varied slightly in its details. Thus it is more effectual to immerse the part bodily in a solution of bichloride (one part in 10,000) for two or three hours after the incisions have been made ; and iodoform may be freely dusted in as soon as the fluid has drained away ; owing to the smaller absorbing surface, there is less risk of poisoning. P3ven when the joint is loose and grating, a very fair result may frequently be obtained by means of this kind ; the sujipura- tion ceases, the granulations begin to organize, fibrous bands form around, or, if the disease is far advanced, between the bones, and rei^air takes place so far as the previous destruction and the health of the patient will allow it. Great care is required throughout to keep the limb in position and prevent displacement. Partly owing to the weight of the lower segment, partly to the action of the flexor muscles, one bone is certain to be displaced from the other if PYEMIC ARTHRITIS. 563 the joint is left to itself without jjropcr splints ; and later, when the attack has snbsided and the cicatricial tissue has begun to contract and grow rigid, there may be the mortification of finding that the joint is fixed in such a position that the limb is almost useless, unless excision or some other operation is performed. Amputation may be required in the later stages of the disease, to prevent the patient sinking from hectic or exhaustion, or because the limb is too much dis- organized to be of any use. It should never be performed during the acute inflammatory period, except as a last resource to save the patient from dying of septicaemia, and then, if the joint is a large one, the prognosis is almost hopeless. In the elbow and shoulder, very good results may be obtained by excision, better than by waiting for ankylosis ; and the same plan may be followed in the case of the hip, when the upper extremity of the bone or the acetabulum is extensively diseased, with the view of saving the patient from the effects of prolonged suppuration. Arthritis from Secondary Infection. {a) Pycemic Arthritis. Inflammation of joints is of common occurrence in pyaemia, although, with- out any reason being known, it varies very much both in frequency and intensity. In some cases a large number of joints is involved within the first few days, and if the patient lives sufficiently long, the destruction is rapid and complete ; in others only one is attacked, or one or two at long intervals, and the effusion remains in the condition of a simple purulent synovitis for a considerable time before it involves the tissues around. It always begins as synovitis, and the effusion is purulent from the first ; gen- erally it is of a peculiarly oily character, and greenish or yellow in color, from the blood with which it is mixed. If the attack is an acute one, this is succeeded by suppurative arthritis : the synovial membrane becomes swollen and vascular, the surrounding tissues sodden and oedematous, and within forty-eight hours the cartilages undergo necrosis and the joint is hopelessly disorganized. If, on the other hand, it is chronic, the interior of the joint may retain its smooth and even character for days, without any evidence, even of hyperaemia ; and at the end of that time the effusion may spontaneously disappear, leaving the joint capable of a certain range of movement, but generally more or less crippled from fibrous adhesions, or weakened from the extreme distention of the capsule. Symptoms. — Pyaemic synovitis is rapid and very insidious in its onset, often beginning without any complaint of pain. One of the joints, especially the knee, or (it is said) the right sterno-clavicular, suddenly becomes filled with fluid ; the synovial cavity is distended ; fluctuation is distinct ; and the limb assumes of itself the characteristic flexed position. The skin at first is pale, or marked by a scattered erythema ; very soon, if the capsule gives way, it becomes soft and doughy, pitting on pressure, and of a peculiarly dusky hue ; and then, as a rule, the pain becomes very severe. In the acute cases a rigor is not uncommon at the commencement ; the muscular wasting is peculiarly rapid ; the cartilages may be destroyed within forty-eight hours ; starting-pains are very severe ; and, owing to the great amount of fluid and the rapidity of the destruc- tion, displacement of the ends of the bone is very likely to occur, unless" special precautions are taken to prevent it. In the more chronic ones there is less heat and less tension ; the skin is unaffected ; often there is no increase in the consti- tutional symptoms ; and not unfrequently the effusion disappears from the joints almost as rapidly as it came, and perhaps makes its appearance in another. Pathological dislocation, particularly of the hip joint, is not uncommon under these conditions, forming the so-called dislocation by distention; the head of the bone lies still within the capsule, which it has stretched over itself. It differs from dislocation by destruction in that the cartilages on the articular surfaces and the bones beneath them are intact. Treatment. — Careful examination should be made every day in a case of 564 DISEASES AND INJURIES OE SPECIAL STRUCTURES. l)ya;mia. to make sure that no joint is attacked. At the first sit^n the limb should i)e placed on a splint in a suitable position, well jjacked with cotton-wool and bandaged. The effusion may subside within twenty-four hours, leaving the articulation stiffened and weakened, l)ut without any more serious result ; but if it continues, or if the tension increases, or the skin becomes red and dusky, steps should be taken at once to empty it thoroughly. Aspiration may be tried first ; and occasionally after this absorption begins and there is no re-accumulation ; more frequently the in"Lj)rovement is only temporary, and it becomes neces.sary to lay the joint open freely, wash it out thoroughly with some antiseptic, if possible before the surface is destroyed, and drain it. Even after this, supposing the pus is not allowed to collect anywhere in the interior, recovery with a certain but limited amount of movement is possible ; much more fre(|uently, however, either the cartilages undergo necrosis, granulations sj^ring from the ends of the bones, and o.sseous ankylosis ensues ; or the patient sinks from some other, often visceral, complication, or from exhaustion. Amputation, if the patient recovers, may be required al a later period, either because the limb is useless, or to save the patient from hectic or amyloid disease. (J)) Puerperal Arthritis. This is a form of pyaemia consequent on septic absorption from the interior of the uterus after parturition, due in most cases to the retention and decomposi- tion of some portion of the placenta. vSo far as the joint affection is concerned, it does not differ materially from other forms; occasionally it is very acute, leading to rapid disorganization and destruction ; more frec}uently it is sub-acute, or chronic, affecting often the knee joint only ; and then, supposing the uterus is thoroughly disinfected, and no further absorption or complication sets in, the prognosis is fairly good. (r) Exanthcjnatic Arthritis. Inflammation of the joints is of common occurrence in connection with the exanthemata, sometimes appearing during the course of the disease, more frequently afterward, as one of the seciuelre. In many cases it is distinctly pyoemic, due to septic absorption from ulcers upon the skin or the mucous membranes, and does not differ in any material respect from ordinary ]^yajmia ; in some, however, it never pa.sses beyond the stage of synovitis, and the effusion is absorbed again without leading to any more serious result than stiffening and weakening of the articulation ; and occasionally it is to all appearance identical with acute rheumatic fever or the acute form of osteo-arthritis. In typhoid, the hip seems to suffer more frequently than other joints ; and even dislocation may take place suddenly, without warning of any kind. The muscles are relaxed ; the capsule of the joint is distended ; the fluid gradually insinuates itself between the articular surfaces, and a very slight degree of flexion and abduction is sufficient to tilt the head of the bone out of the acetabulum. Owing to the want of power of the muscles, and to the fact that the capsule is not torn, the symptoms at the first are not so marked as in traumatic dislocation ; later, when the patient recovers, the deformity becomes characteristic. Scarlatinal arthritis is generally polyarticular, and clo.sely resembles acute rheumatic fever, affecting sometimes the i)ericardium or the cardiac valves, and being followed occasionally by embolism and chorea. It usually occurs during the decline of the fever or even during the period of convale.scence. In other cases it is distinctly pyaemic, ending in suppuration. Variola, measles, dysentery, and even mumps, are in rare cases followed by similar consequences. (^/) Urethral Arthritis. Closely akin to this is a form of arthritis dependent upon some lesion of, or injury to, the genito-urinary mucous membrane. It is most common after URETHRAL ARTHRITIS. 565 gonorrhcea (though the proportion of cases in which it occurs is exceedingly small), whence its common name, gonorrhcjual rheumatism ; but it may follow any urethral discharge, or even the [)assage of a catheter, and, though much more rarely, a similar affection may occur in women in connection with menstruation, following parturition or dependent upon leucorrhoea. According to Clement Lucas it is present sometimes in cases of ophthalmia neonatorum. The nature of this affection is even more doubtful than that of the exanthe- matic variety. In some cases it appears to be pygemic, due to septic absorption from ulceration of the urethra, and ending in acute sui)puration and destruction of the joint ; but in the majority there is very litde tendency to the formation of pus. That it is directly connected with the condition of the urethral mucous membrane is shown by the fact which has many times been noted, that the inflam- mation is liable to return, not only with every succeeding attack of gonorrhoia, but even when, without this, the urethral mucous membrane is subjected to any unusual degree of irritation (possibly in these cases the gonorrhoea is latent). It seems probable that it is due to the absorption of some poison from the urethra, and the gonococcus has been found on several occasions in the fluid of the joint ; but it is also possible that it may be the result of reflex irritation of the nervous system. Ord, for example, has shown that a form of arthritis not altogether unlike this occasionally attacks women who suffer from menstrual troubles, the inflamma- tion returning at each period until the climacteric is passed ; and although this, too, may be explained as the result of absorption, it is peculiarly significant that in several of the cases in which there w^as ovarian tenderness with neuralgia on one side of the body, the disease was limited to the joints on that side. The clinical symptoms and the pathological changes in some of the more severe cases resemble those of acute osteo-arthritis, especially that variety which occasionally follows exposure to cold or over-exertion shortly after parturition or miscarriage ; but the analogy must not be pushed too far. Heart complications are not unknown in connection with it, but they are decidedly rare. Symptoms. — Urethral arthritis exists in two well-defined varieties : acute, attended with fibrinous efl"usion, and involving all the fibrous tissues around and belonging to the joint, so that, when it subsides, dense fibrous ankylosis is left ; and chronic, in which the symptoms are not so severe and the effusion is serous in character, but which also leaves behind it considerable stiffness. As in pyaemia, tendons and tendon sheaths are not unfrequently attacked as well, and occasionally other fibrous tissues not connected with joints, such as the lumbar aponeurosis, the annular ligaments, and even the sclerotic coat of the eye. The acute form is not unlikely to be mistaken for acute suppurative arthritis, though pus is rarely present, and the constitutional symptoms are much less intense. There is seldom a rigor, although a certain amount of shivering is not uncommon ; the temperature is not very high or the pulse rapid, and the appetite even may be fairly good. At the first onset several joints are swollen and painful, but it soon settles down to one or two of the larger ones, the knee and ankle in particular. The skin is tightly stretched, red and shining ; often there are red lines running up to the neighboring glands, but it does not pit on pressure ; the outline of the part is even and rounded, the shape of the synovial sac is lost, the tendon -sheaths and the fibrous tissues around are filled with inflammatory exudation, the temperature is raised, and the pain, especially when the part is touched or moved, is almost intolerable. The worst points generally correspond to the attachment of the liga- ments. At the end of a week or ten days the severity of the symptoms begins to subside, the pain becomes less intense (except when an attempt is made to move the part), the redness disappears, and the skin becomes more or less wrinkled. The effusion is absorbed to some extent, but a very great deal of it becomes organized inside the joint as well as round it, and the ankylosis may be so firm as to give rise to the suspicion of its being osseous. For this reason, and because the ligaments become soft and yielding almost at the first, very great care is necessary to prevent displacement and to keep the joint fixed in the most useful position. 566 DISEASES AND INJURIES OF SPECIAL STRUCTURES. In the chronic form the exudation is less fibrinous and is restricted chiefly to the interior of the joint. The shai>e of the swelling follows the outline of the synovial sac, there is less exudation around, the pain is not so severe, the f)atient may even be a!>le to get about to some extent, and, although there is a great tendency to recurrence, each time interfering with the action of the joint more and more, there is rarely the same rigid degree of ankylosis. Softening of the ligaments, however, is very liable to occur, and if the tarsal joints and the plantar ligaments are involved, a very painful form of flat-foot may result. The diagnosis of the acute form rarely presents any difficulty ; in no other variety of inflammation, scarcely even in acute rheumatic fever, is the pain so in- tense, and from this it can be distinguished at once by the difference in the con- stitutional symptoms and the extent to which the efl"usion involves the periarticular tissues. The chronic variety, on the other hand, closely resembles subacute and chronic svnovitis, esi:>ecially when it involves the knee joint only, and it is not improbable, especially as in many cases there is only an insignificant gleet, that the real cause is frequently overlooked. Prognosis and Treatment. — Urethral arthritis is naturally more common in young adult life, but it may occur at any age, and when it is due to gonorrhoea, it may set in at any period of the disease. Perfect recovery is rare; absolutely rigid ankylosis, with complete muscular atrophy, is not uncommon, and the dis- ease may return again and again until the patient is hopelessly crippled. The condition of the urethra or vagina requires particular attention ; every attempt must be made to allay the irritation of the mucous membrane as soon as possible. The use of sedative and astringent injections and bougies does not ap- pear to be attended with any special degree of danger. Constitutional treatment, so far as the joint affection is concerned, is of very little avail. Iodide of potash, salicylate of soda, and the other remedies usually of service in rheumatic fever, seem here to fail completely. The chief reliance must be placed upon local measures, and especially upon those that check the effusion. The limb should be placed upon a splint and raised, the skin covered o\-er with extract of belladonna and glycerine, invested with layer after layer of cotton-wool, and then bandaged as tightly as possible. In acute cases it is necessary to place the patient under an ansesthetic to effect this thoroughly, owing to the severity of the pain ; and, as a rule, it is as well to give a hypodermic injection of morphia as soon as consciousness returns ; but there is nothing so effectual for getting rid of the exudation, and, as this subsides, the pain and the inflammation and the tendency to displacement dis- appear with it. It may require renewing on the second or third day, and by that time the outline of the bones becomes distinct again. After the acute stage has subsided and the joint has become cold, every attempt must be made to restore its mobility. Bli-sters and counter-irritants may be used to procure resolution of the exudation that has become already organized, or the adhesions may be broken down under an ansesthetic ; passive motion and massage must be commenced as soon a.s the condition of the part will allow it, a certain amount of pressure being maintained in the intervals by means of properly contrived elastic supports ; and hot-water douching, galvanism, friction, and every other measure that can improve the circulation and nutrition must be employed to prevent the wasting of the muscles and the stiffening of the joint. Improvement is always gradual, and there is at first a great tendency to relapse, so that a certain amount of caution is necessary ; but if the treatment is kept up, a very great deal may be effected, so long, at least, as the adhesions are extra-articular ; if thev lie inside the synovial cavity they are almost sure to form again, however often they may be broken down. Gouty Arthritis. Gouty arthritis is occasionally met with in young adults, and has even been known in children, but is much more common toward and after middle life. It mav be acute or chronic ; the former, at least, is mixh more frequently met with G O UTY AR THRITIS. 5 6 7 in men than women. The tendency to it is hereditary, but the numljer and sever- ity of the attacks are dependent, to a very large extent, u])on the mode of life, and ])articiilarly ujion the diet of the individual. The smaller joints are usually affected first, especially the metatarso-phalangeal articulation of the great toe (jjos- sihly because it is so liable to injury from ill-fitting boots), but none are exempt, and it is not uncommon to find, post-mortem, abundant deposits of urate of soda in all the larger ones, even though there is no history of their having been inflamed. In acute cases, provided the joint has not been attacked many times before, the changes are merely those of acute synovitis ; all the softer tissues are hyper- Kiiiic and filled with exudation ; the cavity is distended with a more or less turbid fluid in which there is abundance of urate of soda, and all the loose tissue around is infiltrated too. In chronic cases and after repeated attacks, the changes are more permanent. In the slighter forms there is merely a chalky deposit of urate of soda on the surface and in the substance of the cartilages ; but, after the dis- ease has lasted some time, the bones, ligaments, and all the structures around are loaded with masses of the same material to such an extent that nodes formed from it {tophi) project beneath the skin. Coincident with this, and possibly to some extent dependent upon it, are degenerative changes similar to those met with in other examples of chronic inflammation. The matrix, as the cartilage, breaks up into fibrils, the corpuscles increase in number, and where there is any pressure or friction it becomes so absorbed and worn that in places it disappears altogether and leaves the surface of the bone exposed. Then this undergoes similar changes ; the margins grow out into irregular nodules, the shape of the articular surface is entirely altered, and the distortion and impairment of mobility are as bad as in chronic osteo-arthritis. Later, suppuration may break out in the cellular tissue, leaving sinuses discharging a chalk-like substance from time to time ; and anky- losis even has been known to occur in cases in which the inflammation was more than usually jjersistent. The symptoms of an acute attack are very characteristic. It nearly always begins in the night, toward early morning ; sometimes it is preceded by general malaise for several days ; occasionally it follows an accident. The pain is most intense, coming on in paroxysms; it is usually described as resembling the boring of a red-hot iron. There is extreme tenderness, even the pressure of the sheet cannot be borne. The skin is of a peculiar dusky-red color ; the whole of the joint is swollen and burning hot, and all the surrounding tissues are thickened and oedematous. At the first onset there may be a feeling of chilliness, even a slight rigor ; vtry often there is a certain degree of fever, but it is seldom severe, and usually subsides of itself in the course of the morning as the pain grows less intense. In really bad cases this is repeated night after night for upward of a week, the days being passed in comparative comfort, except for the feeling of exhaustion and dis- tress, the nights in agonizing pain. As the attack subsides the swelling disappears, the skin over the joint peels off, and if it is the first, or one of the first, no visible effect is left. Not unfrequently a second or even a third joint is attacked as the first is getting well, but the inflammation is seldom so severe. In the chronic form the pain, heat, swelling, and redness are not so marked, although they vary very much from time to time and the patient is seldom free from them for long. The amount of deformity is much more serious ; the loss of mobil- ity is often very great, and there is an especial tendency to the permanent deposit of urate of soda in the form of chalk-stones. The hands are nearly always affected ; the metacarpo-phalangeal joints are flexed and adducted, so that the fingers slant down to the ulnar side ; distal phalangeal ones may be hyper-extended ; the knuckles are enlarged and flattened ; movements are much impaired ; the skin is smooth and glossy, and the temperature is usually raised. Other signs are gener- ally present to assist the diagnosis. Little cysts filled with fluid form on the dorsal surface and sides of the fingers ; neuralgia and cramp are of common occur- rence ; a burning pain in the heel is very often experienced, especially at night ; 56S DISEASES AND INJURIES OF SPECIAL STRUCTURES. there is a constant tendency to flatulence and dyspepsia ; the urine is loaded with uric acid, giving rise to attacks of urethritis and cystitis ; the skin is liable to eczema and psoriasis, the tongue and the pillars of the fauces become smooth and glossy ; the teeth become loose, and without the least sign of decay drop out quietly of themselves, and the least indiscretion in diet causes the greatest distress. Treatment. — Rest, position, a moderate degree of warmth, and, if it can be borne, the pressure of cotton-wool lightly ajjplied, are especially useful in mod- erating hypera^mia of the acute form. The pain may be relieved to some extent by laying over the part lint dipped in a lotion containing a grain of atropin and eight grains of morphia to the ounce, and covering it with oiled silk, or by using a solu- tion of menthol in the same way. Lead lotion is better avoided, and leeching is positively injurious. The bowels should be opened freely and as soon as possible, preferably with gray powder or calomel and colocynth ; and if the patient is young and healthy and the attack is severe, colchicum should be given with small doses of iodide of potash, quinine, and sulphate of magnesia. Whether it should be tried in other cases is more doubtful ; its value is proportionate to the acuteness of the attack ; in many people it causes sickness, purging, and great depres- sion ; so that if it has disagreed with the patient on any previous occasion, or if the pulse is weak and feeble, and particularly if the gout is chronic, never really disappearing, and the present attack is merely a sudden exacerbation, it should be given in very moderate doses, and for a short time only, leaving off at once if any signs of depression make their appearance. On the other hand, there is no doubt that it agrees, exceedingly well in many cases, and that by taking it occasionally with quinine, and using other precautions, many patients are able to keep them- selves free from severe or prolonged attacks for years without suffering any ill effects. In the chronic form a great deal may be done by appropriate treatment to relieve the stiffness of the joints and ])revent wasting and deformity. Warmth is especially serviceable ; sometimes when there is a large deposit of urate of soda, a lotion containing a drachm of bicarbonate of soda or five grains of lithia to the ounce may be applied with benefit. Hot fomentations, local vapor-baths, and massage, gently applied so as to encourage the flow of lymph as much as pos- sible, are certainly of use. In some places, especially over the knuckles, the skin has a tendency to give way and leave persistent ulceration, but every care should be taken to keep it intact as long as possible. The general treatment, both in the acute and chronic form, is even more important. The diet must be carefully restricted ; it must be nutritious and palatable, but all highly seasoned and rich dishes should be avoided, and particu- larly any excess in meat. Alcohol is better abandoned altogether, certainly malt liquors must be ; but a distinction must be drawn in this respect between an acute attack of gout in a young man and an apparently similar comjjlaint in one who is old and feeble, unable to digest without assistance, and liable to attacks of cardiac intermittence from dyspepsia ; champagne, sherry, and new wines of all kinds should, however, certainly be interdicted ; whether port, particularly old port, in moderation deserves the opprobium that has been heaped upon it is more than doubtful ; certainly it is less injurious than many kinds of so-called claret. Alkalies may be taken in moderation, but it must be remembered that many of them, particularly the potash salts, have a distinctly lowering effect. The large amount of fluid that is usually taken with them in the form of mineral waters is beneficial to some extent, as it prevents concentration of the urine and increases the amount of excrementitious matter discharged. Tonics, iron and quinine, are often necessary, especially in the chronic form. Baths are of the greatest value, though much of the reputation many foreign health-resorts enjoy is really earned by the dietetic and other restrictions that are willingly submitted to away from home. The clothing should be warm, a fair amount of regular exercise taken, the condi- tion of the bowels and the state of the digestion carefully attended to, and over- work, mental as well as bodily, avoided as far as may be. RHEUMATIC ARTHRITIS. 569 Rheumatic Arthritis. In acute rheumatic fever, although the effusion is chiefly collected in the synovial cavity, the surrounding tissues are always infiltrated to some extent. As a rule it subsides without leaving any permanent change ; the exudation, which is rather more fibrinous than it is in simple synovitis, is completely absorbed, and the joint, though it may be stiff for a time, recovers its mobility. Sometimes, however, the attack persists and becomes chronic in one or more of the joints, and occasionally it is chronic from the first, the inflammation coming on slowly and quietly as a result of exposure to cold and wet. In these cases the tissues are liable to undergo more permanent changes ; the cartilage is opaque and dull ; the surface is irregular; it is thickened in some places and thinned by absorjjtion in others; the cells are increased in number and their definite character is lost ; the matrix is fibrillated, giving it a velvety appearance, and in a few cases even the bone underneath is unduly vascular. In short, the changes are practically identi- cal with those that occur in osteo-arthritis, and the resemblance is heightened by the fact that, in very old-standing cases, eburnation may be present, and out- growths, partly cartilaginous, partly bony, form round the edges. In the acute stage the symptoms are distinctly characteristic, and there is rarely any difficulty in the diagnosis. Later, however, when merely the chronic degenerative changes are left, there is such little difference between this affection and many of the diseases that are classed together under the general name of osteo-arthritis that a separate description is unnecessary. The chief feature is the rigidity and thickening of the capsule and periarticular tissue, consequent upon the organization of the exudation, but this is by no means confined to this disease and cannot be regarded as distinctive. i A^-: rrtiv ^^ ■-^. Fig. 239. — Under Surface of Patella, showing Velvety Degeneration of Cartilage in Incipient Osteo-Arthritis. r . y Fig. 24c. — Knee joint, showing the Cartilage Removed from corresponding surfaces of Patella and Exter- nal Condyle, with lipping of margins and thicken- ing of synovial folds. Osteo-Arthritis. Osteo-arthritis is a general term applied to a group of diseases which resemble each other more or less in their pathological features, but which differ widely in their symptoms, causes, and results. Many of them have been described 37 ' 570 DISEASES AND INJURIES OF SPECIAL STRUCTURES. already under different headings, and will only be alluded to here. Rheumatoid arthritis, chronic rheumatic arthritis, arthritis deformans, rheumatic gout, nodosity of the joints, malum coxai senile, and many other names have been given to some of its varied forms. Pathology. — The ])athological appearances are distinctive. The centre of the articular cartilages, where they are subjected to the greatest amount of friction and are furthest away from the arterial circle which supplies them with blood, becomes rough and fibrillated, so that, when placed under water, the surface has the appearance of very coarse velvet (Fig. 239). The upper layers are affected first ; the primary capsules are enlarged and filled with secondary ones ; the matrix is softened ; the capsules form communications with each other ; the superficial ones degenerate, break down, and discharge their contents into the joint ; and at length only a number of fibrils is left, projecting side by side into the synovial cavity. Gradually the degenerative process involves these too, and the cartilage disappears layer by layer until the bone is exposed (Fig. 240). This soon becomes affected in the same way ; the cancellous tissue of the articular ends grows more open and more vascular ; absorption takes place where it is subjected to pressure ; the shape is altogether changed ; and even when no marginal outgrowths are produced there is a very considerable degree of deformity (Fig. 242). The superficial layer, however, in many cases undergoes a totally different transformation ; it becomes harder and denser, until it resembles ivory or porcelain. Whether it is a product of the articular lamella, or is due to calci- fication in the deeper layers of the cartilage, is uncertain ; but in any case it becomes white, dense, and highly polished from the friction it receives. In some cases the whole of the articular area is eburnated in this way and the surface is perfectly uniform and even ; in others, especially in hinge-joints, it is cut into grooves from mutual friction (Fig. 241); and in others again worm-eaten patches and bright, highly-polished ones lie side by side. Around the margin of the joint, where there is no pressure, the effect of the continual irritation is altogether different. Fibrillation of the matrix and pro- liferation of the cells take place, it is true ; but instead of being worn away, the cartilage increases im- mensely in thickness and forms overhanging lips and nodules which project over the articular edge. Later, many of these become ossi- fied, and at length, as the bone is gradually worn away in the centre, and produced in excess all round the margin, the shape of the surface be- comes entirely altered. The head of the femur, for example, is worn away and flattened from above ; the neck is absorbed ; while beneath, on the under sur- face, there is an immense accumulation of new- formed tissue. As a rule, when this occurs, the op- posing surfaces are similarly affected. Sometimes a fair amount of movement is still allowed to take place \ "N.. Fig. 241. — Advanced Osteo-.Arthrilis of Elbow, with Ehurn.iteil and Grooved Articular Surfaces and Enormous Lips of Bone (Osteophytes). OSTE 0-AR THRITIS. 571 between them ; but occasionally they lock into each other and become dovetailed in such a way that practically the joint is fixed. True ankylosis is rarely met with except in the spine. Osteophytes of a similar description are produced on the shaft of the bone, around the attachment of the capsule, and higher up in connection with the periosteum, but their size diminishes rapidly as they recede from the joint (Fig. 241). Occasionally plates and nodules of cartilage and even of bone are produced independently in the thickness of the fibrous tissue. It is probable that the change is first manifested by the cartilages, but the syn- ovial lining of the joint is affected almost as soon. It becomes more vascular and swollen ; the fat-cells disappear : the exudation that is j^oured out from the blood- vessels undergoes organization, and the folds and fringes, which normally are but slightly developed around the margins of the joint, become enormously hyper- trophied. The surface is roughened with numerous little outgrowths, and these increase in number and size until they form pedunculated masses, which branch in all directions and cover the whole of the interior. In extreme cases, there is no trace of the original structure to be seen at the base. Very often the ends of these grQwths become bulbous or club-.shaped, and then cartilage- corpuscles and sometimes even bony nuclei make their appear- ance in them. Occasionally they are detached altogether and drop off as foreign bodies (Fig. 243). In the early stages the cap- sule and the ligaments rarely show any extensive change ; they are merely sw^ollen and thickened in proportion to the hypersemia ; but later they may be profoundly affected. Sometimes they are rigid, contracted, and incorpo- rated with the fibrous tissues around, until movement is almost impossible ; sometimes, on the other hand, they appear to de- generate, and are softened and loosened to such an extent that the ends of the bones become displaced, and even dislocation may occur. As in the other tissues, the result of the persistent irritation is sometimes thickening and organization, sometimes de- generation and absorption, according to the pressure and friction to which they are subjected. The interior of the joint presents the most varied appearance. In some cases, as already mentioned, it is covered all over with arborescent growths ; in others there are only a few large ones here and there, and in others again it is immensely enlarged and perfectly smooth, as if the fibrous tissue of the capsule had become thinned and atrophied. Not unfrequently these different conditions may all be met with together. In one place there are den.se, rigid bands, standing out by themselves ; in another the fibrous tissue is thin and yielding, and is forced out among the surrounding structures so as to form a kind of hernial protrusion. Large pouches developed in this way, and communicating by a long and narrow neck with the synovial cavity, are of common occurrence in many forms of osteo- arthritis. Sometimes they are formed from bursae, which undergo similar changes and gradually enlarge until they come into contact and finally into communica- Fig. 242. — Head of Femur, showing the absorption above and the accumulation below, until an appearance is pro- duced closely similar to that of impacted intra-articular fracture with bony union. 5 72 DISEASES AND INJURIES OF SPECIAL STRUCTURES. tioii with the joint ; much more often they are genuine hernial protrusions, due to the thinner and weaker parts of the capsule being slowly forced out by the intraarticular l)ressure. They are most common in the knee, projecting through the jjosterior ligament, but I have met with them in the ankle, elbow, shoulder, wrist, and hip. They may be very small ; but not unfre(iuently, especially when they find a con- venient interspace, they form gigantic thin-walled cysts, which approach nearer and nearer to the skin until they either break of themselves or are opened. In the knee they may stretch half-way down the leg, and point in the calf below the muscular mass of the gastrocnemius ; in the shoulder they form a swelling under the coracoid process and down below the middle of the arm, along the course of the biceps tendon ; in the ankle they may occ^ir either at the front or the back of the joint ; but, wherever it is, the place of their appearance is no proof of the l)lace of their communication. I have many times dissected them out, and have ,-ing, caused by the rigidity of the muscles and the endeavor to save the joint as far as possible, is the first symptom noticed in most instances. The hip is never quite straightened in walking; the amount of flexion allowed is limited, so that the step is short, and very often at the same time the toes are turned out more than those of the other foot. At first it is only present, or at least noticeable, when the child is tired, and it may be painless ; later, it becomes continuous and is attended with such suffering that the child can hardly rest any weight upon the affected leg. Fain in the earlier stages is very variable. In chronic cases in particular it is exceedingly slight, and is often regarded as merely growing-pain, coming on after any unusual exertion. In acute ones, on the other hand, and when the bone is exposed, it may be of the most intense description, the patient sitting grasping the limb with both hands to prevent the least movement, and crying out with apprehension if any one approaches the bed. Starting pains at night are often very severe when the cartilage is partly separated from the bone on which it rests. T/ie locality of the pain is very remarkable. In a large proportion of cases it is referred to the skin on the inner side of the knee joint, sometimes to the front, and it is not an unusual thing to find that the knee has been examined time after time, painted with iodine, blistered, and even placed on a splint, while the real seat of the disease has been entirely overlooked. In other instances it is referred to the hip itself generally, or to the front of the thigh, or even to the leg ; some- times, particularly in the acetabular form, it is chiefly seated in the iliac fossa above Poupart's ligament, or over the tendon of the adductor longus. The explanation is to be found in the fact that pain, caused by irritation of a deeply seated branch of a nerve, is usually referred to one of the cutaneous divisions, just as cancer of the larynx causes pain in the ear, and a stone at the neck of the bladder gives rise to an intense cutting sensation at the end of the prepuce. The cutaneous division of the obturator is the one most often selected, because of the peculiar distribution of that nerve to the inside of the hip joint and to the ligamentuni teres ; but it may be referred to the middle or internal cutaneous of the anterior crural, and even to the long saphenous and the branches of the sciatic plexus. There does not appear to be any constant relation between the seat of pain and the extent or position of the disease, though when it is severe, espec- ially at night, it may be taken as indicating that the bone is involved. Tenderness on pressure is usually distinct at an early period, especially in Scarpa's triangle, just below Poupart's ligament, and behind the great trochanter — in other words, where the joint is most superficial — and in association with other DISEASE OF THE HIP JOINT. 591 symptoms is of very great value in distinguishing hysterical affections of the hip from real. In the former, it is usually cutaneous, and often, if the attention is diverted, deep, steady pressure is well borne ; in the latter this is reversed, and superficial tenderness is rarely present unless the inflammation is acute or there is commencing suppuration. Sudden jarring of the heel or knee, so as to bring the two articular surfaces smartly into contact with each other, causes pain at an early period of the disease, and should always be avoided. The attitude of the limb is of very great importance. Throughout the dis- ease, from first to last, the hii), if left to itself, is always flexed. The two legs may be i)laced apparently in fiill extension side by side upon a couch, with the knees perfectly straight, but this is due to the curving forward of the luml)ar verte- bra (lordosis) in compensation, and if the hand is placed beneath the loins, the Fig. 255. alteration can be felt at once — the back does not rest upon the couch. If now, with the hand still there, the affected limb is gently raised, the vertebral column gradually becomes straight, and the hollow disappears. The number of degrees through which the limb must be moved, in order to effect this, may be taken as the measurement of the flexion of the joint. For purposes of diagnosis, Thomas places the patient upon a table or hard couch, flexes the sound limb until the thigh touches the abdomen and the leg the thigh, and then directs the patient to straighten out as far as possible the hip that is diseased. As the back is straight and the pelvis fixed, measurement of the angle is easy (Fig. 255). It rarely happens, however, that the flexion is perfectly straight. In the early stages there may be a considerable degree of abduction and apparent lengthening. In the later, there is always adduction and apparent shortening ; that is to say, 592 DISEASES AND INJURIES OF SPECIAL STRUCTURES. when the patient is lying down with the limbs parallel and extended (the lordosis being neglected for the time), the foot of the affected side ai>pears either much lower or much higher than that of the sound one. That the alteration in length is apparent only at this stage can be shown at once by examining the jjelvis ; the iliac spines are raised or lowered exactly in ])roportion to the feet, but it is necessary to make certain of this, as later, the shortening often becomes real. The association of al)duction witii api)arent lengthening, and adduction with apparent shortening, is sufficiently obvious. The angle of lateral deviation is fixed absolutely beyond the jjaticnt's control, so that the legs, when they are ])laced side by side, cannot be at right angles with the pelvis. If now the lower limbs are brought into the same straight line with the trunk, it follows as a natural conse- quence that the pelvis must be tilted. Just as in flexion there is a corresponding degree of lordosis, so in this there must be a compensatory lateral deviation of the v^=^?^ / iM'fl Fig. 256. — Attitude in Early Stage of Hip-disease; the hip and knee flexed, and the heel rested. Fig. 257. — Side View of the same. spine. The same thing holds good, whether it is abduction or adduction, only the tilting is in the opposite direction (Figs. 258 and 259). The measure of this tilting may be taken by abducting or adducting the affected limb from the middle line, until a tape, stretched from the e])isternal notch to the inner malleolus of the sound leg, passes exactly over the umbilicus, showing that there is no lateral curve, and crosses at right angles another which joins together the two anterior superior spines. Later in the course of the disease, adduction is caused by the alteration in shape of the articular ends of the bones, and by their displacement or dislocation ; and then it is always associated with real shortening. Occasionally adduction of both limbs, with extreme eversion (scissor-legged deformity), is met with, probably, as suggested by Lucas, brought on by the patient involuntarily twisting his leg into the best position for progression under the circumstances. Many reasons have been assigned for the change in the position of the affected limb. Flexion, as already mentioned, is present throughout. In the early period, while it is still slight, and associated with abduction and eversion, it is assumed DISEASE OF THE HIP JOINT. 593 l)ecause it is the position of greatest ease — that which causes least tension on the muscles and ligaments and least pressure ui)on the head of the bone; and it has been found by experiment that this is the position in which the capacity of the hip joint for fluid is the greatest. Afterward, however, when it is combined with adduction and inversion and is carried (as it frequently is if left to itself) to such a degree that the limb is bent to an acute angle with the trunk, this holds good no longer, and the cause then is the spasmodic contraction of the flexors. Just as in the knee joint they gradually flex the leg upon the thigh until the calf is in contact with the ham, so here they overcome the extensors, and flex and adduct the thigh upon the trunk, until, if it is not checked in some way, the limb can go no further. Muscular 7c>asti/ig affecting the extensors is one of the earliest and most valuable signs. The gluteus maximus on the aff'ected side is flattened and feels flabby in comparison with the other ; and the lower gluteal fold is partially obliterated. This atrophy is probably reflex, due, it may be, to some form of Fig. 258.— The Legs Parallel and the Pelvis tilted, because the angle of the affected limb (whether it is abducted or ad- ducted) is fixed, and beyond the patient's control. Fig. 259. — Pelvis Brought to its Proper Position by abducting the thigh on the diseased side. descending neuritis, and must be distinguished from that form occurring later in the disease, and affecting all the muscles of the limb equally, caused by disuse. Impaired mobility, which is always present from the very earliest days of the disease, is the most valuable symptom. At first it is due to muscular rigidity and spasm, and disappears completely under an anaesthetic ; later it is caused by adhe- sions round or inside the joint, and at length in some cases by bony ankylosis. Perfect extension is impossible ; apparently it may be carried out, but this is a deception, due to the lordosis. Perfect flexion is equally out of the question. If the finger is placed on the anterior superior spine of the ilium on the sound side, and the limb is flexed, taking care to keep it in a straight line with the body, without abducting it, the pelvis remains perfectly steady until the front of the thigh touches the abdomen ; if the same is then done on the diseased side, the jjelvis begins to rotate from under the finger, sooner or later, according to the degree of limitation. Rotation is equally important ; if the thigh is flexed to a right 594 DISEASES AND INJURIES OF SPECIAL STRUCTURES. angle upon the trunk, absolute freedom of movement should be allowed in either direction. It is almost certain that hip-disease is not present, if, with the patient lying on his back, with the hip and knee flexed until the foot of the affected limb rests upon the couch by the knee of the sound one, the thigh can be abducted until it rests ui)on its outer side. In this position there is an immense strain thrown upon the inner part of the capsule, and if there is the least degree of inflammation, the pelvis will rock from one side to the other instead. S7i.ielling is exceedingly significant, not so much of the existence of hip- disease, for it may be absent at the first, but of the stage which has been reached. If it occurs in the early days, filling up the hollow of Scarpa's triangle when the limb is flexed and abducted, it points to effusion in the synovial sac, such as is more usually met with in rheumatic and traumatic synovitis than in tubercular disease. Later it may be best appreciated by grasping the joint between the fin- ger and thumb, from before backward. Definite thickening of the base of the great trochanter is almost proof of caseation : general infiltration of the periarticu- lar tissues rarely comes on until the disease is far advanced. Alteration in the Letigth of the Limb. — Apparent lengthening and shortening have been already mentioned ; they are due entirely to abduction or adduction. Real lengthening is very doubtful. It is just possible that it may occur from in- creased growth of the limb ; but the circumstance must be quite exceptional, and it must not be forgotten that inequality of the two legs is by no means unusual. The head of the femur is sometimes separated from the acetabulum by fluid insinu- ating itself between the two cartilaginous surfaces ; and possibly the same thing may be effected by the growth of granulation-tissue from one or both of the bones, but either of these conditions would prevent the limb being placed in extension, and measurement taken with the least degree of flexion is most deceptive. Real shortening, on the other hand, at a later period of the disease, may be caused in various ways. In the most common, the head of the femur and the rim of the acetabulum, against which it is driven by the muscular contraction, mutually destroy each other. Pressure on inflamed bone very rapidly causes ab- sorption and disintegration ; the head of the femur diminishes in size at the same time that it cuts away through the margin of the acetabulum, and the mutual de- struction, even if it does not end in a kind of dislocation, causes a very consider- able degree of shortening. In rarer cases the floor of the acetabulum is per- forated ; or the head of the bone is pushed out from the socket by the fluid that accumulates behind it, forming what is known as dislocation /n' distention ; or the epiphysis is separated from the neck, and the latter is carried up against the upper and back part of the capsule of the joint. In addition, the limb is always shortened by the loss of the ei'iphysis and, what is much more important, by the general failure in nutrition of the part. A sliding-rod should always be used to estimate this in preference to a tape, and the measurements should be taken from the anterior superior spine to the in- ternal malleolus, but there are many sources of fallacy. A slight degree of flexion causes a diminution in length. Owing to the alteration in the shape and position of the articular surfaces, real shortening is always associated with adduction ; as a consequence the pelvis is tilted to one side, and when the legs are brought to the same line with the body, apparent shortening is added to the real. In most cases, therefore, it is necessary to supplement this by Nelaton's line, Bryant's triangle, or by measurement of the bones of the limb sei)arately. Increase of temperature is very rarely present in tubercular arthritis, unless there is an acute abscess ai)proaching the surface. As the disease advances, other symptoms begin to appear. The deformity due to destruction of the bones and ligaments becomes more marked ; flexion and adduction grow worse ; the shortening of the limb is no longer apparent, but real ; wasting is no longer confined to the extensors, but involves all the structures of the thigh ; starting pains make their appearance at night, and ca.seation soon follows. DISEASE OF THE HIP JOINT. 595 True sui)piiration is a complication and may not make its appearance so long as the skin is intact. Sooner or later, however, some caseous focus in the centre of a mass of granulations slowly softens, and becomes licjuid. Usually this begins in the interior of the joint, and often in the interior of the Ijone ; but occasion- ally it is periarticular from the first. The orifice in the capsule, however, is generally very small and is easily overlooked. The direction the fluid takes depends on anatomical relations. It may work its way out through the posterior thin part of the capsule behind, and point under the gluteus maximus, or pa.ss under the transverse ligament to the inner side of the limb. Sometimes it comes out through the front, along the course of the branches of the external circumflex, or, in older patients, it opens into the bursa under the psoas. A very common situation for it to show itself is just in front of the insertion of the tensor fasciae femoris, guided, in all probability, by the firm sheet of fibrous tissue that lies beneath it ; but it may run up the sheath of the psoas or work its way into the perineum, and burst into the ischio-rectal fossa or even into the rectum. Intra- pelvic collections of this kind nearly always point to disease of the acetabulum ; sometimes they originate independently on the pelvic side between the bone and the obturator fascia ; in other cases they are due to perforation of the floor. Even when small their presence can usually be detected by examination with the finger in the bowel ; as they enlarge they spread upward, causing a fullness in the iliac fossa over Poupart's ligament, and pointing generally near the anterior superior spine. When the disease involves the pubes, the opening is usually either by the side of the adductor longus tendon, or in the groove between the scrotum or labium and the thigh. Old cases of hip-disease very commonly present sinuses discharging a thin purulent fluid from time to time, in several of these situations. Constitutional Symptoms. — In the early stage of hip disease these are very slight. Caseation and liquefaction may generally be suspected if there is definite and regular rise of temperature every evening. Later, when suppuration occurs, this is always present. Hectic, the various forms of fever caused by septic absorption from ill-drained suppurating cavities, amyloid disease, and other troubles which are not uncommonly met with at a later period still, must be regarded as complications which occur in tubercular arthritis in common with other varieties of joint disea.se. Diagnosis. — Advanced hip disease is usually clear at the first glance : in the early stages the diagnosis is often a matter of the utmost difficulty. The symp- toms are very slight ; many of them are present in other affections, and worst of all, as it is necessary to prove that the joint is sound, they are often imitated with great exactne.ss in hysteria. The examination must be thorough ; no symptoms may be neglected ; but the limitation of movement even in the slightest degree, the wasting of the extensors, and the position assumed by the limb, are certainly the most important. The diagnosis must be made from other diseases of the hip joint ; malforma- tions ; diseases of other joints ; inflammation of neighboring structures, and hysteria. Inflammation of the hip joint due to other causes is very rarely insidious. Traumatic synovitis may occur in children, and requires especial care, as after a temporary improvement it becomes sometimes the starting-point of tubercular dis- ease. Syphilitic inflammation is rare, even in the hereditary form, and probably could only be diagnosed by the result of specific treatment. Rheumatic synovitis is much more acute, and chronic rheumatoid arthritis, which does, as a rare excep- tion, affect the hip in children, may be distinguished by the character of the artic- ular changes Congenital dislocation of the hip, rickets, and infantile paralysis sometimes produce a condition of things which in the absence of any history, or if the patient is hysterical, may give rise to considerable difficulty. Movement, how- ever — especially rotation in the flexed position of the limb — is rarely restricted. Tubercular disease of the sacro-iliac joint may present essentially the same 596 DISEASES AND INJURIES OF SPECIAL STRUCTURES. symptoms ; in addition, however, there is always pain in attemi)ting to separate or press together the ihac crests ; and usually there is a certain amount of fullness over the joint posteriorly. Lateral curvature of the spine, which may result from disease of the hip, is occasionally mistaken for antl treated as the primary affection. Mistaking disease of the hip for disease of the knee, owing to the ])ain in the latter, is much more common. It must not be forgotten, however, that the two may occur together. Chronic osteitis or periostitis of the upper end of the femur is most difficult, especially as it is always associated with a certain degree of synovitis. The severity of the pain, especially at night, the great tenderness over the trochanter, and possibly the early development of oedema of the skin covering it, distinguish them, but exploratory incision is generally recjuired. The same difficulty occurs with a rare form of central sarcoma involving the upper end of the bone. Inflammation of the bursa under the psoas, or of the psoas itself, imitates hip disease exceedingly well, especially in young adults. The bursa, generally s[)eak- ing, develops in childhood, but does not attain a very large size for some years, and rarely communicates with the joint until late in adult life. As a rule, the diagnosis can be made by the free rotation allowed when the hip joint is flexed. More rarely the same thing occurs in connection with one of the gluteal bursge. rerityi)hlitis, iliac and psoas abscesses, and inflammation in connection with the lymphatic glands, or wnth the cellular tissue around the hip joint, occasionally give rise to a certain amount of difficulty ; but this nearly always results from special attention being paid to one single symptom. If the whole case is thoroughly and carefully investigated, such a mistake can scarcely occur. The same may be said of hysteria : the position of the limb may be exact ; the pain may be felt in the knee ; there may be limitation of movement just as there is in real disease of the joint, but it rarely happens that these symptoms are in accordance with each other. Cutaneous tenderness, for example, may be e.vcessive without there being any pain on deep-seated pressure; intra-artic- ular pressure may be well borne when the hand is applied to the heel, but exceeding painful when the knee is touched ; or there is some other gross discrepancy which effectually negatives the idea of serious disease. The Stages of Hip Disease. — For convenience in description it is usual to divide hij) disease into various periods distinguished by certain clinical features, of which the position assumed by the limb is the one usually selected. In the first, flexion is slight, and is, or is not, accompanied by slight abduction. In the second, flexion is well marked ; abduction and apparent lengthening are present as a rule : sometimes, however, there is adduction. In the third, flexion is combined with adduction and apparent or real shortening. As, however, this gives little or no guidance for treatment, and as it cannot be said that the ]!Osition of the limb invariably corresponds with the pathological changes, a classification closely resembling that proposed by Adams is more .satis- factory. First stage : to the beginning of caseation, without thickening of the base of the trochanter or an evening rise of temperature. Perfect recovery possible, the granulation tissue being completely aksorbed or organized. Fig. 260. — Attitude of Advanced Hip Disease. HIP DISEASE. 597 Second stage: caseation, but no general thickening around the joint or periarticular infiltration. Recovery more doubtful, with great danger of relapse, some risk of general tubercular infection, and some limitation of movement. Third stage : the capsule softened ; the limb adducted ; the shortening apparent at first, but later becoming real ; extra-articular supiniration ; and permanent deformity with much greater risk of tuberculosis and liability to the various forms of septic infection, hectic, and amyloid disease. If the patient escapes these dan- gers the tubercular process may come to an end ; and gradual organization take place, with the formation of residual abscesses from time to time. Treatment. — The general principles are of the most simple character. Every care must be taken, by appropriate hygiene, good food, tonics, cod-liver oil, etc., to improve the general health, as already described. The first thing is to bring the limb into good position ; the second to keep it absolutely at rest until it has thoroughly recovered. During the acute stage and so long as the pain is severe, the child should be confined to bed ; afterward, if it can be kept under proper supervision, it may be allowed to get about on crutches, with the limb protected against move- ment and accident by means of a suitable apparatus. There is no doubt that the evil effects of a pro- longed confinement to bed have been much ex- aggerated ; but, on the other hand, provided the deformity is corrected, and the limb is properly secured, no purpose is served by retaining the child there during the long period of convalescence. {a) In the First Stage. — The apparatus in general use is either a long splint with weight ex- tension, or Thomas' splint ; but the surgeon must be prepared to make use of others, such as Byrant's (Fig. 261), or to devise them for use in exceptional cases, where, for example, there is disease of both hips or some unusual deformity. Weight extension is advisable if the symptoms are very acute ; it prevents intra-articular pressure as well as friction, and secures complete muscular relaxation. It is most easily applied by means of an ordinary stirrup, fastened above, as well as below, the knee with circular pieces of strapping and a bandage. Care must be taken that there is no pressure upon the malleoli ; and that the weight is not applied for some hours after the stirrup is finished, for fear of the strapping giving way. Three or four pounds are sufficient for a child ; six or eight for a young adult. The position of the patient is secured by means of a long splint, reaching from the axilla to below the foot, applied to the sound side of the body. In the case of a child the shoulders should be fas- tened down by means of a chest-band and braces, so that he cannot raise himself from the recumbent position. The direction in which extension is made depends upon the attitude of the limb. If the patient is under an anaesthetic, and the hip joint lies perfectly straight, showing that the deformity is purely muscular, extension — provided it is begun before the muscles regain their tone — may be made 598 DISEASES AND INJURIES OF SPECIAL STRUCTURES. in the axis of the body. The steady jnill uijon the limb, as consciousness returns, prevents the spasmodic contraction causing any pressure upon the articular sur- faces. If, on the other hand, an anaesthetic is not given, if'there are fibrous adhesions present, or if the muscles have degenerated and become rigid, .so that / mm imm. •^-^ ^.»a?^ ^]aj^~ ^«^ a^^ ij^,Tie gs t:;,j^ — ' y KiG. 262. — Weight Extension in the Faulty Position. Abduction and Flexion. the limb cannot at once assume a straight position, extension must be made in the axis of the limb, and the angle gradually straightened every two or three days. In this way the opposing structures, whatever they may be, are slowly ...i,it.~#«v« placing the patient under an anaesthetic and ascertaining the range of movement and the strength of the obstacles that prevent it. Diagnosis. — Bony ankylosis can ;nosed by the extreme mus- and the entire absence of the part is roughly man- iig^^^~^u^f^^^iii~Z,.Ll^V^-„-_i iljulated. it there is the least degree of mobility left, too small to be appreciated by the hand, the muscles round the joint involuntarily start into spasmodic con- traction as .soon as any force is used ; with bony ankylosis they remain absolutely flaccid. The distinction between intra- and extra-articular rigidity turns rather upon the cause than upon any symptom that may be present ; it is rarely possible to be certain, but probably the former is seldom met with by itself. Treatment. — Bony Ankylosis. — In many cases this is the best result that can be obtained under the circumstances, and provided the position is good, it should not be touched. If, for example, the elbow is flexed to a right angle (or prefer- ably a little less) the hand can be used for all ordinary purposes with perfect free- dom ; when it is more open, so that the fingers cannot be brought to the mouth, it becomes a question whether excision should not be performed. The hip and knee when nearly straight impair the power of the limb very little, although the gait is awkward ; if, however, they are much flexed, excision (removing a wedge- shaped piece) should be performed in the one case, osteotomy (either through the neck or below the trochanter) in the other. In the case of the shoulder, ankle, and fingers, neighboring joints compensate so thoroughly that active treatment is rarely necessary. Bony ankylosis of the temporo-maxillary artictdation, on the other hand, naturally cannot be left. Fibrous Ankylosis. — The function of the part maybe restored, or at least im- proved, by stretching the adhesions, or forcibly breaking them down. Nothing, however, may be attempted so long as there is the least degree of inflammation ; it would merely cause a fresh attack, the danger that is feared the most. The probability of inflammation depends chiefly upon the nature of the original cause. If this was traumatic — if, for example, the joint was sprained or dislocated, and the injury repaired at once — the risk is exceedingly small ; break- ing an adhesion across, once for all, in a healthy person, is not more likely to cause inflammation than breaking a bone. If, on the other hand, it was consti- tutional, whether due to gout, rheumatism, tubercle, or any other cause, and the same diathesis is present still, there is no question that violent manipulation may be followed by very serious results. Fortunately, even in these cases, the predis- posing causes are not always of the same intensity ; gout and rheumatism, for ex- ample, admit of being alleviated ; and, especially in the case of joints and bones, the susceptibility to tubercle is of limited duration ; so that, by selecting a i)roper time, when the general health is good and the skin over the affected joint perfectly EXCISION OF JOINTS. 619 cool, and by adopting suitable precautions before and after, a very great deal may be effected in the vast majority of instances, with the minimum of risk. The other question, whether the adhesions should be broken down once for all (under an annesthetic if necessary), or gradually stretched little by little until they give way sufficiently to allow free movement, is more easy. This depends almost entirely upon their e.xtent. If they are small and few in number, or if they are so situated that they can be taken one by one — round the capsule of a joint, for example — and snapped acro.ss by successive rapid action, the chance of inflam- mation following is very much less than if they are strained each day by the application of some continuous force, and recovery is more perfect. It is mainly owing to their skill in localizing lesions of this kind, in the neighborhood of joints, and to the experience they have gained in the necessary manipulation, that bone- setters have acquired so great reputation with many people, in spite of their fre- quent failures, and in not a few cases disastrous results. Very little, on the other hand, can be done in this way in the case of the short and dense intra-articular adhesions that form after suppuration or advanced tubercular disease. These may be stretched to a certain extent by continued traction so as to alter the position of the limb if that is faulty; but, as a rule, any attempt at restoring mobility by more active measures is only too likely to end in failure. Tenotomy is rarely required in cases of fibrous ankylosis, except for distant tendons or thickened portions of the fascia that have undergone passive contrac- tion. The punctures should always be allowed to heal soundly before the least manipulation or extension is attempted for fear of the skin giving way. Whichever plan is adopted, it must always be remembered that tearing, stretching, or cutting the resisting bands is only half the cure. Owing to pro- longed rest, all the structures around the joint are wasted, stiffened, and incapable of work, and, after all gross mechanical obstacles have been removed, these must be brought into a thorough state of nutrition before they can be expected to work freely and painlessly. The joint must be well steamed and douched ; all the tissues kneaded thoroughly and well rubbed with oil ; the muscles manipulated and stretched ; and passive and what are known as resistive movements assiduously practiced. SECTION VI.— EXCISION OF JOINTS. By excision is understood the formally-planned removal of more or less of the articular surfaces of a joint, not merely the synovial membrane (erasion) or the part that is obviously diseased. It may be required either for injury (this is some- times distinguished as primary excision), disease, or deformity. {a) In cases of injury, excision is performed as an alternative to amputation. Except at the hip joint, it is the more serious operation of the two, entailing pro- longed confinement, and should not be preferred unless the age and constitution of the patient (particularly the state of the kidneys) are favorable. It is essential that the main blood-vessels and nerves of the part should be intact, and the skin not too much bruised. (J)) For Disease. — Tubercular arthritis is the most frequent cause, osteo- arthritis an exceptional one, and other forms of disease still more rare. For it to succeed, the inflammation must be chronic or past ; the age of the patient suit- able ; the viscera sound fwithout amyloid degeneration, or, at the very most, a sus- picion of it) ; the bone not too extensively diseased (if the epiphyses are cut away the growth and utility of the limb are so much impaired as to raise the question whether amputation would not have been better) ; and all the soft parts involved capable of free removal. {/) For Deformity. — This may be the result of injury, or of antecedent in- flammation — septic, tubercular, or rheumatic — or in some rare cases it may be con- genital. The question here is an entirely different one, depending upon the 620 DISEASES AND INJURIES OF SPECIAL STRUCTURES. utility of the joint in its deformed position ; the probable utility of the part after excision, judging from previous exj^erience ; and the possibility of rectifying the deformity more or less completely by some less serious operation, such as subcu- taneous osteotomy. General Principles. — The soft parts are incised in such a way as to expose the interior of the joint with the minimum of injury to the structures around. The epiphysial lines must be kept intact. How much bone is taken away (beyond that which is diseased) is regulated by the kind of union that is required, bony or fibrous. The whole of the disease must be removed ; if there are outlying sin- uses or tubercular foci in the bones, they must be thoroughly scraped out. Perfect drainage must be provided for, and the dressing and splints must be arranged so as to keep the part at rest and exert sufficient pressure upon it, while at the same time they admit of being changed, if required, with the minimum of disturbance. Passive motion, if enough bone has been taken away, need not be commenced until the wound is practically sound ; but where, as in the case of the wrist, tendons that move other joints have been exposed and handled, these should be worked after the first day in order to prevent the formation of adhesions. The preservation of the periosteum is only to be attempted when a great re- production of bone is advisable. If the bones are soft and inflamed, as in most instances of tubercular arthritis, its separation presents no difficulty, but in pri- mary excisions it adheres so closely that very often it is too much bruised to live. In cases of fibrous union and when movement is desired, massage, shampooing, and galvanism should be commenced as soon as possible. The muscles and nerves are atrophied from prolonged disuse, the circulation through the limb is very feeble, and it requires much time and patience to bring back the part to its normal state of nutrition. EXCISION OF SPECIAL JOINTS. I. The Upper Extremity. Excision of the Shoulder Joint. This may be required for injury or disease. Ankylosis is compensated for so thoroughly by the mobility of the scapula that it is a question whether operation is advisable. It has also been performed for unreduced dislocation in which the head of the bone was resting upon the brachial plexus, and for tumors in connection with the upper extremity of the humerus. {a) Injury. — In this case the operation merely consists in removing com- minuted, displaced, and detached fragments of bone through the wound (enlarg- ing it if necessary), cleansing the cavity thoroughly, and providing free drainage. {b) Disease. — Tubercular osteitis of the head of the humerus, involving the synovial lining secondarily and spreading to the glenoid fossa, is the most fre- quent cause ; but, even in this, expectant treatment, removing carious or necrosed fragments of bone and scraping out old sinuses, is usually followed by such a good result that excision is seldom practiced. For other forms of inflammation — osteo- arthritis, urethral arthritis, acute necrosis, or chronic suppuration — it is still more rare. The^ usual incision is vertical, between three and four inches in length, be- ginning just outside the coracoid process, on a level with it, and carried through the skin, fascia, and deltoid, down to the bone. If the arm is rotated outward and the soft part drawn to the sides, the tendon of the biceps is exposed at the bottom. This should be preserved if possible ; sometimes it is in a pulpy condition, or has already been eroded, and occasionally it is fixed firmly to the bone in its groove, and the upper end of it lost. The capsule is then freely opened and the condition of the i^arts examined before determining how much it is necessary to take away. So far as the subsequent utility of the linib is concerned, there is no doubt that the more of the bone that is left the better. Partial resections (in which EXCISION OF THE ELBOW JOINTS. 621 some of the head is left, the rest being gouged away) give better results than when the anatomical neck is divided ; and this is to be preferred to the surgical neck. The whole of the disease must be removed (and in cases of tumors springing from the head of the bone one-third and in some cases even more of the shaft has been excised, preserving the elbow and the hand), but consistently with this, as little as possible of the healthy bone. The (juestion of subperiosteal excision is still open, but there is ground for believing that where it is practicable the results are superior to the other method. If the surgical neck requires division the arm must be strongly rotated out- ward by the assistant as soon as the capsule is opened, in order that the tendon of the subscapularis may be cut; and then inward for the short external rotators. As soon as this is done the head of the bone rises well up into the wound, and may be either sawn off with a narrow-bladed saw in situ, the soft parts being protected and held aside by retractors, or thrust bodily out. The glenoid fossa very rarely requires more than the application of a gouge. [Prof. Senn's method of exposing the shoulder joint by temporary resection of the acromion, was performed by the editor at the Rush Medical College Clinic, January, 1893. The operation is not difficult of performance, and the conserva- tion of muscular attachments by this procedure is of extreme value in the result.] A counter-opening at the back of the joint is usually advisable for drainage. The wound is thoroughly cleansed ; the margins drawn together with sutures ; a large tube placed across it ; and the cavity of the axilla, the space behind the shoulder, and the outer side and front of the arm thoroughly packed with wood- wool. Stromeyer's elbow cushion should be used as long as the patient is in bed, and passive motion commenced as soon as the condition of the wound allows it, the fingers and wrist being exercised from the first. Results. — All underhand movements can be carried out exceedingly well ; elevation above the horizontal line is only possible in those cases in which the head of the bone is partially preserved or reproduced ; in all others the deltoid loses its fulcrum, and the perfect apposition of the two bones, which enables rotation of the scapula to raise the arm, becomes impossible. Excision of the Elbow Joint. Primary excision for compound comminuted fracture extending into the joint is very successful. As usual in primary operations, the reaction is greater than in the cases of disease, and, if suppuration occurs, a very large amount of callus may be thrown out, endangering the movement of the joint. It is chiefly required when the lower end of the humerus is comminuted. When this occurs it is prac- tically impossible to restore the fragments to their proper position, and owing to the irregularity of the articular surface and the filling up of the coronoid and ole- cranon fossge, a much wider range of movement can be obtained by operation. Excision for Disease. — Tubercular arthritis is the usual cause, but the pro- portion of cases in which the operation is required is a very small one. Strumous disease of the elbow joint is essentially an affection of childhood, a time in which excision should if possible be avoided, owing to the way in which it interferes with the growth of the arm ; and in the vast majority of instances, if the patient's surroundings can be improved, the joint kept at rest upon a splint, abscesses opened from time to time, and sinuses and carious bone scraped out, the result is an exceedingly good one. The range of movement, it is true, may not be so wide ; but if proper attention is paid to position it is usually sufficient, and there is no risk of a "flail joint," or of failure of growth. There is certainly the danger of the tuberculosis becoming general, but it rests with the advocates of excision to prove that this is serious. Of course, if the bone is so extensively diseased that repair is unlikely, or if improvement does not take place under ordinary treatment, or if the amount of discharge is so great that there is risk of the general health failing, there should be no hesitation. 622 DISEASES AND INJURIES OF SPECIAL STRUCTURES. For other diseases excision is rarely necessary ; l)iit it may be performed for supijiirating osteo-arthritis (in a patient sixty-three years of age under my care the result was most successful), and for chronic suppuration consequent upon injury or jjya^mia. /// cases of deformity, whether arising from old unreduced dislocation, from ankylosis after inflammation, or from cicatricial contraction of the soft parts, excision often gives a very good result. The (juestion as to its advisability turns upon the usefulness of the arm and the occupation of the jjatient. liony ankylosis at an angle of 75° to 80° is a wonderfully slight impediment to many jjeople ; on the other hand, if the angle is in the least degree obtuse, so that the patient can neither feed himself with an ordinary spoon or fork nor place his hand at the back of his head, the arm is almost useless. Operation. — An elastic band may be applied around the arm, but the bleed- ing is usually slight. The shoulder is raised on a pillow and the forearm held by an assistant. If the right elbow is in question, the arm should be held across the patient, with the olecranon presenting upward, the operator standing on the same side, the assistant on the opposite one. If the left, it is more convenient for the surgeon to stand upon the right. A linear incision, four inches in length, is made over the back of the joint, its centre corresponding to the tijj of the olecranon. It should lie just to the inner side of the middle of the arm and be carried right down to the bone at once, splitting the fascia of the triceps longitudinally. The next step is to detach from the bone the aponeurosis covering the back of the olecranon, first upon the outer side, then upon the inner, until the narrower part of the process is reached. In cases of disease this is easily accomplished with a blunt elevator, but in primary excision it is more difficult. If now the olecranon is cut across with a pair of bone forceps, the cavity of the joint is ojjened, the triceps and the jwsterior parts of the lateral ligaments are detached from the ulna without risking the insertion of the muscle into the fascia, and abundant space is obtained for separating the soft parts from the condyles. This, especially in cases of injury, is the most tedious part of the operation. The inner side must be cleared first, taking care of the ulnar nerve, which is seldom seen. The soft parts are raised with the thumb from the bone beneath, and carefully sepa- rated from their attachment with a stout scalpel, keeping the knife parallel to the nerve. The external is treated in the same way, the a.ssistant helping by keeping the arm as nearly vertical as possible. As soon as this is done the end of the humerus protrudes through the incision, and the bone can be cleared with ease as high as necessary. How much should be removed depends upon the general condition ; the whole of the cartilaginous surface should certainly come away, the line of section passing above the condyles ; but the age of the patient, the cause, whether injury or disease, and the state of the arm, which in some ca.sesof old ank\losis is greatly wasted, must all be taken into consideration. The stump of the olecranon and the head of the radius are then cleared in the same way and sawn across together, above the insertion of the biceps. It is often recommended to open the joint above the olecranon, and remove the necessary portions of the ulna and radius first; but I have found the method described more expeditious. In tubercular disease the condition of the synovial membrane and of the bones J Fig. 278. — Seclionof the Bones in Excision of the Elbow Joint. EXCISION OF THE WRIST. 623 may renuire attention. One or two small arteries may need to be tied or twisted, but there is very little bleeding. The wound can usually be washed out at once with a hot solution of corrosive sublimate, and sutured, leaving an orifice in the middle for drainage, or better, a short drainage-tube. Many splints have been devised for use after this operation ("some surgeons use none at all) ; but as convenient a contrivance as any, at least while the patient is in bed, is an inside angular one, interrupted and hinged opposite the elbow, proviiled with a rounded end (as in Carr's splint) for the fingers, and with two cross-l)ars underneath, so that it may be slung from a pulley over the bed, and supported by a counterpoise of shot. With this the dressings are easily changed ; the angle can be altered if required, the fingers can be exercised, and the patient can sit up and move about in bed without the least fear of disturbing the wound. Passive movement of the fingers and wrist should be commenced at the end of the first week ; the new joint need not be moved until the wound is nearly sound. \{ too little bone has been taken away, passive motion will not prevent osseous union. In some cases all the movements of the joint — flexion, extension, pronation, and supination — are almost perfect from the first ; but these are the exceptions. In the majority there is very little power for some time, but gradu- ally, as the muscles grow accustomed to' their shortened position, and as the nutrition improves under the influence of galvanism, massage, passive motion, and exercise, the strength returns, and the range increases until it is almost, if not quite, as good as in the normal arm. This may take place even after a twelve- month. If the movement becomes restricted, in spite of passive motion, the cjuestion must be considered whether the operation should be repeated and more bone removed, or the limb allowed to become rigid (as it cannot be prevented) at the most convenient angle. If, on the other hand, a flail joint results, the usefulness may be greatly increased by providing the patient with a suitable leather or poro- plastic splint, taking the whole of the arm and the forearm as far as the wrist. Excision of the Wrist. This is very rarely required except for strumous disease. I have on several cases performed a partial operation in cases of injury, removing bruised and broken fragments of bone with a good result; but an accident that rendered complete ex- cision necessary would almost certainly cause too great destruction of the soft parts. It may be performed in various ways, but the two chief are those practiced first by Lister and by Langenbeck. I. Lister s Operation. — Two lateral in- cisions are made ; the whole of the carpal bones except the hook of the unciform and the osseous portion of the pisiform are re- moved, and five tendons only (the carpal flexors and extensors) divided at their in- sertion. Esmarch's bandage is applied and the adhesions broken down. The first incision begins on the middle of the dorsal aspect of the radius, on a level with the styloid pro- cess, and runs thence to the radial side of the base of the second metacarpal and along the bone ft»r half its length. Its first part lies just internal to the extensor secundi inter- nodii, and it turns just before it reaches the radial artery Fig. 279. — Lister's Incision for Excision of the Wrist. If carried down to 624 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the bone at once it necessarily cuts across the extensor carpi radialis brevior ; this may, however, be avoided with a bttle care and the tendon divided immediately afterward at its insertion. The tendon of the long extensor of the carpus is then separated from its attachment ; the radial artery with the tendons of the thumb drawn outward ; the trapezium detached from the rest of the carpus with cutting-forceps, and all the tendons on the dorsal surface of the carpus raised from the bones beneath as far toward the ulnar side as possible. They should not l)e lifted out of their grooves on the radius. The second incision is on the palmar asi)ect of the ulnar side. It begins two inches above the joint, internal to the flexor carpi ulnaris, and is carried down to the middle of the fifth metacarpal. The tendon of the extensor carpi ulnaris is cut at its insertion ; the dorsal and internal lateral ligaments divided, and the raising of the extensor tendons completed by working toward the radial side. The soft parts on the palmar surface are separated next, the pisiform bone witli the tendon of the flexor ulnaris being detached from the rest and the unciform process cut off. The wrist in doing this must be flexed and care must be taken not to work down on to the metacarpus for fear of the deep palmar arch. The anterior ligament of the carpus is divided at the same time. The carpal bones (except the trapezium) can now be extracted through the ulnar incision with sequestrum-forceps, the ends of the ulna and radius forced out, and their articular surfaces removed with a gouge or saw, as the ca.se requires. Fig. 280. — Lister's Splint for Excision of the Wrist. The Styloid process of the ulna should be left, and the tendons on the dorsum of the radius disturbed in their grooves as little as they can be. The metacarpus is then treated in the same way : the trai)ezium dissected out, taking care of the tendon and the artery (if this bone appears fairly sound it may be left), and the articular surface removed from the pisiform bone. Lister's splint, with a cork pad to support the fingers in semi-flexion, and a bar for the thumb, is nearly always used. The fingers and thumb must be thoroughly flexed and extended at every joint after the second day, in order that the tendons may cut channels for themselves in the va.scular lymph that fills the wound ; but the wrist itself must be kept at rest until union is assured. 2. Latigenbecfi s. — A single incision four inches in length is made along the dorsal surface of the wrist between the tendons of the exten.sor secundi internodii and the exten.sor indicis, commencing well above the wrist joint and ending at the middle of the second metacarpal bone on its ulnar side. The tendons on the radial side of the incision are then lifted up from the radius and the carpus, with the periosteum, so that the sheaths are not opened ; the proximal row of carpal bones separated from each other and extracted one by one, beginning with the scaphoid, and then the second row treated in the same manner. It must be re- membered that in cases of stnmious disease the bones are softened ; the ligaments for the most part easily divided ; and the soft tissues around matted together so that they can be much more easily detached ; otherwise this operation is one of considerable difficulty. The cases for which excision of the wrist is required are few and far between. EXCISION OF THE HIP JOINT. 625 In young subjects, if caseation is not yet far advanced, a very great deal can be done by rest, tonics, and thorougli general treatment, the joint being easily pro- tected afterward. If caseation and suj^puration have occurred already, local operations, such as gouging out soft carious bone and packing the cavities with iodoform gauze, frecpiently suffice, and leave a very useful hand. In older people it is so often associated with plithisis that great care must be taken in the selection of cases. The operation itself sometimes yields a very good result; but, on the other hand, not unfrecpiently all the tendons become matted together, or the tubercular disease returns, or suppuration sets in, or the patient's health begins to fail and amputation has to be performed. In what proportion of cases this occurs it is impossible to say, but there is reason to believe that it is a very large one. The TJiunib and Eifiger Joints. Excision of the metacarpo-phalangeal articulation of the thumb may be per- formed without difficulty through a vertical dorsal incision. It is sometimes re- quired for compound comminuted fractures or old unreduced dislocations, and gives an excellent result. Occasionally a similar operation is advisable in injuries of other joints. ri. The Lower Extremity. The Hip Joint. Excision of the hip is performed for compound comminuted fractures of the head of the bone (such cases are very rare in civil life), as an alternative to am- putation, and occasionally for old unreduced dislocations. The total number of these, however, is very small ; nearly always, when excision of the hip is mentioned, the presence of tubercular arthritis is implied. The operation may be performed either through an anterior or a posterior incision ; the former is preferred if the disease is in its earliest stages, before sup- puration has occurred, and when there is reasonable hope of securing ])rimary union ; the latter if the parts are disorganized and a large amount of discharge expected. (i) The Anterior Method. — The patient is placed on his back with the limb slightly flexed. The incision, three or four inches in length, is begun immediately below the anterior superior spine and carried downward and a little inward, par- allel and just external to the sartorius, so as to open up the capsule of the joint at once between this muscle on the inner side, and the tensor fascise femoris and the glutaeus medius on the outer. A deeper incision is now made in the capsule, parallel to its fibres : the soft parts are pushed on either side with an elevator, the finger introduced to examine the part, and a narrow-bladed saw passed down by its side on to the top of the neck. As soon as this is divided the head of the femur is grasped with a pair of forceps and twisted out. If the acetabulum or the great trochanter is involved, the carious bone is gouged away, and any caseous deposit in the neighborhood thoroughly scraped out. Then the wound is washed out with a hot antiseptic solution ; dried thoroughly ; dusted with iodoform and sewn up, leaving a drainage-tube of suitable size. As Barker has shown, the actual cavity left by this operation is a very small one, and in a certain proportion of cases primary union can be obtained. This, however, is only practicable in the earlier stages of the disease. (2) The Posterior Method. — The patient lies upon the sound side near the edge of the table. The incision, three to four inches in length, begins about midway between the anterior superior spine and the great trochanter, and, as Jacobson recommends, is carried downward over the middle of the latter, so as to end upon the shaft. If it is taken round the trochanter, it encroaches upon the substance of the muscles. The capsule is opened freely by deepening the incision ; 626 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the soft parts are separated from the bone with an elevator, the periosteum as a rule coming away without difficulty, and as soon as the parts are sufficiently free the neck is divided with a keyhole saw. The finger should be used to jjrotect the soft parts on the inner side. Afterward the condition of the acetabulum must be e.xamined ; any se(iuestra that are present removed ; and if there is any evidence of a pelvic abscess (which may often be ascertained previously by rectal exami- nation) sufficient of the floor taken away to ensure thorough drainage. [These methods are vastly inferior to that of Koenig, which in every case where the trochanter is sound should be adopted in ])reference; or the method may be modified by the preservation of the entire trochanter. The ojjeration as modifietl is performed as follows: A curved incision is made, commencing just below the crest of the ilium and directly over the trochanter major, and extending downward about two inches. The incision is deepened until the trochanter is exposed. By means of a chisel the trochanter is separated at its base from the shaft of the bone at the upper level of the neck of the femur. The trochanter, with the muscles intact, is now turned upward, and the neck of the femur with the capsule are exposed to view. Incise the capsule, examine the joint after irrigation. If there is much caries of the head of the bone, it may now be removed by a {rovided with two cross-bars, so that it can be slung from a pulley over the bed and supported by a counterjioise of shot. If this is well adjusted and the mattress cut away on the diseased side from below the fold of the buttock, the limb swings absolutely free, entirely out of the patient's control. It may be secured either with two interrupted side-splints like an ordinary compound fracture, or with a mixture of paraffin and wax applied hot, as recommended by How.se. \n either case the fixation is absolute. Union is fairly sound in a successful ca.se at the end of six weeks, and the patient may then be allowed to get about on crutches, the limb being protected either with a poroplastic casing or with Thomas's knee-splint. Some appliance of this kind must be worn for several years, in the case of children, until the period of growth has cea.sed. The details naturally require modification in many particulars. The patella, for example, is sometimes preserved, its articular surface being thoroughly gouged away, or it is divided and sutured together again. Sometimes it is sufficient merely to shave off the ends of the bones, and occasionally the bones themselves can be left untouched, only the soft, pulpy synovial tissue being removed, as in erasion, but when this is done great care is required to prevent flexion afterward. Results. — Excision of the knee rarely succeeds in patients over thirty years of age, or in those under ten ; in the former the reparative powers fail, in the latter the growth of the limb is too much impaired. Puberty is the most favor- able time. In some few cases a movable joint has been obtained (in erasion in which the articular surfaces are not taken away, this is usually the case, and .some- times the range is nearly as good as the normal one), but it is certainly wiser to try for bony ankylosis. Failure may occur from the whole of the tubercular disease not having been removed, from the strength of the patient being unequal to the strain, or from too much bone having been taken away. In this ca.se, even if union does take place, the limb remains .so weak and wasted, and is so much shorter than the other, that amputation is usually preferred. Later, even after years have passed, the osseous union sometimes yields and causes serious deformity. Excisiofi of the Ankle. This operation is rarely practiced ; the reparative power of the foot is not very great, stability and firmness especially are required, and neither in the case of disease nor injury is the mischief likely to be limited. Compared with excision, Syme's amjnitation involves very much less risk, and may be relied upon for an excellent practical result. It may be performed either by two lateral incisions, or an anterior trans- verse one. In the former (i) an incision is made on the outer side of the foot over the peronaei tendons, from two inches above the external malleolus to within an inch of the base of the fifth metatarsal bone. The skin and the periosteum are raised from off the bone, the tendons drawn to one side, the fibula divided at the upper angle, and the lower end drawn out from al)ove and removed, dividing the external lateral ligament. The foot is then turned over and (2) an incision similar in length and direction made along the posterior margin of the internal malleolus, the tendons and periosteum being treated in the same way. The lower end of the tibia is then forced into the wound, by everting the foot, and removed with a narrow saw ; the upper surface of the astragalus is treated in the same way, the whole of the gelatinous tissue scraped out, and the woimd thoroughly washed out and drained. If the astragalus is much involved it is better to scoop it out of its periosteal shell altogether. The anterior transverse incision is more simple. A cut is made across the EXCISION OF THE ANKLE. 629 front of the joint, beginning at the tip of one malleolus, dividing all the tendons, the anterior tibial vessels and the nerve, and ending at the corresponding point on the opposite side. The ligaments are then divided as far as may be necessary, the under surfaces of the ti])ia and the upjjer of the astragalus successively exposed and removed, all carious bone gouged away with the granulation tissue, and then the tendons and the nerve sutured together. The skin wound should unite by the first intention. An outside angular splint, with the knee well bent, is the best appliance until the seat of injury is partially consolidated and the discharge reduced in amount, and after that a plaster or paraffin bandage, strengthened, if necessary, by slips of tin. 630 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER VII. IXJUR/ES AXD DISEASES OF THE HEAD. SECTION 1.— MALFORMATIONS. ENCEPHALOCELE AXD MENINGOCELE. An encephalocele is a congenital tumor caused by the abnormal expansion of some part of the cerebral vesicles, so that the brain substance i^rotrudes between the bones of the skull and prevents their proper development. In a meningocele the protrusion consists of dura mater and arachnoid only, but this is very much more rare. When in addition to the brain substance there is a great collection of fluid, causing immense distention of the ventricle, it is known as hydrenceph- alocele. An encephalocele can only develop at those parts of the skull which normally contain processes of the ventricles ; immediately over the nose, that is to say, cor- responding to the anterior cornua (the exactly median situation is due to secondary growth of the bones) ; behind the mastoid process, where the lateral cornua come down ; and in the neck and occipital region over the fourth ventricle. A few cases are recorded of a similar prolongation of the third ventricle into the pharynx, through the sphenoid, or between it and the ethmoid. Encephalocele has noth- ing to do with the fontanelles. The occipital is the most common, the portion of the occipital bone between the inion and the foramen magnum being deficient. The frontal comes next ; the others are very rare. Many cases of supposed menin- gocele, especially in the occipital region, are in all probability encephaloceles in which the brain substance has either atrophied or has never been developed. Hydrencephalocele explains itself. An encephalocele forms a roundish, sessile, or jjedunculated tumor, of very variable size (sometimes a n^iCre nodule, sometimes larger than the rest of the child's head) projecting from the surface of the cra- nium. The skin covering it is generally normal, but it may be excoriated ; and, when the distention has taken place very early in life, so that the development of the dorsal mesoblastic plates has been checked, it may consist merely of the undifferentiated brain tissue and meninges, covered over with epidermis, as in some analogous cases of spina bifida. It swells up and be- F.G. a8i -.Meningocele at Root of ^^^^^^^ ^^^^^ ^^.j^^^ ^j^^ ^j^jj^ ^^.j^^^ 3,^^j ^^^^^^\\y admits of partial reduction on pressure, although this may cause convulsions and other cerebral symptoms. Occasionally the outline of the opening in the cranial bones can be felt distinctly. An encephalocele is usually opaque, with indistinct fluctuation, and is only partially reducible ; and it pulsates distinctly. A true meningocele is always small and as a rule pedunculated ; its contents admit of complete reduction, and, if it is large enough it is perfectly translucent. Hydrencephalocele is always very large and unusually pendulous, the rest of the child's head being ill-developed. In some instances, particularly when the tumor is situateil over the glabella and the skin covering it is red and vascular, great care is required to distinguish it from a navus. They are both congenital and reducible ; tTiey both swell up INJURIES OF THE SCALP. 631 when the child cries ; the color is the same ; and if the intracranial tumor is a small one, reduction of its contents need not be followed by any cerebral symp- toms ; and it need not exhibit any arterial pulsation. I have known the diagnosis left undecided by surgeons who were certainly capable of discriminating, if any were. Prognosis. — If the protrusion is small and the skin covering it healthy, it may not interfere with life; and in a few raie cases it has hapjiened that as growth proceeded the neck of the tumor has be- come more and more constricted, until at length it cea.sed to have any connection with the interior of the skull. Large ones as a rule continue to increase until they f,c. 282.— Encephaioceie. rupture. Treatment. — The growth should be carefully protected from injury and not otherwise interfered with e.xcept under one condition — that it is on the point of rupture. Repeated tappings and injections of Morton's fluid have succeeded in cases of meningocele, as in spina bifida ; but, except in those instances in which from the small size or pedunculated character of the tumor there is some prospect of natural cure, the probability of a good result is very remote. SECTION II.— INJURIES OF THE HEAD. These include injuries of the scalp, of the bones, and of the brain. The .scalp may be bruised or cut ; there may be hemorrhage, either externally or into the tissues ; the pericranium may be stripped off, the bone bruised or fractured ; blood extravasated between it and the dura mater, or between the membranes, of the brain ; and the brain itself contused or torn. No wound or blow, however slight, should be neglected ; even when the superficial structures have escaped unhurt there may be serious injury to the much more important ones beneath. Afterward inflammation may set in, even though there is no ex- ternal wound. If this occurs it may attack the scalp or the loose cellular tissue beneath ; it may begin in the bone, causing osteophlebitis and necrosis, and end- ing either in general pyaemia or in thrombosis of the sinuses, inflammation of the membranes or cerebral abscess, according to the method of its extension ; and finally it may start in the brain itself. Injuries of the Scalp. The scalp presents certain anatomical features of considerable surgical im- portance. The skin in the first place is so closely bound down to the aponeurosis beneath, that merely cutaneous wounds never gape, and superficial inflammation is never attended by much swelling or redness. For the same reason contusions often cause what apparently are incised wounds. Further, the chief vessels lie between the aponeurosis and the skin, and are imbedded in such dense tissue that when they are cut they cannot retract, and can hardly be tied. On the other hand, beneath the aponeurosis the tissue is so loose that blood or pus can collect until the skin floats as on a water-bed, bounded by the zygoma, the eyebrows, and the superior curved line ; and the scalp can be stripped off and hang down in 632 DISEASES AND INJURIES OF SPECIAL STRUCTURES. flaps. Sloughing, however, owing to the position of the vessels, is rarely caused in this way. Finally, the i)ericranium is easily separated from the bone, except at the sutures ; it only supplies the outer table, not the diploe or the inner, so that when necrosis occurs from this cause the sequestrum is usually sujjerficiai. It is peculiar also that it hardly ever produces any new bone to repair an injury. Contusions of the Scalp. The blood may be extravasated (i) in the scalp itself; (2) in the sub-aponeuro- tic layer ; or (3) between the pericranium and the bone. The first, owing to the denseness of the tissue, is always insignificant. The second may be either diffuse, and of enormous extent, or circumscribed, and then very often it is curiously deceptive. The blood around the margin coagulates into a hard, dense ring, the inner edge of which is sharp and well-defined, while the outer is beveled off; in the centre it remains fluid, so that when the finger is pressed upon it the margin stands out as clearly as the edge of a dei)ressed frac- ture, for which it may easily be mistaken. The ring, however, is distinctly raised above the level of the surrounding bone, and it can always be indented. I have known the opposite mistake made. Absces.ses sometimes give rise to the same kind of impression, and it must be remembered that the presence of a hematoma does not exclude the existence of a fracture. The third (cephalhematoma) only occurs in infants and nearly always from injuries received at birth. It is most common on the parietal bone, though I have seen it on the occipital, and it is easily recognized by the way in which it is limited to one bone ; it never extends over the sutures. Like the former, the margin becomes hard, and a certain amount of organization, and even ossifica- tion, takes place ; the centre remains fluid, and for a long time gives rise to a sensation of parchment crackling when pressed upon. Absorption in all these cases is slow, but, unless inflammation sets in, they should never be incised ; and aspiration is rarely necessary. The cephalh^ematoma of infants should never be touched ; in other cases lead lotion may be applied at first, or, if the patient will lie down, an ice-bag, to check the extravasation and hyper^emia ; afterward well-applied pressure is the most efficient remedy. Wounds of the Scalp. These, like contusions, may be superficial, involving the skin only ; or extend into the subaponeurotic layer ; or lay the bone bare. The first are rarely of any extent ; in the second, if the hair is entangled in machinery, or the head caught under a cart-wheel, the whole scalp may be detached and hang down in a»flap, but it rarely sloughs; in the third there is an additional danger, for the bone is exposed, and is often brui.sed or scratched. Hemorrhage from the torn vessels is often abundant, but neither ligature nor torsion is of any use. Pressure stops it at once. Acupressure may be used, but a bandage is nearly always sufficient; care, however, is neces.sary, as it may be applied so tightly as to cause a slough. Treatment. — Scalp wounds require no special treatment, the same princi- ples must be followed as elsewhere ; the only peculiarities are the extraordinary vitality of the skin, and the ease with which inflammation, if it once sets in, spreads in all directions. Therefore no portion of scalp should ever be sacrificed, no matter how bruised or dirty it is ; and perfect cleanliness and perfect drainage must be insisted on. If this is carried out, they maybe treated like other wounds, and with exceptional success. The head must be shaved around the injury, the wound carefully explored and wash d out thoroughly with an antiseptic, all oozing stopped, and any bag- ging or collecting of fluid prevented. Counter-openings may be made and drain- age-tubes inserted, if there is a dependent pouch ; but in most cases it is sufficient to support the skin well against the skull so as to keep it at rest and ensure early WOUNDS OF THE SCALP. 633 adhesion. Then the edges of the wound may be dusted over with iodoform and covered with an absorbent dressing, such as wood-wool, or a sponge wrung out of carbolic solution. There is no objection to the use of sutures, if care is taken ; but of course, if the wound is tightly sewn up, and suppuration allowed to take place beneath, .serious consecpiences must ensue. Even if half the scalp is stripped off and hangs down the back of the neck, or over the face, it may be treated in this way, and often will adhere at once. If it does not, the under surface throws out granulations, and union takes place by the third intention. In all cases of severe injury the patient should be confined to bed, and kept perfectly quiet, on low diet ; and care mu.st be taken that the bowels do not become confined. It must never be forgotten that, in addition to the scalp wound, there may be very great injury to the brain. So long as there is no pain or fever, the wound should be left alone. If, however, one spot is tender, or if the temperature rises, or if there is any shivering, it must be exposed at once and carefully examined ; it nearly always means that some of the secretion is pent up. As a rule it is sufficient to introduce a probe or to loosen a suture : a drop or two of fluid escapes and the symptoms are re- lieved at once. Erysipelas sometimes attacks scalp wounds, but they are not more liable to it than others that are equally exposed. The danger is that the superficial wound may close, and the discharge collect and decompose beneath. The cellular tissue is so loose that suppuration soon spreads all over the head ; the scalp becomes boggy and cedematous ; the eyelids are swollen and the forehead reddened ; the pulse becomes quick and feeble; the temperature rises ; delirium sets in ; and the condition becomes one of extreme gravity. If left to itself the whole of the cellu- lar tissue may slough, leaving the bone absolutely bare ; or the patient may sink from exhaustion or septic poisoning (especially as this is likely to occur in those whose health is broken down), or the inflamma- tion may spread along the emissary veins into the diploe and sinuses of the cranium, and set up thrombosis and pyaemia. In such a case the wound must be laid open at once, only such sutures being left as are absolutely necessary to prevent a flap hanging down ; small incisions, parallel to the main arteries and going right down to the bone, made wherever the skin is- boggy ; and warm boracic fomentations applied, to encourage the discharge as much as possible. Quinine and carbonate of ammonia are nearly always required ; it is very seldom that any food can be taken ; and in many cases the condition of the pulse is such that stimulants must be given freely. When the pericranium is detached the risk is greatly increased. Necrosis of the outer table fio. 283. -Exfoliation of a Triangular Plate ■' • 1 /■ -ill] „i u •_ of Hone from the Vault of a Skull, caused may occur simply from its blood-supply being by denudation, three weeks after the injury. cut off ; more frequently it becomes va.scular and throws out granulations, minute red dots making their appearance on the bare white bone, and projecting more and more as the compact tissue becomes ab- sorbed, until they form a perfectly uniform layer. Or worse than this may hap- pen : inflammation may set in. If this occurs, the whole thickness of the bone is almost sure to perish, and the mischief may extend to the membranes of the brain or into the venous sinuses, and cause either diffuse meningitis or general constitu- tional infection. Every case of scalp wound in which the bone is exposed requires to be watched with the greatest care, 41 634 niSEASES AND INJURIES OF SPECIAL STRUCTURES. Fractures of the Skull. These are divided into fractures of the vault and fractures of the base. They are nearly always the result of direct violence. If the area on which the blow falls is limited, the injury is limited too ; and naturally this is more common on the vault. If, on the other hand, the force is diffused over a wider area, the cranium is comi)ressed, the most inelastic and unyielding part gives way, and a fissure is produced which generally runs across the base and part of the vault as well. The distinction, therefore, is not perfect, but it is found to work con- veniently. I. Fracture of the Vault. Owing to its arched shape, its elasticity even in adults, and the presence of sutures breaking up and softening the force of blows, this escapes more frequently than might be expected. In infants it is sometimes bent in like a piece of tin, without any actual tearing, but in many of these cases the inner table gives way, as in greenstick fracture. The fracture may take the form of a simple fissure, or it may be stellate or comminuted. Occasionally the outer table only is hurt, and a few rare cases are / '\-,. - v.. c Figs. 284 and 285. — Fracture of Vault of Skull Caused by the Impact of a Blunt Instrument (a hammer), showing the greater area and more extensive splintering on the inner surface. recorded in which this has escaped, and the inner only has given way, but nearly always it extends through the whole thickness. If the bone is driven in, the frac- ture is sa4d to be depressed ; in most instances the whole substance is forced in, but over the frontal sinuses, and in contusions, the inner table may not be affected ; generally it is splintered a great deal more than the outer. In children, owing to the elasticity of the bones, depression may take place without fracture, especially if the area is extensive, but probably in many of these there is really some tearing of the inner layer. Elevated fractures, caused by oblique cuts, are rare in civil life, and can only occur while the bones are still capable of yielding. Punctured fractures, which are produced by the impact of some sharp body, such as a nail, are particularly serious, owing to the amount of injury inflicted on the inner table. There may be only a small, round hole in the outer, while the inner is fringed all round with a row of spikes, projecting at right angles from the surface into the dura mater. The inner table, as a rule, splinters more readily than the outer, partly because it is thinner and more brittle, and forms j^art of a smaller circle, but mainlv because, in all ordinary accidents, the blow falls ui)on the outer first, so that the force, in traveling through the diploe, becomes distributed over a wider area (Figs. 284 and 285). If a bullet passes through the cranium from within outward the reverse is the case. FRACTURES OF THE SKULL. 635 {a) Simple Fractures. Of themselves, simple fractures of the vault are of little or no consequence; contusions, fissures, and fractures without displacement do not admit of proof, and even when the bone is comminuted and the depression considerable, the diagnosis is often only a conjecture, owing to the amount of blood extravasated. Their gravity arises from the fact that serious injury to important structures is so often associated with them. Concussion or contusion of the brain, hemorrhage between the membranes, or, especially if the course of the fissure traverses the middle meningeal artery, between the dura mater and the bone, rupture of the venous sinuses and laceration of the membranes are of frequent occurrence after simple fractures ; more rarely the contents of the cranium (the cerebrospinal fluid at least) find their way out, and form a soft, fluctuating and pulsating swelling underneath the aponeurosis — cephalhydrocele. Later, especially in cases in which the bone is severely contused, inflamma- tion may set in, though it is very rare in comparison with compound fractures. It may be either acute or chronic. In the former case the whole thickness of the bone perishes, lymph is poured out beneath the pericranium, the scalp becomes boggy and oidematous (Pott's puff'y tumor), and suppuration follows and spreads to the inner surface of the cranium. A few cases are on record in which the abscess resulting from this hks been merely local, between the bone and the dura mater ; much more frequently the inflammation rapidly involves the venous sinuses, and ends in either diffuse suppurative meningitis or pyaemia. Chronic inflammation is even more uncommon, but an extraordinary thicken- ing of the bone is said to have occurred after simple fracture. The whole skull may be affected, or irregular nodules may grow out and cause constant wearing pain and neuralgia. Loss of power, partial paralysis, and even insanity or epi- lepsy have been known to follow. {b) Compound ( Open) Fractures. In the majority of instances the nature of the injury can be seen at once. There is a fissure, appearing as a thin, red line, out of which blood continues to ooze, contrasting with the white bone around, or the bone is plainly comminuted and driven in, or the broken edge of a knife or other foreign body can be seen upon the surface. But this is not enough ; the wound must be carefully and thor- oughly explored with the finger, the mere diagnosis is not suiificient ; its extent and the depth and character of the displacement must be made out as accurately as possible, especially in the case of punctured wounds. There are many sources of fallacy ; a suture can be easily mistaken for a fracture, or the edge of a pericranium, if it is cut and one side is adherent to the bone, may feel like a fissure, especially if a probe is used. The temporal aponeurosis has before now given rise to diffi- culty : a foreign body may be broken off flush with the surface so that it can scarcely be detected, or, as in the case of the frontal sinuses in men, though the outward depression is very considerable the inner table may not be injured at all. Serious complications are much mare common in compound fractures. In the first place, the force is often greater, and nearly always is concentrated in one small spot, so that the inner table is driven inward and extensively sijlintered. The more nearly a. fracture approaches the punctured form the more dangerous it becomes ; it does not matter so much if the depression is wide and extensive, or if, owing to the softness and elasticity of the bones there is little or no splintering ; the dura mater is not injured, and symptoms of compression, merely from displaced bone, are exceedingly rare ; but where the inner opening is fringed with a circle of little spikes projecting vertically inward, and tearing and irritating the membranes and the brain, inflammation is almost certain (Fig. 286). In addition, compound fractures are always exposed to the risk of 636 DISEASES AND INJURIES OF SPECIAL STRUCTURES. decomposition. Blood is extravasated into the diploe, and between the dura mater and the bone ; the fracture is often comminuted ; there are numerous little spaces and fissures between the fragments which cannot drain, and the wound is frequently filled with dirt and other foreign substances. Under these circumstances, unless steps are taken to prevent it, inflammation must break out, and though fortunately it often remains limited to the wound, and merely causes necrosis of the broken fragments, it mav at any moment spread into the surrounding bone, or, especially if the dura mater has been pricked, into the mem- branes of the brain, and set up fatal meningitis. Treatment. — (a) In Simple Fractures. — So far as the bone itself is concerned, injury to the vault of the skull rarely requires anything. Unless there are definite symptoms of '""Fra^reofSkuu"* compression. either growing worse or refusing to clear up, nothing should be done. But it is so often associated with concussion and contusion of the brain, and the e.vtent of the injury is so entirely unknown, that in any case in which there is the least ground for suspicion the utmost precautions must be taken. The patient must be placed in a darkened room with the head shaved, and an ice-bag, or, better, Leiter's coil applied ; every source of irritation or excitement should be ex'cluded, the bowels should be opened, preferably with a calomel purge, and nothing but the simplest diet allowed. Rest in bed must be strictly enforced for at least three weeks, and the patient must be carefully watched for months. The great fear during the first few days is that hyjjeraemia and inflammation of the brain may occur; after that the chief risk comes from the bone, which may inflame and cause necrosis, meningitis, or pyaemia ; still later, even years after, symptoms of cerebral irritation may make their appearance, sometimes merely undue e.xcitability or fits of temper, especially if there is any indiscretion in diet or abuse of stimulants ; occasionally, but fortunately very rarely, more serious trouble, such as epilepsy and even insanity. {b) In compound fractures the wound in the soft parts and the injury to the bone require something further. The former should be treated as already described ; the hair should be shaved off, the scalp well-washed, the hemorrhage stopped, for- eign matter and dirt carefully removed, and then all the part that has been exposed thoroughly washed out with corrosive sublimate or some other antiseptic. It should then be well dried, the edges dusted over with iodoform and brought together with sutures (catgut is especially useful where there is no tension), leaving suitable open- ings for the escape of the lymph, and if neces.sary one or two tubes may be inserted. Then it should be carefully covered over with a thick layer of some dressing suffi- ciently absorbent to soak up any discharge at once, and bandaged to avoid dis- placement and secure rest. Simple linear fissures, not depressed and not caused by the impact of a sharp weapon, may be covered in at once, the pericranium being replaced if it is torn off. There is no splintering in such a case, no fear of spicules irritating the dura mater and the brain, and the sooner the fracture is converted into a simple one the less the risk of decomposition and suppuration. Punctured fractures, on the other hand, should always be trephined, the wound in the outer table being included in the circle of the instrument. It is impossible to ascertain the condi- tion of the inner table : in nearly every case it is starred and the splinters driven inward : the operation adds nothing to the gravity of the case, and deep punc- tured wounds passing through strata of different consistence cannot either be cleaned or drained. In compound depressed fractures, portions of bone that are detached or loose or driven into the substance of the dura mater, must be carefully picked out. If there are symptoms of compression, or if the size and depth of the wound make it probable that the inner table is splintered, the bone must be elevated. FRACTURES OF THE SKULL. 637 and, if necessary, part of a circle removed with the trejjhine, the pin resting on the uninjured margin. No pains must be spared to make the elevation effectual, and to exclude the possibility of splinters being left under the overhanging edges. It is true that a large proportion of patients never suffer in any way ; that fragments of bone and even foreign bodies have remained embedded in the substance of the brain itself for years, without its being known ; but they are never safe. So many ca.ses are recorded of disturbances of the most varied character — motor, sensory, and psychic — being caused by the presence of a depressed fracture, and being cured by its elevation, that unless the depression is smooth and even, as it nearly always is in children (fractures of the skull in them rarely require much interference), it is better to raise it at once. The operation does not increase the patient's risk ; trephining, when done as a precaution and not as a last resource for a disease that has almost proved fatal already, is very rarely followed by any ill result; and in many cases in which the wound, filled with extravasated blood, has been exposed to the air, and perhaps ground in with dirt, the cleansing process cannot be thor- oughly carried out, or the risk of decomposition and inflammation avoided, with- out its being done. Sometimes it is merely necessary to introduce the point of an elevator under one of the edges of a depressed fragment, and gradually lever it up until it is on a level with the rest. Very often, however, the fragments are so locked together that this cannot be done without first removing a portion of bone ; or it is found that the injury is much more extensive than it appeared to be at first sight, and that the splintering extends a long way under the edge of the outer table. Then it becomes necessary either to remove some of the overhanging edge with Hofmann's gouge-forceps (or Keene's vongeur), or to apply the trephine on the margin. In any case great care must be taken to pre.serve the pericranium and to avoid detach- ing any adherent fragments. The wound must be dressed in the ordinary way. The portion of bone that has been removed may be replaced, and in some cases it retains sufficient vitality to form fresh adhesions ; more often it gradually becomes absorbed, or, if suppuration sets in, perishes and is thrown off as a foreign body. It very rarely happens that there is any reproduction of bone ; the edges of the opening become rounded and smooth, and a dense fibrous cicatrix forms upon the surface of the dura mater, strong enough of itself to act as a protection to the brain, unless the opening is very large. 2. Fracture of the Base. Fracture of the base of the skull is sometimes the result of direct violence — when, for example, a revolver is discharged into the mouth, or a stick is forced through the roof of the orbit, or the condyle of the jaw is driven through the glenoid fossa. More often it is caused by a fissure extending from the vault. The fracture starts from the point that is struck, and generally passes across the base of the corresponding fossa, sometimes when the force is great involving more than one. The middle suffers the most frequently, as might have been expected, and a very common course for the fissure to take is across the petrous portion of the tem- poral bone and the internal auditory meatus. Occasionally it is produced in other ways. The skull, for example, may be driven down on to the vertebral column, just as a hammer-head is forced on to the shaft, with such violence as to break the bone round the foramen magnum ; or, as it falls upon the head, the vertebral column may be driven against the skull. In fracture by contre-coup the injury is on the opposite side of the head, at the other end of the diameter. The orbital plate of the frontal bone, for example, is sometimes fissured from a fall upon the occipital region. The skull is suddenly shortened in its antero-posterior diameter, and correspondingly widened in its lateral and vertical ones ; both the frontal and the occipital regions are flattened out ; but the former, being the thinner, more brittle and less regular in its elasticity, gives way first. It must not be forgotten that fractures extending into the ear, nose, and pharynx are really compound. 638 niSEASES AND INJURIES OF SPECIAL STRUCTURES. The diagnosis of fracture of the l>ase of the skull can only be made either from an escape of some of the contents of the cranium, or from injury to some of the structures that pass out through it. It may be suspected whenever there is evidence of serious injury to the brain after a severe blow upon the head but it can only be proved by one of these. I^rol)al)ly it is present in many of the cases of severe contusion to the brain, in which the patient, after lying in a state of semi-unconsciousness for days and even weeks, slowly recovers. If it is compound It adds very distinctly to the danger of the case. v»-.~ X ■?: Fig. 287.-B.->se of Skull showing the most frequent Lines of Fracture (lete loss of function, if slight, it is only partial, and if the bleeding continues, the effect spreads in order to the neighboring centres, first irritating them and causing monospasms, then compress- ing or destroying them, so that monoplegia sets in. Spasmodic contraction or paralysis of the upper part of the face and eyelids, after a severe blow upon the head, is due to injury of centres that lie a little higher up in the ascending frontal convolution. The lower i)art of the face and the platysma are affected when it extends to the ascending parietal on the same level. Brachial monospasm or monoplegia is the result of irritation or compression of the middle portion of the same two convolutions, the centre for the movements of the arm, like those of the muscles of the face, lying on both sides of the fissure of Rolando. If the stimulus continues to spread upward (as, for instance, in hemor- rhage from the middle meningeal) the associated movements of the leg and arm become involved, and if it extends so far backward that it reaches the superior parietal lobule, those confined to the leg alone. The muscles of the trunk appear to be under the control of centres that lie on the inner side of the hemisphere facing the falx cerebri. 1. Cortical Paralysis. — If the bruising is severe, this is immediate ; if not quite so bad, it comes on gradually, some hours, perhaps, after the accident, and, as the hemorrhage extends, spreads by degrees from one group of muscles to another. Often, especially if there is hemorrhage into the subarachnoid space, the paralysis is preceded by convulsions, which may involve the same muscles, or may be gen- eral, or may even affect the opposite side of the body ; the blood, as it spreads over the surface of the cortex, stimulates it first, and then compresses it, until, perhaps, the whole of one hemisphere is covered in. As a rule, the paralysis of simple contusion (without compression) stops short of complete hemiplegia. If it makes its first appearance after the lapse of several days, or if it continues to extend, it is a sign either that the softening is spreading, or that there is the com- mencement of a cerebral abscess. 2. Cortical Spasm. — In some cases this is immediate, caused by the irritation of the laceration or by the blood as it spreads over the surface of the brain ; in others it does not make its appearance for some time. If the interval is only a few days, it is probably due to the hyperaemia that sets in around the injured area ; either the sensitiveness of the cortex increases so that repeated discharges of nerve force take place without any apparent stimulus, or the circle of hyperaemia is spreading and now for the first time involves the motor area ; whichever it may be, the prognosis is very grave, for though such injuries may end favorably, inflam- mation and suppuration sometimes occur, even when there is no fracture. If the first appearance is still fiirther delayed, not perhaps until a month has passed, the suspicion of cerebral abscess at once arises. The convulsions are always sudden, occurring without any warning ; and they may either ht purely local, or, especially if they are repeated, they may spread from one centre to another, always extending in a definite and intelligible order until they become general and involve the whole body. The fits may be momen- INJURIES OF THE BRAIN— COMPRESSION. 645 tary, or they may last half an hour or more ; consciousness is not lost, as a rule, unless they occur in rapid succession or become general ; and they may either subside or end in paralysis. If the hemorrhage is extending, each outbreak may be followed by a further diminution of consciousness and an increase in the area of loss of power, until at length coma and general paralysis occur together. General convulsions, resembling an epileptic fit, coming on immediately after an injury, may be the result either of powerful stimulation of one part of the cortex only, or of raj^idly increasing compre.ssion and anaemia. In the latter case they are followed by profound coma. ij)) Medullary Lesions. — Much less is known with regard to the symptoms and localization of these. Multiple contusions are not uncommon in the white sub- stance of the hemispheres, and if they interrupt the course of the fibres from the cortex, the general effect is the same as if the centres themselves were destroyed ; but unless the blood makes it way into one of the lateral ventricles (which as the result of injury is very rare) and sets up compression, the extent of the hemor- rhage is never great. In fatal cases of concussion minute points of contusion are usually found, but it seldom happens that there are any very definite signs of their presence during life. Sometimes, however, there are symptoms which point to injury about the floor of the fourth ventricle ; there may be persistent vomiting, possibly due to some irritation about the root of the vagus ; or the pulse rate may remain abnormally slow, perhaps for the same reason ; or there may be dis- turbances in the region of the vasomotor centre, giving rise to diabetes, polyuria, albuminuria, or haematuria. Compression, In its most typical form, apoplexy, for example, compression of the brain presents a striking contrast to concussion ; but very often one can scarcely be distinguished from the other, and if, as not unfrequently happens, compression follows concussion before the rallying stage sets in, it may be impossible to say when the addition takes place. Causes. — It may arise from injury, inflammation, or the presence of new growths. Extravasation of blood and inflammation are the most common causes. The former occurs either immediately after an accident, or within a very {q\\ hours, and may lie between the dura mater and the bone, in the subdural or subarach- noid space, in the substance of the brain, or in the cavity of the ventricles. Compression when due to inflammation does not appear until later. If the brain is involved primarily, as sometimes happens after concussion, there may be some indication of it within the first three or four days ; if it is secondary, consequent on meningitis or acute suppurative osteitis, it rarely occurs for a week or more ; and when there are no definite signs of it for weeks or months, it is probably the result of chronic abscess in the substance of the brain. Whether depressed bone by itself can ever give rise to general compression is very doubtful ; when there is a tumor it is often present toward the end, especially if it is a rapidly growing one, or if there are hemorrhages in connection with it. The effect of pressure upon the nerve centres depends to a great extent on the rapidity with which it acts. If it is sudden, convulsions and even an epileptic fit may occur before the function of the cortex is abolished ; but this is more common in animals than in man. If it takes place slowly, the brain accom- modates itself to the change so far as it can. In some cases as much as eight ounces of blood has been found, but probably the amount necessary to produce fatal compression varies very much in different individuals. The cerebrospinal fluid first makes way by flowing down the spinal sheath ; then the smaller vessels in the brain become compressed ; the stream becomes slower and slower, until it stops altogether. At first the effect is local, and limited to the region of the cause; but gradually it spreads to other parts that are to some extent protected by the falx and the tentorium ; finally, the base of the brain becomes bloodless, convulsions perhaps set in, and life becomes extinct. Unless there is hemorrhage 646 DISEASES AND INJURIES OF SPECIAL STRUCTURES. into one of the lateral ventricles, compression is nearly always gradual, and leads steadily from impairment of function to complete loss, the higher centres suffering first ; but in inflammation or abscess of the brain, the last stages maybe relatively very rapid. The chief difficulty arises from the fact that compression is seldom met with unmixed ; nearly always it is associated with concussion, contusion, or hyperi-emia, not unfrequently with all three at the same time. Symptoms. — {a) \\'hen the compression is general they are very much the same, whatever the cause may be. The patient lies in a state of complete coma ; voluntary movement and reflex excitability are both abolished ; the limbs lie absolutely helpless, just as they are placed, and nothing that is said or done produces the least effect. The surface of the body may be cool, or bathed in i>erspiration ; in some cases extreme high temperature has been noted. The breathing is slow and labored, often stertorous from jiaralysis of the soft palate, and accompanied by a peculiar puffing in and out of the cheeks ; the pulse is full and strong ; the vasomotor and the cardiac centres in the medulla are both affected ; the pupils are fixed and generally dilated, or one of them is dilated (generally the one on the side of the compression) and the other contracted ; the urine is retained until the bladder becomes full, and the faeces are passed involun- tarily. Convulsions are very rarely present unless the compression takes place suddenly, and then they are soon followed by coma and complete paralysis. {b) In local compression, on the other hand, the symptoms depend upon the nature and position of the exciting cause, and consciousness is not lost. If the pons or medulla is involved, the effect, as may be imagined, is of the most serious character, threatening life from interference either with the nerve centres them- selves, or with the trunks on their way through the skull. The anterior part of the brain, on the other hand, may be almost destroyed without any definite local evidence, unless the third left frontal convolution is involved at its posterior extremity. Pressure upon the motor area of the cortex is the best defined, causing paralysis of the opposite side of the body, either of certain movements only, or of one limb, or of the whole side, according to the extent of the injury.* When the sensory zone is affected there is rarely any local evidence, although, as MacEwen has shown, a depressed spiculum from the inner table, driven into the anterior portion of the angular gyrus on the left side, may cause typical mind- blindness. In addition to these symptoms, which are directly dependent on the brain, there may be pain from the stretching to which the dura mater is subjected ; or there may be evidence of pressure upon the nerves inside the cranium, choked disc, facial paralysis, or neuralgia corresponding to the fifth, or even the blood- vessels may afford some indication — the cavernous sinus, for example, may be compressed so that the eyeball is protruded and the veins of the orbit distended. Diagnosis. — No absolute distinction can be drawn between conci/ssioti and compression. It is true the former is immediate, while the latter, as a rule, comes on gradually, and that loss of consciousness is rarely complete in the one, while coma is a symptom of the other ; but when there is a condition of profound shock, such as often occurs after severe head injuries, it may be imjjossible to make an exact diagnosis, especially as one is not seldom only a prelude to the other. The same may be said of contusion. The effect on a centre in the cortex is much the same, whether it is crushed by an extravasation between the dura mater and the bone, or by one in its own substance ; only in contusion monoplegia is either im- mediate or is preceded by monospasm, and extensive paralysis, especially hemi- plegia, is uncommon ; while in compression, pure and simple, there is usually an * In one case under my care, in which the whole of the left side of the I^ody was paralyzed, more or less, consequent on a severe blow immedistely in front of and above tlie right jjarietal eminence, there was a decided fall of temperature on the affected side. The patient w.ts a cliiUl six years old ; concussion was well marked, but passed off; symptoms of local compression followed and became more and more intense for forty-eight hours, aft'ecting the face and tongue (very .slightly), the arm (almost completely), and the leg. Twenty-four hours later the loss of power began gradually to disappear. WOUNDS OF THE BRAIN. 647 interval of a few minutes, or even of some hours, and the paralysis, if the symptoms are not masked by concussion, commences imperceptibly. Convulsions only occur in compression when it is rapid, and this rarely happens, for hemorrhage into the lateral ventricles is not common as the result of injury; depression of bone is hardly ever sufficient, and bleeding on the surface or in the substance of the brain is nearly always gradual. Alcoholic cojiia, especially that which is induced by rapid spirit poisoning, is sometimes mistaken for comi)ression, particularly if there is an injury to the head at the same time ; more often the converse happens. There is nothing in the tem- ])erature, or the pulse, or the respiration, that can be relied upon. MacEwen, how- ever, has shown that in alcoholic coma the pupils, which are contracted to a pin's point, very slowly dilate when an attempt is made to rouse the patient, and then, if he is left undisturbed, gradually begin to contract again, until in ten or twenty minutes they have resumed their former size. If there is any doubt the urine should be drawn off and examined for alcohol, which is often present in large quantities in these cases ; but it must always be remembered that the two condi- tions may very easily occur together. Opium coma, in the absence of history, is sometimes a little difficult to dis- tinguish, though the diagnosis may be suspected from the peculiar character of the pulse and respiration and the fixed contracted condition of the pupils, unless they have become dilated again-, and they do toward the end. In the case of laudanum the odor or the stomach-pump may make the question certain ; but this fails com- pletely with morphia, especially if it is injected subcutaneously. In urcemia the coma is not so continuous, there are epileptiform convulsions, the breathing is quiet, not stertorous, and there is no paralysis. When compression occurs immediately after an accident, without any interval, it can only be the result either of very extensive depression of bone, or of extrava- sation of blood, either into the cavity of the lateral ventricles or at the base of the brain. If it is more gradual, if it does not make its appearance for some min- utes, or even for some hours, the extravasation is either between the bone and the "dura mater, in the subdural space, or in the substance of the brain. Of these the two former cannot be distinguished from each other ; the last may be suspected if there are signs of cerebral irritation in addition to those of compression, or if the patient does not regain consciousness after the accident. Compression following inflammation of the meninges is always general; that due to cerebral abscess or tumor may be local at first ; in either case the diagnosis must be based upon the previous symptoms. Wounds of the Brain. Incised, punctured, and contused wounds of the dura mater and the brain are not uncommonly met with in conjunction with fracture of the skull. They may be produced by cutting instruments, such as knives and sabres, penetrating the bones, or even slicing off a portion of the skull and the brain beneath it ; or by blunt weapons, such as sticks or slate-pencils, driven throvvgb either the roof of the orbit or the cribriform plate of the ethmoid, often without any apparent external injury; more often still by fragments of bone driven inward; or as a result of gunshot injuries. These last are, generally speaking, fatal at once ; but instances in which small revolver bullets have entered the skull and have remained lodged in the substance of the brain for years are not uncommon. The cortex is the part that is usually affected ; the base rarely suffers except in gunshot injuries through the mouth ; and the immediate symptoms depend upon the extent and locality of the injury. As a rule there is no difficulty in the diag- nosis, but in some cases of depressed and punctured fractures the rent in the dura mater may lie concealed beneath an overhanging margin of bone, and be over- looked if this" is not elevated. The prognosis is always grave, even when the in- jury is so slight that there is no immediate risk to life ; foreign substances are 648 DISEASES AND INJURIES OF SPECIAL STRUCTURES. often carried inward — bullets, fragments of bone, hair, even portions of a hat ; the wound is exceedingly difficult to clean thoroughly : in many cases — as, for exam- ple, gunshot injuries — no attemjjt can be made; it is, generally speaking, more or less valvular, that is to say, there is a small ojjening in a tough, unyielding mem- brane leading into a space fdled with broken down brain substance and extrava- sated blood, and inflammation of the membranes or of the brain and hernia cerebri are proportionately likely to occur. Intracranial Hemorrhage. This may take place, as already mentioned, between the dura mater and the bone ; in the subdural or the subarachnoid space ; in the substance of the brain itself; or in the cavity of the ventricles ; and it may occur rapidly when there is a large space for it to collect in or when a large vessel is torn across ; more often it takes place slowly and continues until either the tension and the coagulation are sufficient to close the vessels or fatal compression is induced. 1 . Hemorrhage between the dura mater and the bone may occur from injury to one of the venous sinuses, but it is rarely of any surgical importance unless it is caused by rupture of the middle meningeal artery or its anterior branch ; then it gives rise to a series of symptoms which may be taken as the type of those of compression. It may be produced either by direct violence or by a fissure extending from the vertex ; sometimes the force of the blow is exceedingly slight, and there is no concussion, or only a transient sense of giddiness ; and it is said to have occurred without fracture of any kind being detected. Generally speaking, the extravasation takes place on the same side as the injury ; but the opposite artery may be torn if the fissure extends across the base of the skull, and possibly in fracture by contre- coup. In a characteristic case the patient is stunned for a time and gradually re- gains consciousness. Then after an interval sometimes of half an hour, some- times of a day, symptoms of compression begin to set in. The patient becomes drowsy ; the muscles on the opposite side of the body begin to lose power, those of the face perhaps first, then those of the neck and arm, and finally the leg and trunk; the pulse becomes slow and full; the drowsiness deepens into coma ; the respiration becomes stertorous and the compression complete. Convulsions are not generally present, though I have known them to be brought on, in a case of comminuted fracture associated with only meningeal hemorrhage, by i)ressure with the finger over the seat of injury. The eyeball on the injured side is sometimes protruded, probably from pressure upon the cavernous sinus, causing congestion of the orbit ; and, what is of very great significance, the pupil on the same side (op- posite to the hemiplegia) is dilated. It is said that this is due to pressure upon the trunk of the third nerve, and that it may be preceded by a transient contraction, pressure when it is slight first acting as a stimulus, and then as it increases de- stroying the conducting power ; but it may certainly occur when the extravasa- tion is nowhere near the course of the nerve. The diagnosis can only be certain when there is a distinct interval after the concussion, and when the compression begins locally and spreads gradually without there being any evidence of cerebral contusion or irritation. If the latter is present the subcranial hemorrhage is probably associated with cortical or subarachnoid, or these may be i)resent alone. Subcranial extravasation, due to rupture of the middle meningeal artery, forms a black granular clot of peculiar solidity and hardness between the dura mater and the bone. It is usually disc-shaped, three and even four inches across, thickest at the centre, sometimes as much as an inch, and thinning off toward the margin. There is a cup-shaped depression to correspond on the surface of the brain, and all the convulsions are flattened down. If not so large as to cause fatal com- pression, the coagulum may become absorbed, but only after a long time. 2. Subdural hemorrhage is rarely met with by itself and cannot be distin- guished from other forms. Nearly always it is secondary to cortical and subarach- INTRACRANIAL HEMORRHAGE. 649 ^^--;::" Fig. 3. — Hemorrhage m tnt Artery. ^Nliddle Meningeal noid extravasation, and adds the element of gradually spreading compression to the other symptoms. The blood comes either from the vessels of the pia mater or cortex, the arachnoid being torn across, or from the large veins on the upper sur- face of the brain, which sometimes give way just where they enter the superior longitudinal sinus. More rarely the dura mater is wounded, and the bleeding pro- ceeds from the meningeal arteries or the venous sinuses. When it occurs by itself, the blood gradually extends over the sur- face of the hemisphere and does not re- main localized or become hard and dense, as in the subcranial form. The vessels are smaller and the tension of the extravasa- tion not so great. The symptoms are the same as those of subcranial hemorrhage, and, like them, come on slowly and gradu- ally, but they are more vague, the com- pression is incomplete ; there is stupor, lasting perhaps for days or even weeks, but not necessarily coma ; there may be loss of power over certain muscles, or even over one side of the body, but there is no well-defined paralysis. If the patient survives, cerebral hypereemia and irri- tation are almost sure to set in ; head- ache, irritability, spasmodic contraction of the muscles, even general convulsions may occur ; and there is always a certain degree of fever and some risk of inflammation. Recovery in these cases is always very slow and often remains imperfect; the blood may be absorbed completely, but it often forms a false membrane adherent to the dura mater or arachnoid, at first soft and vascular, later becoming tough and hard ; or it becomes organized into a cyst, which at length loses its color completely, l)ecoming transparent, and floats free in the arachnoid space. Memory often remains defective ; or the patient becomes liable to violent outbreaks of passion, or there may be complete loss of self-control ; and even insanity and epilepsy have been known to declare them- selves at length. 3. Subarachnoid hemorrhage is practically always associated with severe in- jury to the cortex, and is secondary to it ; often it extends into the subdural space as well. The blood, if the arachnoid does not give way, pours down into the sulci and over the convolutions, until it may reach the big subarachnoid space at the base of the brain. There are no symptoms which are peculiar to it ; if, how- ever, after an accident there is evidence of severe contusion to one part of the brain, and if the symptoms, local at first, rapidly become general, involving one centre after another in quick succession, causing first convulsions and then paralysis, it m^y be conjectured that extravasation into the subarachnoid space is part at least of the injury present. 4. Cerebral hemorrhage when slight rarely admits of diagnosis. There is little doubt that minute extravasations are present in all cases of concussion, but, as a rule, they give rise to no special symptoms. When they are extensive — when, for example, a diseased artery gives way under a sudden .shock and the ex- travasation bursts into one of the ventricles, causing an apoplectic fit — the symp- toms are altogether general ; there is no local indication of any kind. 42 650 DISEASES AND INJURIES OE SPECIAL STRUCTURES. Injuries of Nerves. The cranial nerves may be injured either at their deep origin or in their course through the cranium. They may be torn across in fractures of the skull, or conii)ressed by an e.xtravasation of blood around them or in their sheath ; or later on they may be aftected by a neuritis, which commences gradually, lasts a few weeks, and gradually disappears again. The olfactory may be injured in fractures of the anterior fossa ; sometimes complete anosmia occurs without any evidence of injury to the bone, jjossibly caused by momentary separation of the bulbs, tearing across the nerves at their origin. The optic is frequently affected. If the tract is injured, there is loss of sight in the corresjionding half of the field of vision of both eyes — lateral hemiopia; if the chiasma itself, either the inner or the outer side of both retinse is blind, ac- cording to the position of the lesion. The trunk of the nerve may be torn across at the optic foramen, or crushed by a splinter of bone, leading to simple atrophy and complete blindness ; or hemorrhage may take place into the sheath, so that compression of the nerves and choked disc are produced at once ; or, later, if meningitis or cerebral abscess occurs, double optic neuritis may set in. Paralysis of the third nerve gives rise to ptosis, immobility of the eyeball in the position of external strabismus, dilation of the pupil, and loss of power of accommodation. Sometimes the eyeball appears slightly too prominent. If the injury is in the crus there is coincident hemiplegia of the opposite side. Paralysis of the fourth merely affects the superior oblique, so that there is diplopia or look- ing downward ; giddiness, when going down stairs, is often the first thing noticed. The sixth, which supplies the external rectus only, is injured more frequently than any other of the orbital nerves. Injury to the fifth nerve at its origin, with com- plete anaesthesia of that side of the face, may occur in gunshot injuries through the mouth ; but the lesion generally proves fatal in a few hours. When the sen- sory divisions are affected after their separation, there may l)e intense neuralgia from irritation of the fibres or complete anaesthesia. If the latter persists the skin on that side of the face becomes cold and purple ; the conjunctiva loses its sensi- bility and becomes inflamed ; the lachrymal and salivary glands cease secreting; and there is complete loss of smell and taste on that side, from the dryness of the mucous membrane. The anjesthesia and trophic influences are more marked when the injury is peripheral than when the origin of the nerve is involved. Paralysis from injury to the motor portion is rare, but may be diagnosed from the irregular character of the movements of the lower jaw. The facial, which is frequently involved in fractures through the middle fossa of the skull, may be injured at its origin, in the meatus, or in its course through the aqueduct. In the first case the sixth usually suffers as well, and there is hemi- plegia of the opposite side of the body ; in the meatus the auditory nerve is either torn or compressed at the same time, so that there is deafness on that side ; in the aqueduct the paralysis is limited to the muscles of expression, and if the petrosal nerves are injured, to those of the soft palate. Deviation of the velum, however, may occur in paralysis of the fifth, the glosso-pharyngeal, and even, it is said, the hypoglossal. Loss of the sense of taste is usually present wh^n the chorda tympani is injured. If the nerve is only compressed by extravasation or exudation, the symptoms are not immediate ; they come on by degrees and gradually disap- pear again. In a few cases neuritis sets in afterward. The other cranial nerves are rarely hurt in fractures of the skull unless the injury is of extreme severity ; but it is not improbable that some of the instances of remarkably slow pulse, of constant vomiting, of peculiar respiratory rhythm, and of such vasomotor disturbances as diabetes, or polyuria, may be due to deep- seated extravasation nuclei of their near origin. TREATMENT OF INJURIES OF THE BRAIN. 651 General Treatment of Injuries of the Brain. Injuries of the brain may either prove fatal at once, from the extent or the situation of the laceration, or death may ensue in the course of a {e\v hours or days, from shock, inflammation, or compression ; or at a much later period secondary complications may set in — softening, cerebral abscess, or epilepsy — and lead at length to the same result. No injury of the brain, no matter how trivial it appears to be, even if it is only attended by a transient giddiness, should be neglected. Coneussion. — The collapse of the first stage of concussion may be merely momentary, or may last for hours. In exceptional cases it may terminate fatally, either at once or after a couple of days, without the patient ever having rallied. The state of the pulse, therefore, requires to be very carefully watched. In most instances stimulants are not only unnecessary, but absolutely injurious : the danger is that the symptoms of reaction and the hypercemia that attends it may run on to inflammation, or that the bleeding may continue, and undoubtedly they would encourage this ; but every now and then cases are met with in which they seem indispensable ; the heart will fail without ; and it must not be forgotten that the mere prolongation of the period of collapse is in itself a source of danger, and tends to aggravate the intensity of the reaction when it once begins. The patient should be placed in bed with the head low, wrapped up in warm blankets, and surrounded with hot-water bottles ; then, as soon as he can swallow, a small quantity of hot tea or coffee maybe given. In the vast majority of cases the collapse passes off of itself without anything further being required; if the condition of the pulse becomes alarming, some good may result from the rectal injection of hot water, or the hypodermic injection of atropin (yi^ grain) ; if it distinctly begins to fail, ether or ammonia must be given at once ; and if these do not succeed, brandy must be injected subcutaneously. Cases of this kind, how- ever, in which the collapse is so intense, are fortunately very rare. As soon as reaction commences every effort must be made to keep the hyper- aemia within bounds. The room must be darkened, all noise prevented, conversa- tion absolutely forbidden, and complete rest in the recumbent position insisted on. In severe cases the head should be shaved, Leiter's coils applied, and if there is much aching, or if the temperature rises more than a degree, leeches should be placed behind the ears. Milk and beef-tea only should be allowed, and in small quantities ; and the bowels should be opened as soon as possible, either with five grains of calomel or with a minim of croton oil. The former may have some influence on inflammatory exudation, but in addition it is no slight advantage that it may be placed upon the tongue of a person who is insensible with perfect safety, and that there is little risk of its being vomited. If this does not succeed, if the temperature continues to rise, and particularly if the head begins to throb and beat, there should be no hesitation in making use of venesection, and withdrawing six or even ten ounces of blood. Whatever may be the way in which this acts, there is no doubt that it sometimes stops incipient delirium at once. [Fluid extract of ergot has extreme value in reducing cerebral hypersemia, and it will be found useful in all varieties of cerebral injuries where hyperaemia is manifested by the symptoms. A teaspoonful to a dessertspoonful will be required, to be repeated according to the urgency of the case.] In the case of children with slight concussion it is very difficult to keep them in bed more than two or three days ; in more severe cases, especially adults, and where, from the continuance of the symptoms, it is morally certain that there has been some considerable contusion of the brain, and that it has been followed, as contusions are in every part of the body, by hyperaemia and exudation, rest in bed must be insisted upon, until every sign of the mischief has disappeared. This rarely happens under a fortnight, in many cases not for three or four weeks ; and until then no precaution must be relaxed. Compression. — The treatment of compression of the brain depends upon what 652 DISEASES AND INJURIES OE SPECIAL STRUCTURES. can be found out from the history and the symptoms with regard to the locality and nature of the cause. 1. Where it is either general from the first, or where there is no definite evidence of local origin, surgical interference is out of the question. If it is recent, within a few hours of an accident, and therefore probably due to hemor- rhage, means must be taken to render the return of venous blood from the head as easy as possible by position, and possibly by venesection (though this is not of such service here as it is in controlling the commencement of inflammation), to favor the absorption of cerebro-s|)inal fluid by free purgation, and to diminish the amount of blood going to the head as much as possil)le by the application of cold. If some days have passed since the accident, and symptoms of inHam- mation are already present, the same remedies may be employed, with, in addition, the free use of mercury, but with very little hope. The compression in either case is only a late symptom of an injury over which we have at present little or no control. 2. Where, on the other hand, the signs point to some local cause, and where the nature of the case is such (as it nearly always is when the compression is the result of accident) that there is but slight prospect of spontaneous improvement, means must be taken as soon as possible to relieve the brain. (rt) If the symptoms are immediate they may be due to depression of bone. Mayo Robson has recorded a case in which l)rachial monospasm and monoplegia were caused by this, and relieved almost at once by trephining, ten days after the accident. The dura mater was intact and there was no evidence of subdural hemorrhage or of cortical bruising. Whenever anything of this kind can be ascertained, the depression must be elevated, and the sooner the better ; the longer the case is left the greater the risk of inflammation breaking out, or of a discharg- ing lesion being set up in the cortex, so that, after the original cause has been removed, epileptiform convulsions continue. (/;) If the symptoms do not set in at once, if there is a distinct interval of partial or complete return of consciousness, without any evidence of cereljral irrita- tion, there is probably sul)cranial hemorrhage, with, excei)tionally, subdural in addition. It may come from the anterior division or the trunk of the middle meningeal ; more rarely from its posterior division or the lateral sinus ; very rarely from any other vessels. Hemorrhage from the middle meningeal is not necessarily fatal, from the anterior division at any rate ; but it is so in the great majority of instances, and consecjuently, if the diagnosis is clear and the symptoms show that the extravasa- tion is extending, an attempt should be made to check it either by ligature of the external carotid artery, or by trephining. The former operation has not been tried sufficiently often to justify its recommendation ; the latter may be carried out without much difficulty, so long as the case is recent. If there is an external wound this should be made use of; if there is not, the artery maybe found mid- way between the auditory meatus and the external angular process of the frontal bone, an inch or an inch and a half above the level of the zygoma. A triangular flap, comprising the skin, the temporal aponeurosis, the muscle, and the periosteum, is reflected downward from off the bone, and the surface of the greater wing of the sphenoid and the inferior angle of the parietal examined. If there is a fissure, the point of the trephine is applied over the spot where the fracture and the line of the vessel intersect each other. As soon the circle is removed a dense, almost black, coagulum presents itself in the opening. This has to be literally scraped out, and often it is necessary to enlarge the opening in one or other direction by means of Hoffmann's forceps in order that this may be done eff"ectually. A greater difficulty is to secure the bleeding point. The artery is superficial only where it occupies the canal in the parietal bone ; for the rest of its course it lies in the dura mater, and this, with the brain, is pushed away from the skull by the coagulum. In recent cases the brain may rise up again as soon as the clot is removed, but this is not invariable, especially if the injury is of some days' stand- TREATMENT OE INJURIES OF THE BRAIN. 653 ing : or the trephine opening may not have exposed the wound in the vessel ; or the cavity fills up again with blood as fast as it is emptied, so that the bleeding spot cannot be seen. Ice-cold water, and pressure upon the carotid, are usually sufficient to check the hemorrhage for the time ; but if the bleeding jjoint is not exposed, it is better to enlarge tiie trephine oj^ening until it can be found and ligatured. If this is not done, the bleeding is very likely to return as soon as the parts are restored to their position and the normal temijerature is regained. After- ward the wound must be well washed out with corrosive sublimate or some other antiseptic, the whole of the clot removed, and free drainage provided for from the posterior extremity. If the cavity is a large one, it is advisal)le to make a second opening in the bone. If instead of the clot presenting in the wound the dura mater is dark purple in color, and is forced up into the opening without the normal pulsation being per- ceptible, it is probable there is subdural hemorrhage. This, if the pressure symp- toms are so severe as to threaten life, must be treated in the same way as subcranial ; the opening in the bone must be enlarged to a sufficient extent, the dura mater in- cised and reflected in a flap so arranged as not to injure its own vessels, the clot washed away, or, if the arachnoid is injured, carefully picked off, and then the membrane, the bone so far as possible, the pericranium and the skin, carefully re- placed and sutured to their corresponding parts, one by one, an opening for a drainage-tube being left at the spot that is most dependent when the patient is lying down. Even when there are symptoms of cerebral irritation and laceration in ad- dition to those of compression, the treatment must be conducted on the same principles so long as there is evidence that the injury is local. If it is general, nothing can be done ; but if local convulsions occur, and if they spread and involve other groups of muscles in definite order, and particularly if every convulsive fit is followed by an increase in the area of paralysis and a further diminution of con- sciousness, so that it is almost certain, not only that there is an extravasation of blood involving a particular portion of the cortex of the brain, but that it is spread- ing and that it will inevitably result in fatal compression, the question arises whether it is not advisable to trephine and explore. Cold, bleeding, first local and then general, profuse purging with calomel, or, if there is no time for that to act, w-ith croton oil, and internal remedies that assist in causing hsmostasis, may be tried ; but if the symptoms persist, and particularly if the compression is extending, there can be little doubt as to the ultimate result if the case is left to itself. Everything depends upon an exact diagnosis of the locality ; and, of course, this is only practi- cable when certain portions of the brain are involved, and when there has been an interval of at least partial consciousness since the accident. The history is of the utmost importance ; the condition of the scalp and skull must be thoroughly ex- amined, as well on the sound side as on the injured one, and the closest attention must be paid to the course the symptoms take. In such a case, where everything points to an injury that is local at first, and where the prognosis admits of little doubt, the scalp should be reflected, bringing the pericranium with it ; a large open- ing should be made wnth the trephine, unless, as probably happens, the bone is already comminuted, and if the dura mater bulges into the wound or appears pur- ple in color from the extravasation beneath, or if when it is touched spasmodic contractions make their appearance in any of the muscles, it must be reflected as well, the clot turned out from beneath, and the seat of hemorrhage exposed. Such cases must always be rare, for unless consciousness returns, for a time at least, it is scarcely possible to prove that one portion of the cortex has been involved ; and it is absolutely beyond our power to show that there are no deeper lesions. 654 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Traumatic E filers v. Injuries of the head are occasionally followed by epilepsy. CJenerally it does not make its appearance for some time after the accident ; and at first the fits are slight and infrequent, not attended by loss of consciousness ; but as time passes the fretpiency and intensity increase, until at length they end in permanent im- pairment. The severity of the accident does not appear to have anything to do with it ; and in many cases the immediate cause seems rather to be an injury to the cover- ings of the brain than to the brain itself. In some cases the cicatri.x on the scalp is tender and sensitive, with a constant sense of burning ; pressure on it may cause a fit ; or an aura may start from it. In others some injury to the bone seems to be the exciting cause ; it may be thickened or hardened ; or there may be irregular nodules on its inner surface ; or there may have been inflammation, leaving a se- iiuestrum. In others again the stimulus proceeds from some affection of the mem- branes ; the dura mater has been found thickened and yellow : sometimes it is adherent to the cortex ; or it has undergone calcareous degeneration ; or there is a cyst, possibly developed from a blood-clot, upon its inner surface. In another class no lesion can be found in any of the structures that cover in the brain. The exciting cause is in the cortex itself; and if the affected part lies in the motor area, if the spasm always starts in certain muscles, or extends in a certain order, the exact spot may be defined without reference to the injury. There may be no gross lesion perceptible in the brain ; but that the disease is dependent upon some alteration in this particular part is clear from the fact that excision of it is followed by complete and, in some cases at least, permanent cessation of the fits. Treatment. — If it can be shown that the convulsions are excited by a local irritation anywhere, the part should be excised without delay. In the case of injury the superficial scar should be removed altogether, the bone beneath carefiilly ex- amined, and, if there is the least suspicion of any alteration, trephined. Where it is thickened or otherwise affected, and where the dura mater appears healthy be- neath, this may suffice ; but if the membrane is marked with scar ti.ssue, or if it is yellow, or if it is fixed down to the cortex, it should be cut away from under the trephine opening and the adherent portion of brain removed with it. It is true that when the motor area of the cortex is excised loss of jjower in the correspond- ing muscles follows ; but as a rule this is only temporary, and even if it were per- manent the cost would be slight. Hughlings Jackson and Ferrier have shown, in non-traumatic ca.ses, that the removal of an epileptogenous focus in the cortex of the brain (if it can be localized) is not only justifiable, but called for, whether any gross lesion, such as scar tissue or tumor, can be found or not ; and when there is in addition the evidence of injury to assist in the diagnosis of the situation, there should be no hesitation. One or two convulsive spasms not unfrecjuently occur after the operation, but in many cases the improvement has not only been marked, but has persisted. This operation must be clearly distinguished from that ])erformed by Arcilza, who, in a case of true epilepsy, commencing with convulsive movements of the left arm, extirpated the whole of the brachial motor area on the right side. Paralysis followed, and as this passed off the convulsions returned as badly as ever. Traumatic Insanity. This does not occur so frequently as epilepsy, but there are several cases re- corded in which it has followed injuries of the head. Byrd has reported four in which the operation of trephining was jierformed : one died, one improved for a time, and two are stated to have entirely recovered. DISEASES OF THE SCALP. 655 SECTION 111.— DISEASES AND INJURIES OF THE HEAD. SURGICAL DISEASES OF THE SCALP. Erysipelas. This is frequently met with as a complication of wounds ; even in the so- called idiopathic cases it is probable that there is some scratch or abrasion [through which the pathogenic germ gains entrance]. It does not differ in any essential respect from the same affection in other parts of the body, but, owing to the anatomical structure of the scalp, the local signs, the swelling and redness, are generally ill-defined, while the constitutional ones, especially those which, like the headache, wandering, and drowsiness, may be referred to the disorder in the subjacent structures, are unusually prominent. The prognosis is always grave, owing to the possibility of cerebral complications. SUPPUR.A.TION. This may be either diffuse or circumscribed. The former is exceedingly grave, owing to the rapidity with which it spreads through the loose subaponeurotic layer. The inflammatory products, unable to escape, make their way in all directions under the tendon of the occipito-frontalis, spreading down into the eyebrows in front, to the superior curved line of the occipital bone behind, and as low as the zygoma at the sides. The whole surface of the head becomes swollen and puffy. The skin is hot and exceedingly painful ; at first, owing to the dense aponeurosis between it and the seat of inflammation, it is white and tense ; later, if left, it becomes soft and boggy ; red patches form in the temporal and mastoid regions, and, finally, it gives way, allowing the escape of an immense amount of pus, mixed with shreds and sloughs. The constitutional symptoms are most severe : the head- ache is intense, the temperature many degrees above normal, and wandering and delirium are rarely absent. If left to itself, the whole of the cellular tissue beneath the aponeurosis may gradually come away, and after a prolonged illness, the oppos- ing surfaces may grow together, or the skin and the pericranium may slough, leaving large districts of the cranial bones deprived of their blood supply, or the inflam- mation may spread along the emissary veins into the diploe, causing osteophlebitis, or meningitis, thrombosis of the sinuses, and pyaemia may follow. The cause is nearly always the sealing up of an imperfectly cleansed wound. There is no harm in sutures if the injured surface is thoroughly washed out and a loophole left at the most dependent angle for drainage ; but at the first sign, if there is any rise of temperature, or the least tenderness by the side of the wound, one or two of the stitches should be cut, and the edges gently separated with a probe. Probably a small bead of pus will escape, and all will be well. If this stage is past and the inflammation is already diffuse, the whole wound should be reopened, incisions parallel to the main vessels made wherever there is the least sensation of bogginess, and warm boracic fomentations applied to encourage the discharge. If the vitality of the tissues is not already broken down, they will begin at once to throw off the poison and protect themselves with a layer of vascular granulations. Convalescence, however, is always very protracted ; drainage requires careful watching ; the scalp itself may need to be fixed by strapping ; the sloughs often take a long time separating ; and, as a rule, the patient's constitu- tion is not of the best. Circumscribed suppuration may occur in the skin and subcutaneous tissue ; deeper, in the subaponeurotic layer, or between the pericranium and the bone. 656 DISEASES A. YD INJUR IE S OF SPECIAL STRUCTURES. Abscesses that form in the loose celUilar tissue may be of considerable size ; the others are smaller, but are much more painful. Suppuration beneath the deep temporal fascia is difficult of diagnosis, owing to the tenseness of the membrane over it ; and sometimes, for the same reason, the constitutional symptoms are very severe. The pus usually tends to gravitate downward beneath the zygoma, but the opening should be made above it as soon as there is any feeling of l)ogginess or of deep-seated fluctuation. [The sudden ri.se in temperature is the usual guide to the formation of pus.] [Here, as elsewhere, the cause of the disease must be destroyed. Tincture of iodine and strong solutions of bromine, by their anti-bacillary power, are of much value injected into the wound, or into pus cavities ; they soon destroy the strepto- coccus, and, although irritating locally, they produce no general toxic effect. Even the j)ainting of the shaved scalp with tincture iodine has considerable value.] Tumors of the Scalp. I. Congenital. Ncevi are exceedingly common, both the cutaneous and venous form, but they do not require any special treatment. Dennoid cysts, containing fine hairs as well as sebaceous matter, frequently occur at the outer angle of the orbit, and sometimes are found elsewhere along the lines of union. For the most part they are small, seldom exceeding half an inch in diameter ; but they may be deeply seated, lying in little recesses in the bone, or even in perforations extending right through, so that they are in contact with the dura mater. As a rule, they are better left alone. 2. Acquired. Sebaceous cysts, developed in connection with the hair follicles, and showing their origin by the small black dot upon their surface, are very common after adult Fig. 289. — Sebaceous Tumors in Sc.ilp, and Horn. life, and not unfrequently are multiple. They lie just beneath the skin, to which they are closely adherent. The small ones are firm and den.se ; as they grow larger and project further above the level, the contents become softer and the skin that covers them thinner, so that the hair follicles waste away and the hairs fall off; and sometimes at length they rupture and discharge a thin fluid mixed with sebaceous DISEASES OF THE BONES OF THE SKULL. 657 matter and crystals of cholesterin, often of a peculiarly offensive odor. This is especially likely to occur if they are injured or if they become inflamed ; and then the interior begins to throw out granulations and forms a fungating vascular mass, which, in appearance, closely resembles einthelioma, and possibly may in some cases pass into it. These cysts should always be removed before they become inflamed. The simi)lest way is to make a linear incision through the skin over them, down to, but not into the cyst wall, and then quickly isolate them by separating the soft cellular tissue on either side with the handle of the scalpel. The larger ones, however, and these which have been inflamed must be transfixed, emptied by stpieezing, and then dissected out, the edge of the wall, where it has been divided, being firmly grasped with a pair of forceps. In no case may any portion of the cyst be left behind, or union will not take place. Hornv excrescences are occasionally produced from sebaceous cysts that have ruptured or been oijened. The sebaceous material on the outside dries up and shrinks into a kind of horny layer, while a fresh production is continually going on at the ba.se. In some cases they attain a length of .several inches. Other varieties of tumor are rare in comparison. Cirsoid aiieurysm may occur ; circumscribed //^r^;//«! is occasionally found, and there are a few instances on record of an enormous diffuse grow.th of fibrous tissue, forming great pendulous masses (^pachydermatocele). Probably it is akin to elephantiasis, and may be con- genital. Epithelioma and 7'odent ulcer are sometimes met with, but sarcoma, with the exception of those forms which originate in the bone or dura mater beneath and involve the scalp secondarily, is very uncommon. DISEASES OF THE BONES OF THE SKULL. Hypertrophy. In osteitis deformans the vault of the cranium is usually immensely thickened. The inner surface becomes irregular and is marked all over by arborescent grooves ; the outer remains smooth and even ; the diploe disappears, and on section the bone is hard and dense, like ivory. Beyond a gradual increase in the circumference of the head, it does not appear to give rise to any symptoms ; and no treatment is of any avail. Other forms of enlargement are described under Diseases of the Bones. Rickets. A peculiar form of atrophy of the inner table, known as craniotabes, is occa- sionally met with in infants suffering from rickets. It aff'ects especially the poste- rior inferior angles of the parietal bones and the tabular part of the occipital, probably because of the recumbent position of the child, for a certain flattening of that part of the head is not unfrequently noticed at the same time, and in one or two instances, in which the disease existed before birth, a similar change has been found on the inner surface of the vertex. The sulci for the cerebral convolutions are unusually plain, and here and there are marked in their course by little conical pits, which, in some places, are so deep that nothing but a parchment-like layer of dura mater and pericranium is left ; the whole thickness of the bone is absorbed. Sometimes in addition there is a granular deposit of new bone under the pericra- nium on the outer surface, and occasionally a very considerable amount round the fontanelles and along the sutures, sufficiently to be felt plainly through the scalp. In all probability it is due to the effect of continued pressure acting on soft- ened hyper-vascular bone. It certainly may occur independently of hereditary syphilis, although it is often associated with it {e. g.. Parrot's nodes), and a few instances are recorded in which other evidence of rickets was unusually slight. The diagnosis can only be made in well-marked cases by the peculiar parch- ment-like yielding on pressure with the fingers. No special treatment is required. 658 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Inflammation. Inflammation of the bones of the cranium may be caused by mechanical in- jury, by the products of septic decomj^osition, and pyogenic micrococci ; and by syphilis, tubercle, and occasionally other specific diseases. {a) Simple inflammation {rarcfyin^i^osfcitis) may result from mechanical injury, if it is sufficiently i)ersistent in its action, but naturally such conditions are rare in connection with the cranium. It may, however, occasionally be seen when a portion of bone which has been killed by external violence is quietly removed and detached without suppuration. The tissues around become soft, vascular, and filled with lymph ; the bone immediately adjacent to the portion that is dead is absorbed and replaced by a layer of granulations, and at length the sequestrum is loosened, and, as soon as the condition of the scalp will allow it, thrown off. Suppuration is usually present in these cases, but it is an addition and not in any way essential. The i)ortions of bone that are reimi)lanted after trephining sometimes behave in the same way. In many instances they contract adhesions to the structures around ; in some they appear to become welded together by masses of new bone, although this is not quite certain ; but in others they cause a certain degree of irritation ; vascular granulation tissue is forijied around them ; if the constitution is sound and the tissues healthy, they are absorbed ; if, on the other hand, the irritation is too great for the tissues to bear, pyogenic micrococci find their way in and cause suppuration, exactly as they do round buried sutures and old sequestra. {!>) Suppurative osteitis is rarely met with except in compound fractures and the later stages of tubercular or syphilitic caries, after pyogenic organisms have gained entrance as well as specific ones. Exceptionally it may follow a simple contusion, the pyogenic germs being carried to the injured spot by the blood stream (as in Pott's puffy tumor), singly, or, as in pyaemia, in the form of emboli. In any case, there is very grave risk of extension to the meninges on the one hand and the emissary veins and venous sinuses on the other. {c) Tubercular caries of the vault of the skull is rare, even in childhood, and is seldom recognized until the skin has given way and left a tuberculous ulcer, the floor of which is formed of softened carious bone. ((/) Syphilitic osteitis is exceedingly common in all stages of the disease. Intensely painful periosteal nodes are often present during the secondary period. There is very little swelling, but the most extreme tenderness, so that the patient will not allow a finger to come near. Possibly the severe local headache that occurs sometimes about the same period may be due to a similar affection of the dura mater. Gummatous deposits, leading to caries and necrosis, are even more common in the tertiary and late hereditary stages. There may be merely a soft and tender swelling on the scalp, or an ulcer with a base of carious bone and undermined overhanging edges ; or half the frontal bone may be bare, black, and dead, even through its whole thickness, while the skin around is thickened and curled inward, as if it had shrunk away from the centre as soon as the tension on it had yielded. Immense portions of bone may be lost in this way, and it may be years before the sequestra separate. No new bone is ever formed, and deep radiating cicatrices, through which sometimes the pulsation of the brain can be felt, are left, causing the most hideous and characteristic deformity. In other cases, corresponding to the diffuse gummatous infiltration of other organs, the diploe becomes completely obliterated, so that the bone on section is solid throughout and exceedingly dense and hard ; and occasionally, in addition, great bosses are developed from the inner surface, especially over the frontal region, so that the grooves for the sinuses and meningeal arteries become deep channels. Parrot's nodes, periosteal thickenings of soft vascular new bone, arranged in lamellae, are characteristic of the hereditary form. They occur round the anterior TUMORS OF THE CRANIUM. 659 fontanelle, one on each parietal bone, and one on each half of the frontal, seldom invading the normal centres of ossification, and leave a cruciform sulcus in between, the so-called natiform skull. Occasionally this is associated with wasting or gela- tiniform degeneration affecting the posterior portion of the skull, but distinguished from craniotabes by its occurring on the outer surface. For a further description see Syphilitic Diseases of Bone. Treatment.— The consti- tutional treatment varies natu- rally according to the cause. The local is much more simple. Free exit must be given to all dis- charges ; secjuestra removed as soon as they are loose ; and de- composition prevented by proper drainage and antiseptics. Tu- bercular caries can sometimes be greatly benefited by free scraping • , u u and the application of iodoform. Sometimes exfoliation may be assisted by the use of strong sulphuric acid ; and occasionally trephining is necessary, either to drain an extra-dural collection of pus, or to release a fragment that is locked in, owing to its peculiar shape. Fig. 290.— Syphilitic Necrosis of the Frontal Bone. Tumors of the Cranium. Osteomata and sarcomata are the most common. Carcinoma only occurs as a secondary deposit by extension. Hydatid cysts and angeiomata have occasion- ally been described. Osteomata.— i:\\o'&Q growing from the outer table are sometimes called exostoses ; those from the inner and diploe, enostoses. Most of the latter are, however, inflammatory and probably syphilitic. Cancellous exostoses upon the cranium are rare ; ivory ones are more common, growing chiefly from the frontal bone and in the external auditory meatus. Some- times they are multiple and symmetrical. As a rule they are of very slow growth and should be left alone ; but when they grow in the frontal sinus they may cause the most fearful disfigurement from displacement of the eyeball, or even more serious symptoms from pressure upon the brain ; while in the ear they may lead to deafness and ultimately to complete obstruction of the meatus, with its con- sequences (acute suppurative osteitis and meningitis) if the secretion collects behind and decomposes. Fortunately, it frequently happens that the necks of these growths are much more slender than would be imagined from their size, so that they have even been known to break off". As a rule, they can be detached with a drill fitted to a surgical engine, but very great care is required in the selection of proper instru- ments. In one or two instances the growths have detached themselves, like the anders of a stag, the vascular canals in the neck gradually becoming smaller and smaller until at length the blood supply is altogether cut off". ^arr^wa/^.— Spindle-celled and myeloid sarcomata occasionally grow from the diploe and cause expansion of the outer table. In some cases the two tables are widely separated from each other, and the intervening space traversed by a complex arrangement of radially arranged trabeculae. Occasionally the bone gives way and the growth spreads rapidly under the skin, or compresses the dura mater and the brain according to the direction it takes. There is usually a good deal of pain at the first, and the symptoms may be masked to a considerable extent by the inflammation around. Sarcoma of the dura mater (and more rarely of the other membranes) some- 66o DISEASES AND INJURIES OF SPECIAL STRUCTURES. times perforates the cranium and spreads rapidly underneath the scalj) (fungus of the dura mater). This may he distinguished from the preceding by its pulsation (which is communicated from the brain beneath), reducibility (so long as it is small), and by the sharp opening in the skull through which it jirotrudes. Some- times, also, the attempt at reduction gives rise to characteristic cerebral symptoms. Excision is the jjroper treatment for both, if the diagnosis is made in time, but as a rule the disease is much too far advanced to justify an operation of such a serious nature. DISEASES OF THE BRAIN AND MENINGES. Inflammation. Inflammation may begin in the brain (cerebritis) or the membranes (menin- gitis) ; or it may spread to them from structures around, the bones, the scalp, the mucous lining of the tympanum, or the eye. It may be acute, or chronic from the beginning, and it may end in resolution, or persist in a milder form ; or, if pyogenic organisms gain entrance, lead to diffuse or circumscribed suppuration. {ci) Simple Acute Inflammation. Cerebritis. — Inflammation of the brain may follow the reactionary stage of concussion, or may be caused by the intense hypera^mia that attends prolonged over-excitement. It is common after severe contusions, a zone of red softening, formed partly of l)roken down brain substance, ])artly of inflammatory exudation, developing around the injured area; and it is always found around al)scesses (with the excei)tion of the most chronic), in acute suppurative arachnitis, and to a less extent around rapidly growing tumors. When it follows concussion or is due to over-excitement, it is diffuse and involves the whole cortex of the brain ; under other circumstances it is usually local, although it may be multiple and, sometimes at least, involve a very large area. Meningitis. — Simple acute inflammation of the dura or pia mater is rare as a primary affection ; it may, however, occur in com]:)ound fractures of the skull, caused by septic decomposition of extravasated blood (arachnitis, for example, may start from a fissured fracture of the petrous portion of the temporal bone, laying open the cavity of the tympanum and the prolongation of the arachnoid in the internal auditory meatus), and then it nearly always ends in suppuration. On the other hand, consecutive meningitis, due to extension from neighboring structures, is by no means uncommon. The infection may travel along the blood- vessels or lymphatics, by progressive thrombrosis (as in orbital cellulitis and diffuse inflammation of the scalp), or by embolism (as in i)yffimia) ; or it may s])read into the membranes directly from the adjacent structures, either the bones (most of the cases of acute suppurative meningitis after compound fractures are caused in this way) or the brain. In the one case the dura mater is attacked the first, in the other the pia; but although the pathological changes, hypera^mia, softening, exudation, and extravasation, may be more marked in the one than in the other, it rarely hai)pens that the inflammation is limited. Morbid Appearances. — In the early stages of the attack, and when the whole brain is affected, these are only slightly marked. The venous sinuses are full ; the vessels of the pia and the plexuses engorged ; the meshes of the arachnoid opaque and milky ; the ventricles distended with turbid fluid ; and the brain itself infiltrated, oedematous, and studded with minute red points like hemorrhages. In cases of longer standing, and when the mischief is limited, the affected part appears swollen and pulpy ; if it is cut across the surface rises above the surrounding level ; and the color is most conspicuous. Later still it becomes so soft that a gentle INFLAMMATION OF THE BRAIN. 66 r stream of water washes it away, leaving an irregular excavation with ragged, ctdematous, and softened walls, breaking down at the slightest touch. Symptoms. — The constitutional ones are merely those of acute pyrexia. There is rarely a rigor; that is the signal for pyremia or suppuration, but the temperature rises rapidly until sometimes it attains an extraordinary height; the pulse becomes full, quick, and bounding ; the respiration hurried and shallow ; the bowels confined, and the appetite lost. The local ones, on the other hand, those that depend upon the organ involved, exhibit a greater variety. Headache is always present, and usually is described as agonizing. At first there is general hvperffisthesia ; the least noise causes intolerable suffering ; the eyes cannot face the light; the pupils are contracted to pin's points; and even the skin may be exceedingly tender. Vomiting and delirium are rarely absent ; sometimes there is merely a certain amount of wandering at night, but not unfrequently there is a condition approaching that of furious mania. Then, by degrees, as the disorder of the cortex becomes greater, the abnormal state of excitement passes into a con- dition of insensibility ; the pupils dilate ; the eyes remain staring widely open ; the breathing becomes stertorous ; consciousness is lost, and stupor and coma set in. The character and extent of the cerebral symptoms vary with the seat of the disease. In some cases there is weakness of the limbs on the of)posite side of the body ; in others there are general convulsions. Occasionally, when, for example, the inflammation spreads from a contusion in or near the motor area, the spas- modic contraction is local at the first, and gradually extends from one group of muscles to another in definite order. On the other hand, when the attack com- mences in the bones, as in syphilitic osteitis, and spreads from them to the dura mater, it may be some time before any symptoms that are definitely cerebral make their appearance. There is no delirium or wandering in such a case ; convulsions are not present until sometimes quite late ; there is no intolerance of light or sound ; but there is the most acute tenderness all over the inflamed bone, espe- cially on percussion ; the pain is intense, particularly at night ; and if the base of the skull is involved optic neuritis and affections of the other cranial nerves, paralysis or neuralgia, are often present. Cases of this kind, in which the inflam- mation is local at the beginning and remains so for some considerable time, are naturally much less severe than those in which the pia mater and the cortex of the brain are involved from the first. The course and termination depend chiefly upon the intensity and persistence of the exciting cause. 1. Resolution may take place if the irritant is mechanical and transient, an extravasation, for example, that becomes absorbed. Every severe contusion of the brain that does not prove fatal at once is surrrounded by a considerable area of red softening ; and it is not uncommon for patients who have sustained injuries of this character to remain for two or three weeks in a very critical condition, feverish, exceedingly irritable, with photophobia, intense headache, quickened pulse, hot, dry skin, and often a certain degree of delirium. Then, at the end of that time, the temperature gradually falls and convalescence begins, although the least excitement or over-indulgence is sufhcient to bring on a relapse. 2. Death may ensue, either because of the extent or importance of the part of the brain affected ; or from exhaustion and the intensity of the fever. 3. The inflammation may become chronic if the irritant (without being pyogenic) is a persistent one. It may be a depressed plate of bone, or a foreign body driven in, or a cyst or patch of dense fibrous tissue developed from an old extravasation ; or it may be a specific organism, such as that of syphilis, tubercle, or actinomycosis, sufficiently irritating to cause the production of a mass of granu- lation tissue, but not, at first at any rate, lowering the vitality of the surrounding structures so far that they become unable to withstand the action of pyogenic organisms. 662 DISEASES AND INJURIES OF SPECIAL STRUCTURES. 4. Suppuration may follow, whether other germs are present or not. If the vitality of the tissues is very feeble, or if the action of the pyogenic micro-organ- isms is assisted by septic decomposition and tension, it will be diffuse and rapidly fatal. \{ the conditions are not so unfavorable, a limiting wall of granulation tissue may be developed, forming a cerebral or meningeal abscess ; and this, according to the rapidity with which it extends, may be acute, chronic, or even latent, remaining concealed perhaps for years. It takes, however, three weeks, or at least a fortnight, for the surrounding brain tissue to protect itself in this way ; and, consequently, circumscribed suppuration is rarely met with after com- pound fractures, and never until some considerable time after the receipt of the injury. The organisms may gain access directly through a wound ; or indirectly by e.xtension along the veins (thrombosis, which is usually retrograde) ; by sudden embolism, as in pyaemia ; or by continuity through the adjacent tissues. What- ever the way, unless everything is perfectly healthy and well nourished (when probably the germs, like those of putrefaction, are soon destroyed), they begin their work at once ; the leucocytes perish and become pus-corpuscles ; the plasma and formed tissues melt away ; and suppuration begins, diffuse or circumscribed, according to the ability of the surrounding tissues to repel the assault. {p) Chronic Inflammation. Chronic inflammation of the brain or its membranes may be the relic of an acute attack, resolution having been imperfect ; or it may be chronic from the beginning. In either case the immediate cause is the presence of some persisting irritant, which may be mechanical, chemical, or a living organism. The inflam- mation may begin in the brain or the membranes; but unless a definite exciting cause, such as a depressed spiculum of bone, is known to be present, it is rarely possible to distinguish one form from the other. Causes. — Fracture of the skull not uncommonly leaves behind it symptoms of chronic irritation of the brain, arising, certainly in many cases, from the per- sistence of some gross lesion. Starring of the inner table ; angular depressions (smooth extensive ones, such as occur in children, are not so serious) ; detached spiculae of bone ; and even foreign bodies (fragments of knife blades) have been known to occasion it. Intra-meningeal extravasation is more rare, but sometimes it leaves a dense, hard layer of organized blood clot, or a cyst, pressing upon the cortex. (Subcranial hemorrhage between the bone and the dura mater, whether occurring at birth or later, rarely gives rise to symptoms of irritation. Like smooth dei)ressions of the cranial bones, it may cause spastic paralysis, or some form of birth palsy, if it does not of itself prove fatal; but the symptoms are nearly always referable rather to atrophy than anything else). In other cases a dense, sclerosed condition of the bone, with nodes projecting from its inner sur- face, may be found ; or a thickened and partially ossified plate in the dura mater ; or a spot in which all the membranes are so fused with each other and with the cortex that there is nothing left but a fibrous ma.ss with a few shriveled or calcified ganglion cells in its substance. Syphilis, as it affects the membranes and the cortex of the brain more often than other parts, is a frequent cause. Osseous nodes may grow out from the inner surface of the bones (the frontal in particular, on either side of the longitudinal sinus) ; or gummatous deposits may occur in the dura or pia mater, or in the substance of the brain, leaving, after they have been absorbed, dense rigid cica- trices which perpetuate, or even, by their contraction, intensify the mischief already done. The coats of the arteries may be diseased, so that either the lumen is blocked and softening ensues, or their walls give way and aneurysms or hemor- rhages follow; or, again, slowly extending ])atches of sclerosis may develop, and by degrees involve one part after another. Tubercle, when it begins in the mem- INFLAMMATION OF THE BRAIN. 663 branes, usually runs an acute course, and ends in a speedily fatal form of menin- gitis ; when, however, it takes the shape of a caseous mass ; deeply buried in the substance of the brain, the chief symptom, until compression sets in, is the chronic irritation of all the surrounding parts. Slowly growing tumors and cysts, whether originating in the brain itself or springing from the bones, act in the same way. The persistent abuse of alcohol is said to cause the same result, leading to chronic inflammation and induration of the membranes and surface of the brain, especially on the vertex; and sometimes there are other causes, some acting directly, others giving rise to reflex irritation, and others again affecting the circulation chiefly, if not entirely, so that, post-mortem, no local pathological lesion can be found. Symptoms of chronic irritation of the brain, whether sufficiently severe to excite visible inflammatory changes or not, are of the most varied character. In many instances they are entirely general, without the least indication of any local lesion. A peculiar condition of general irritability, for example, is often left after severe contusions. Recovery does not appear to be complete ; there is a great ten- dency to headache, especially after any mental exertion or excitement ; the patient is irritable, giving way to fits of passion without any apparent reason ; memory is defective, sometimes generally, sometimes only for certain special things ; the power of mental concentration is impaired, and the patient is quite unable to do what he used to do without effort before. It seems as if the circulation through the brain does not easily regain its power of self-control ; for a long time the least mental excitement or over-exertion is enough to throw it into disorder, and to bring back, temporarily, the condition of hyperaemia and congestion that followed immediately upon the receipt of the injury. As a rule this passes off; but some-" times, if the part is not kept at rest, it becomes permanent, and a lasting condi- tion of cerebral incapacity is left. The symptoms are the same when the irritant is a persisent one, but they are usually more intense. Headache is never absent, sometimes it is general, sometimes local ; but wherever it is, it is always made worse by excitement, or by hanging the head down, or by the use of alcoholic stimulants. Vomiting, such as is met with in cerebral affections, apparently purposeless in character, is not infrequent. Ver- tigo may occur, especially when suddenly rising up. Optic neuritis is nearly always present, especially when the membranes at the base are concerned ; and in many cases there are other affections — neuralgia, for example, or paralysis of the other cranial nerves. Some form of mental disturbance is rarely absent. It may be merely irrita- bility and wakefulness, with an uncertain temper ; or there may be loss of memory and power of concentration with want of mental vigor, and in extreme cases de- mentia. The local symptoms are no less variable. Spasmodic convulsions may occur if the irritant affects the motor portion of the cortex, and without occasion- ing any loss of consciousness, may spread from one centre to another. Traumatic epilepsy may follow, the discharging lesion from constant repetition becoming per- manent. Or paralysis may occur, but this is less frequent, as lesions that cause chronic irritation or inflammation are usually connected with the membranes or the surface of the brain, and slow destruction of the cortical motor centres in one hemisphere admits very largely of compensation. Valuable information, both as to the site and nature of the lesion, may fre- quently be obtained in other ways. In traumatic cases, for instance, there may be a depression or irregularity on the surface of the skull. Pressure may be exceed- ingly painful at one particular spot ; or the whole bone may be tender on percus- sion. The pain may be altogether of a different character, dull and heavy, infin- itely worse at night, due chiefly to the osteitis. The temperature of the part may be higher than that of the corresponding point. The skin may be puffy or raised ; or there may be evidence of obstruction to, or pressure upon, structures passing out through canals in the bone ; and these symptoms of course vary in every casei 664 DISEASES AND INJURIES OF SPECIAL STRUCTURES. SL'I'PURA'IION. Acute inflammation of the brain and its membranes may terminate in sup- puration. The pus may form between the bone and the chira mater (subcranial), probably always extending inward from the bone; between the meninges (sub- dural) ; or in the substance of the brain. In this last situation the ab-scess may be separated from the external focus of disease from which it started by a layer of healthy brain ti.ssue, and even by intact and unaffected membranes, the infection having traveled inward along one of the veins or in its perivascular sheath. Suppuration is limited or not, according to the relative vigor of the tissues on the one hand and the irritants on the other. If the latter are much the stronger, it will be diffuse and set in acutely \ if the difference is not so great, it may be cir- ciimscrihcd, two or three weeks being recjuired for the development of the limiting wall of granulation tissue ; and if the balance is only just in their favor, it may be chronic and even latent, remaining concealed perhaps for some years. Cause. — Intracranial suppuration may originate in three different ways : — (i) It may break out after contusion or concussion of the brain, even though the skin has not been injured or the bone fractured, the pyogenic organisms being carried by the blood, but not causing embolism. Fortunately it is very rare. It may be either diffuse, acute cerebritis running on to sup])uration, and proving fatal within a few days, or circumscribed, the area of red softening round the contusion gradually growing more and more liquid in the centre until it simply becomes a collection of pus. Abscesses caused in this way are nearly always single and in the substance of the brain. Not unfrequently they are situated on the side oppo- site to the injury — in the right frontal or temporo-sphenoidal lobes, for example, when the blow has fallen upon the left side of the occiput, owing to the fact that in such cases this is the part of the brain that usually suffers most. (2) It may be due topycemia consequent upon the impaction of infected emboli from some distant focus of suppuration (usually in the lungs). If it occurs in con- nection with the membranes it is always diffu.se ; if it is in the brain it is nearly always multiple and generally in the course of the middle cerebral artery. (3) It may be due to extension from suppuration near. This, which is by far the most common and the most important variety, may be the result either of injury or disease. {a) After Injury. — Acute suppurative meningitis may be caused either by the organisms entering through the wound directly, or by extension inward as a result of suppuration in the diploe. In the former case the inflammation breaks out within a day or two after the injury. It usually occurs after small punctured fractures, not when the bone has been extensively comminuted and all the loose fragments have been removed. In these cases a considerable amount of blood is often extravasated ; it collects in the wound exposed to the air, and so long as the fragments remain impacted is unal)le to escape. If septic decomposition is allowed to take place, the i)roducts soak into the bruised and damaged tissues around, and lower their vitality to such an extent that suppuration follows at once, and is always diffuse. The meshes of the pia mater are filled with exudation, which surrounds the veins, dips into the sulci, and covers the convolutions, until it can be stripped off like a cast of yel- lowish-green wax, bringing with it the surface of the softened and infiltrated cortex. In the latter case, when the meningitis is secondary to acute suppurative osteitis, the apjjearances and the result are generally the same, although it may be several days before the di.sease is so far advanced. Sometimes, however, when the dura mater is not torn, the course is more protracted, and subcranial (extra-dural) suppuration occurs, and persists for some little time before the inflammation gains the subdural space and becomes diffuse ; and, occasionally, even when the dura mater has been punctured and spicules of bone driven into the substance of the brain, there is no definite evidence of the formation of pus, though weeks may INTRACRANIAL SUPPURATION. 665 have passed since the receipt of the injury. Probably in this latter case there has been no septic decomposition, and the pyogenic organisms, with only a limited area of damaged tissue at the seat of injury, without the assistance of the poisonous i)roducts of putrefaction, have only been able to cause the minimum of destruction. In exceptional instances intracranial suppuration may follow a simple contu- sion of the cranial bones, sui)purative osteitis breaking out at the seat of injury and extending inward. A severe blow is received upon the head ; blood is extrava- sated into the veins of the diploe and under the pericranium ; usually it becomes absorbed ; occasionally days or weeks after the injury suppuration breaks out, the organisms having entered from some already existing focus of suppuration, through a wound, or through the mucous membranes. At once the inflammation becomes much more severe ; the pericranium is detached from the bone on one side and the dura mater on the other ; the exudation pours out into all the tissues around, lifting up the skin (Pott's puffy tumor) and glueing together the membranes ; acute osteophlebitis sets in, and the pus spreads rapidly through the softened and inflamed tissues. Suppurative osteitis of this character is so often associated with liysmia. sometimes as its cause, that when the pus does burst through the bone it rarely remains limited; nearly always, however early an incision is made, the pericranium is already stripped up, the bone is bare, rough, and brown, and if a trephine is applied, pus wells out from the groove mixed with the bone-dust. When the disc is lifted out, instead of a circumscribed abscess, the dura mater is already perforated and the arachnoid and sub-arachnoid spaces are filled with a thick layer of yellowish-green pus. {b') As a Reszdt of Disease. — Intracranial suppuration is frequently caused by extension inward from a purulent focus in the surrounding tissues, without fracture or other injury. The pathological process is essentially the same as when it follows an open wound or a compound fracture ; the route, that is to say, may be direct, the micro-organisms simply invading one part after another and forming a continuous track of suppuration ; or the inflammation may spread along the veins or lym- phatics without leaving in the intervening tissues any evidence of its passage through .them ; but the difficulty of localization is so great, and the onset of the disease in the majority of cases so insidious, that a separate description is advisable. As in the case of compound fractures, the suppuration may be either diffuse, involving the membranes, or circumscribed, and usually in the substance of the brain (cerebral abscess) ; but the relative frequency of the two is very different. The former, which is by far the most common after injury, is rarely met with unless there is acute extra-cranial inflammation, such as orbital cellulitis, facial carbuncle, diffuse inflammation of the cellular tissue of the scalp, the so-called phlegmonous erysipelas, or acute suppuration in connection with the ear. In all probability the infection extends along the veins or their sheaths, the ophthalmic for example, or the mastoid, or those that pass back through the sphenoidal fissure, for the meningitis is nearly always associated with thrombosis of the sinuses and general pyaemia. So far as the pathological appearances are concerned, it does not diff"er in any material respect from the diffuse suppurative meningitis that occurs after compound fractures. The latter {cerebral abscess) results almost always from chronic suppurative disease, and is usually consecutive to caries of the ethmoid, or especially the petrous portion of the temporal bone. Catarrhal inflammation of the middle ear is exceedingly common after the exanthemata (particularly scarlatina and measles), and may occur whenever the mucous membrane of the throat becomes inflamed. In most cases it subsides without any ill consequence ; but if it runs on to suppuration it may lead to per- foration of the membrana tympani and destruction of the auditory ossicles ; or it may become chronic, spread from the mucous membrane to the periosteum and the bone beneath, and give rise to caries and necrosis. When this takes place there is always imminent danger that it may extend further still. 43 666 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Extension may take place while the inflammation is acute, or later when it has become chronic, and there is nothing to attract attention l)ut the loss of hearing and a little purulent discharge from time to time. In the former case, as in traumatic intracranial suppuration, it is usually diffuse ; if the conditions are so favorable that the jjyogenic germs can si)read without difficulty tlirough the petrous portion of the temporal bone to the meninges, they are not likely to remain localized and confined there. In the latter case it is nearly always circumscribed. So long as the exit is free and the discharge is not allowed to accumulate and decompose, the danger is not great, although suppuration does sometimes occur even under these conditions, the abscess remaining latent in the brain. If, however, the outlet becomes blocked, whether this is due to dried- up discharge or to the growth of polypoid granulations, the pus that is retained begins to decompose, the tension becomes higher and higher, and extension of the inflammation is the natural consecpience. It depends chiefly ujjon the accidental anatomical relations of the focus of disease, whether the pyogenic organisms spread to the dura mater (causing subcranial abscess or diffuse menin- gitis), to the brain (fmding a route by direct continuity of structure, or along the veins or lymphatics), or to the blood-vessels in the diploe, giving rise to osteophlebitis, thrombosis of the lateral sinus, or pyaemia. These relations, and particularly the development of the mastoid cells, vary at different jieriods of life. In a child two years of age, there is only a small air space lying immediately behind the tympanum ; the cells that occupy the mastoid process have as yet no existence, and the lamina of bone which forms the roof of the tympanum and helps to separate the external meatus from the middle fossa is exceedingly thin. On the other hand, in adults, the mastoid i>rocess may be excavated by great hollows quite up to the lateral sinus and the mastoid vein (especially when the sinus curves rather more forward than usual, for its position is very variable). Suppuration, therefore, in connection with the mastoid cells would tend to spread more easily toward the middle fossa in the child, toward the sinus in the adult ; but further evidence is wanted to establish this as a fact. In many cases, the inflammation spreads by direct continuity of structure ; the bone becomes inflamed, and necroses ; the dura mater over it sloughs, and either the pus spreads into and through the arachnoid space at once, or the membranes become glued to each other and to the cortex by inflammatory exudation before this can occur. There are, however, many other routes almost as direct, along which the infection may travel. It may spread, for Fig. 29.. -Section (slightly example, dowu the internal auditory meatus, or through the oblique) through the mas- hiatus Falloijii, or the aciueductus vestibuli, or it may extend toid process and the lat- r .1 11 • / 1 ., \^A erai sinus, showing the along some of the numcrous small veins (each surrounded ofherTnEd.tu'""'''' L)y a perivascular lymi)h sheath; which run between the in- ternal and middle ear on the one hand and the dura and pia mater on the other. Some of these pass directly from the tem])oro- sphenoidal lobe of the brain to the dura mater, covering the petrous portion of the temporal bone ; others run through the squamo-petrosal suture, and through the slit for the dura mater that lies by the side of the aqueductus vestibuli ; others, again, lie in small canals (immediately behind the superior semicircular canal) which connects the middle ear directly with the middle fossa of the skull ; and not a few communicate with the middle meningeal veins and the superior petrosal and lateral sinuses. In most cases of disease in the middle ear the abscess is in the temporo-sphe- noidal lobe ; sometimes the dura mater covering the anterior surface of the petrous portion is unaffected ; generally it is sloughing, or at least inflamed. The abscess is usually of large size (an inch and a half or two inches in diameter) ; its walls may be very thick (occasionally acute suppuration develops round an old encysted INTRACRANIAL SUPPURATION. 667 abscess) ; and it may lie in the substance of the lobe, covered over by a layer of apparently healthy cortex a (juarter of an inch in thickness, or communicate with the suppurating focus in the bone through a sinuous channel. The pus is generally exceedingly fcetid. The abscess if left to itself may remain latent for years ; or acute symptoms may suddenly develop from some comparatively trivial cause, exposure to cold for example, or a blow upon the ear : usually it terminates sooner or later by rupturing into the lateral ventricle or the subarachnoid space. Cerebellar abscess is less frecjuently met with. There is a certain amount of evidence that it is more common, comparatively, in children than in adults and when the mastoid cells are inflamed. Thrombosis of the lateral sinus is associated with it in many instances. Abscesses in many localities are more rare : but they are sometimes found between the dura mater and the bone (extra-dural) ; in the centrum ovale ; even on the opposite side of the head (probably py?emic, or at least thrombotic ; and in the pons. It is said that the last is consecutive to disease of the internal rather than of the middle ear. In comparison with this, intracranial suppuration consequent on disease of bone elsewhere, is seldom met with. Both forms, however, the diffuse and the circumscribed, may occur in the region of the frontal lobes from caries of the ethmoid and ozsena ; and one or two instances are recorded in which the same thing has happened in connection with the orbit. Symptoms. — i. Diffuse Suppuration. — It is rarely possible to tell when sup- puration begins in a case of acute inflammation of the brain. Sometimes there is a rigor, but it is by no means invariable, and if it does occur it more frequently indicates the commencement of pyaemia. The constitutional symptoms simply grow more and more severe, the temperature in particular rising to an exceptional height, while the local ones gradually merge into those of compression. The cortex becomes more and more disordered ; convulsions, excitement, and delirium give way to paralysis, loss of consciousness, and coma ; the pupils dilate ; the eyes remain widely open ; the face becomes flushed and dusky : the pulse slow and full ; and respiration labored and stertorous. 2. Intracranial Abscess. — The symptoms depend upon the rapidity with which it is formed, the rate at which it extends and the locality in which it occurs. In rare instances intracranial abscesses are acute, ushered in with a rigor and high fever. Much more often they are chronic and even latent, without any elevation of temperature ; sometimes there is an actual fall, so that, for a time at least, it is subnormal. Occasionally, after existing without a symptom for an indefinite period, an abscess suddenly becomes acute, spreads rapidly, and breaks into the ventricular or subarachnoid space. The local symptoms are those of pressure upon or irritation of the structures that lie around it. The most important varieties are the traumatic and that which is secondary to disease of the middle ear. Others are more rare and seldom admit of diag- nosis. («) Traumatic Intracranial Abscess. — The symptoms are partly general, in- dicative of disturbance of the whole nervous system ; partly local, arising from aff"ections of special portions of the brain, or the nerves, or the bones and mem- branes covering them in. There is always a latent period after the accident, at least a fortnight, gener- ally much longer, sometimes years. At the time there may have been concussion, or evidence of contusion of the brain ; but in a typical example this has passed away. Recovery, however, is not perfect ; the patient grows thinner, or loses his memory ; perhaps he becomes irritable, or there is general failure of power, bodily as well as mental. Sometimes these signs are so marked that the friends notice them and become anxious ; sometimes they are scarcely perceptible. The tem- perature is usually subnormal, although slight chills may occur, the pulse is quick and irritable at first, very slow toward the end. Pain is rarely absent ; in most cases it is very severe ; usually it is general, affecting the whole head ; sometimes 668 DISEASES AND INJURIES OF SPECIAL STRUCTURES. it is local, and associated with great tenderness on pressure or percussion. (Jptic neuritis is present in nearly every case, and irregularity of the pupils is often noted, the one that is more dilated and fixed corresponding to the affected side. Very often local signs are entirely wanting ; there is merely headache followed by drowsiness, paralysis, and at length coma, without its being possible to say from the brain symptoms more than that it is a ca.se of gradual compression. Valuable information is often gained from the condition of the skin or the bone. Sometimes there is a scar or an irregularity on the surface of the cranium from depression of a portion of bone. In many instances there has been a history of purulent discharge following fracture, and of very protracted healing. Occa- sionally the discharge has stopped, collected, and begun again more than once before the symptoms l)ecame serious, although each time there may have been a certain degree of headache and feverishness. Tenderness on percussion over the affected bone is not uncommon. Sometimes there is a dull, aching pain, espe- cially severe at night. In a few cases there is a soft puffy swelling on the scalp, due to effusion under the pericranium (Pott's puffy tumor), and pointing to com- mencing suppuration in the dii)loe. Intense neuralgia in all the three branches of the fifth pair has been noted once or twice. Paresis from j^rcssure, occasionally passing into paralysis, is more common, affecting especially the motor nerves of the eyeball. Cerebral symptoms, monospasm and monoplegia, gradually extending over a wider area, are rare. They only occur when the motor area is involved, and are not always present then. When cerebral abscess is caused by cont re-coup they are the only local signs that are present. Diagnosis. — Diffuse suppurative menini::;itis usually runs a much more rapid course ; it begins within a short time of the injury, almost always in the first week, sometimes in forty-eight hours, and is associated with high fever, headache, delirium, and other signs of rapidly-spreading destruction of the cortex. Chronic tneningitis is often present as a complication in cerebral abscess ; by itself it does not give rise to symptoms of compression. Py(2mia is the most difficult, especially when it commences as osteophlebitis in the injured portion of the cranium. The difference is merely in the method of extension. Each commences, in many cases at any rate, as a purulent osteitis, with a soft, puffy, and exceedingly tender swelling upon the scalp. In the one, the suppuration spreads through the contiguous structures to the membranes and the brain beneath, until an abscess is formed. In the other the veins of the diploe and the sinuses are thrombosed, and the infective emboli carried off to cause abscesses elsewhere. The local signs are the same ; the early constitutional ones present no material difference ; a single rigor may occur in either ; indeed it is not until pyaemia has shown its presence by local indications in other parts of the body, or by repeated shivering fits, that the diagnosis is certain. The difficulty is not so great when cerebral abscesses are dependent upon other causes than disease of bone, but then, not unfrecjuently, all l)ut the most general symptoms are wanting altogether. {b) Intracranial Abscess Due to Disease of the Middle or Internal Ear. — Nearly three-fourths of these are situated in the temporo-sphenoidal lobe, and many are associated with a sloughing condition of the dura mater. The rest occur in the cerebellum, between the dura and the bone, in the pons, and occasionally in distant parts of the brain. They never appear while the inflammation is acute ; there is always a history of chronic purulent discharge lasting for years, and often of its having stopped on some previous occasion which was marked by severe head- ache, vomiting, and perhaj)S other symptoms. In most instances two stages can be distinguished ; the first, while the abscess is slowly forming, of very indefinite length ; the second, that of rapid extension, rarely lasting more than a week. The transition may be gradual, but more often it is sudden, caused by some comparatively trivial accident, such as a blow upon the ear or exposure to cold and wet. Many apparently unaccountable cases of INTRACRANIAL SUPPURATION. 669 fatal coma are explained in this way ; an old cerebral abscess, which has already lasted weeks or months without giving rise to any definite symptoms, suddenly giving way and bursting into the ventricular or subarachnoid space. The symptoms in the early stage are vague and ill-defined. There is always headache, sometimes very severe, and, not unfretiuently, vomiting without any apparent reason, as is usual in cerebral affections ; but in many, the only sign is a dull, sluggish state of mind, sometimes uniformly lethargic, sometimes, on the other hand, diversified by strange fits of irritability, and, in rare cases, delirium and convulsions. Rigors, pyrexia, and optic neuritis seldom occur. In the acute stage, the symi)toms present the same general characters but they are infinitely more severe. The headache is of the most intense description, radiating from the ear and causing such fearful agony that the patient can do nothing but scream or rock himself from side to side, clasping his head in his hands or burying it in the j^illow. The lethargy rapidly deepens into stupor ; there may be an attack of vomiting or a single rigor, but this is more commonly associated with subdural abscess and thrombosis of the lateral sinus ; the face be- comes dark and cyanosed, the respiration labored and stertorous, and coma, with or without convulsions, quickly follows. Death usually takes place within the week, sometimes within a few hours. Diagnosis. — An accumulation of decomposing ///j-, /dv// /// //; the mastoid antrum, may cause many of the symptoms of cerebral abscess, including, accord- ing to Barker, double optic neuritis. In any case of doubt a preliminary explor- ation should be made, a trephine or gouge applied to the outer wall half an inch behind and above the centre of the external meatus, the cavity thoroughly opened and washed out. This difficulty of course only occurs in the early period of the disease, before there are any symptoms of compression. ThfoDibosis of the Lateral Sinus. — According to Pott, this is usually due to direct extension from the bone on the posterior surface of the petrous part ; more rarely from the mastoid cells along the vein of the cochlea. The clotting mav be local or extend into the other sinuses and down into the jugular vein. When due to osteitis it nearly always proves fatal from pyaemia. The symptoms resemble to some extent those of cerebral abscess, but there is usually a rigor, or at least a very irregular temperature ; the pain is more local ; there is a tendency to retract the head ; the neck is stiff; and occasionally subcutaneous oedema may be noted over the mastoid, or the internal jugular vein can be felt as a hardened cord in the neck. Optic neuritis, vomiting, headache, giddiness, and even coma may be present in these cases before any clearly pysemic symptoms make their appearance. Hitherto these cases have been regarded as practically hopeless : it has, however, been shown by Ballance and others that recovery is possible even after pyaemic symptoms have made their appearance in distant parts of the body, if only the disease is treated thoroughly. The mastoid antrum must be cleared out first : if nothing is found in it to account for the symptoms, or if, in spite of this having been done, the pyrexia and irregular temperature continue, the orifice of the mastoid vein (an inch and a quarter behind the meatus) should be exposed, and if it is thrombosed a further operation undertaken. The jugular vein must be liga- tured in the neck ; the whole of the dead bone between the meatus and the wall of the lateral sinus cut away, so that there may be free exit for the pus that lies between the membranes and the bone ; and the cavity that is left, the sinus itself, and the upper part of the vein thoroughly syringed out with a solution of corrosive sublimate. Subdural abscess may form on the posterior surface of the petrous portion of the temporal bone, or over the roof of the tympanum close to the squamoso- petrosal suture. In the former locality it is nearly always associated with throm- bosis of the lateral sinus, the pus spreading between the dura mater and the bone until it reaches the fibrous wall and so alters the endothelium that a clot forms upon it. In the latter, it may occur independently by itself. It is very doubtful, w^hen it exists by itself, whether it can be distinguished from cerebral abscess ; 670 DISEASES AND INJURIES OF SPECIAL STRUCTURES. rigors api)ear to be more common ; percussion over the temporal bone is more jjainfuland the cerebral symptoms are less distinct ; but the two maybe associated together. The diagnosis is not perha]js of so much importance, as in any case in which the symptoms continued after the mastoid cells had been cleared explora- tion must be continued in the same direction : behind the mastoid process if there is any evidence of sinus throml)Osis, above and slightly in front (so as to expose the anterior surface of the petrous part) if there is not. The diagnosis of tlic locality of cerebral abscess, when consecutive to osteitis, is equally difficult. The majority are situated in the tem])oro-si>henoidal lobe, especially in the case of adults ; of the rest, most are in the lateral lobe of the cerebellum, the others are practically inaccessiljle. An abscess in the temporo-sphenoidal lobe does not cause any localizing symptoms until it has attained a very considerable size. As it increases, the third nerve on the same side becomes compressed, so that ptosis, fixed mydriasis, and paresis of the ocular muscles ensue ; and then the lower part of the ascending frontal and i)arietal convolutions, so that the facial muscles on the opposite side of the body become paralyzed (retaining, however, some jjower of emotional ex- pression), and then, later, those of the arm. The leg is never affected ; and .sensibility remains unimpaired. Cerebellar abscess is still more indefinite. It appears to be relatively more common in the young, and there is no doubt that it is often associated with throm- bosis of the lateral sinus. Severe occipital pain, persistent vomiting, and retraction of the head are suggestive of its presence ; but unless there is definite evidence of disease of the posterior surface of the petrous portion, exploration for cerebellar abscess should never be made until the existence of a temporo-sphenoidal one has been excluded. Prognosis. — Intra-cranial suppuration, whether traumatic or consecutive, if left to itself is practically ho])eless. A few cases have recovered, the former by the cicatrix giving way so that the pus was discharged externally, the latter owing to the abscess becoming surrounded by a dense capsule ; but the number is very small. Death may be caused by compression, or by the abscess rupturing suddenly into the ventricles. Occasionally a condition of marasmus sets in and proves fatal without any definite reason ; and sometimes sudden death occurs, as in the case of cerebral tumors. General Treatment of Inflammation of the Brain. — i. Preventive. — If there is a wound no effort should be spared to free the surface from all possible sources of irritation, whether mechanical, such as depressed fragments of bone, or chemical, such as the products of decomposition ; and to secure perfect drainage, so that there may be no retention of lymph and no tension. In the same way, if there is suppuration in connection with the middle ear, and the membrana tympani is bulged outward by a quantity of opacjue white pus, it should be incised from top to bottom behind the malleus, and transversely below it, and the cavity thoroughly drained. Still more is this necessary if the disease has already involved the bone, so that a foul collection of decomposing jjus lies buried behind the meatus. If there is no wound, but merely a history of a severe blow upon the head, followed perhaps by symjttoms of concussion or contusion of the brain, absolute rest must be enforced. Everything that causes hyperemia of the brain — mental exertion, excitement, want of rest, stimulants, even conversation — is injurious, and tends to delay recovery. The head should be shaved, cold applied, the room darkened, the bowels thoroughly opened (preferably with calomel) and only the lightest diet allowed ; nor should any precaution be omitted until a sufficient time has elapsed for the extravasated blood to become absorbed and the damaged tissue repaired. In other jjarts of the body this often takes a fortnight or three weeks : and there is no proof that a shorter time is required in the case of the brain. 2. Curative. — {a) Acute Inflammation. — If, in spite of this, the symjjtoms of acute inflammation, the headache, pyrexia, and delirium, grow wor.se, leeches may be applied behind the ears ; venesection may be tried ; the calomel may be repeated INTRACRANIAL SUPPURATION. 671 so as to produce copious evacuation, and if there is great excitement small doses of opium, or, better, bromide of potassium and chloral, may be given ; but if the inflammation is general, if no local cause can be found and removed, there is very little hope ; it is almost sure to run on to diffuse suppuration. {b) Chronic Intlainiiiation. — The treatment clei)ends upon whether a local cause can be found or not. If there is a tender spot on the bone corresponding to an old injury, or a depression, or a suspicion of some alteration on the inner surface, such as splintering of the inner table, thickening of the dura mater, or the formation of a cyst in the arachnoid, the cicatrix should be reopened, the peri- osteum reflected, and a circle of bone removed with the trephine. If nothing is found to account for the symptoms, the dura mater should be examined too and incised ; and if the brain projects upward into the wound, indicating a certain amount of pressure, it should be explored with a grooved needle or a fine trocar and cannula. Possibly there may be a chronic abscess or a cyst. If nothing is discovered, the dura mater should be readjusted, sutured or not, according to the size of the opening, and the bone, provided it is not thickened or sclerosed, re- placed again. Where there are no local symptoms, but merely, instead of perfect conva- lescence, a condition of irritability, excitement, or headache, great relief may be obtained by counter-irritation, blisters, and even setons. Mercury pushed to salivation has been strongly recommended ; iodide of potash is also said to have been of service ; but probably most reliance must be placed upon the effect of time and perfect rest. Change of air and scene, and the avoidance of everything that can cause cerebral hyperc'emia, naturally suggest themselves, and, of course, special attention should be paid to the presence of any diathesis, such as syphilis or gout. {c) Iiitracranial suppuration can only be treated by operation. The diffuse form in which the whole surface of one hemisphere is covered over with a layer of pus, dipping down into the sulci and sheathing all the vessels, is practically beyond reach. The localized one requires trephining. /// traumatic cases there can be no question. Except in those rare instances in which the abscess has developed as a result of contre-coup (and they rarely admit of diagnosis), an exploratory operation should be performed at the seat of injury ; and when the brain is exposed, if the cause still remains undiscovered, a grooved needle should be thrust into it in all directions. Many cases have been relieved in this way, some temporarily, the immediate symptoms of compression passing away, so that the patient recovered consciousness and the pulse regained its vigor (I have, on several occasions, seen all the vessels in the scalp begin to spirt as soon as the tension was relieved) ; others permanently, recovery having been complete. The same thing holds good with regard to cases that are consecutive to middle ear disease, but the difficulty is much greater. Other affections, especially throm- bosis of the lateral sinus and pyaemia, are caused in the same way and give rise to very much the same symptoms ; and even when these are excluded there is often no definite evidence as to locality. In all such the mastoid antrum should be thoroughly explored first, and a free communication established between it and the external auditory meatus ; in many instances relief is obtained at once by this, the incipient meningitis, which is probably the cause of the cerebral symptoms, subsiding as soon as the cause is removed. If this does not succeed, or if no evidence of accumulated pus is found, the exploration must be carried further. Whether it should be made half an inch above and slightly in front of the meatus, so as to expose the anterior surface of the petrous portion, or behind and on the same level, must be guided by what is known of the condition of the sinus. In either case, the exit must be as free as possible, not only for the pus in the brain, but for all the gangrenous shreds of dura mater. In all cases the orifice of the mastoid vein must be exposed first. If this gives no evidence of thrombosis, and there is no other sign, the anterior operation 672 DISEASES AND INJURIES OF SPECIAL STRUCTURES. should be selected, the under surface of the temporo-sphenoidal lobe exposed, and, if there is no extra-dural collection of pus, thorouglily explored with a grooved needle. If, on the other hand, there is any symptom pointing to the sinus, the bone should be removed from l)ehind the meatus ; and if an extra-dural abscess and septic thrombosis are found, the jugular vein shoukl be ligatured too. The only hope lies in thoroughly clearing out the clot and removing the whole focus of disea.se. If no abscess is found in the anterior operation, either between the dura mater and the bone, or in the substance of the brain, and there is no evidence of thrombosis, even when the mastoid vein is exposed, the periosteum and the muscular attachments must be separated from the occipital bone beneath the superior curved line, and the lateral lol)e of the cerel)ellum explored. In many cases of cerebellar abscess, however, there is sinus thrombosis as well, and there must always be con- siderable danger of one of the two being overlooked if the other is found. Hernia Cerebri. Hernia cerebri is a protru.sion through an opening in the cranium of brain substance that has been softened by inflammation ; and it is caused by the differ- ence between the external and the internal pressure. When a portion of the brain is excised the cavity fills almost at once, and the edges of the incision become everted. If the seal]) is laid down again, and union takes place by the first intention (protection being afforded in the meantime by the dressings), the outside tension is restored and there is merely a slight sink- ing inward, corresponding to the amount of tissue removed. (Sometimes, when, for example, the loss has been very great, and the walls cannot fall in, a serous cyst forms to fill up.) If, on the other hand, inflammation sets in instead of repair, the brain tissue becomes softened, the intracranial tension rises higher and higher, and either symptoms of compression follow, or the pulpy brain substance is s(]ueezed out through the opening. The defect in the cranial walls may be caused by injury (compound fractures wounding the membranes), or by necrosis, syphilitic or otherwise, causing gradual softening of the dura mater. The inflammation of the brain may be produced by any of the causes already mentioned (the area of red softening, for example, that exists round a rapidly growing tumor might lead to the development of a hernia after excision) ; but inasmuch as nearly all the ca.ses of inflammation that coexist with an opening in the cranium are due to decomposition of the extravasated blood and end in suppuration, hernia cerebri is almost always regarded as the product of sup- jjurative meningitis. The protrusion, in cases of injury, consists at first of extrava.sated blood mixed with inflam- matory exudation ; later of the latter with a varying proi)ortion of softened and broken down brain tissue. In cases of necrosis the first layer natu- rally is wanting. .Xs the tension in- creases and the process of softening extends, more and more of the under- lying brain tissue is forced out, until sometimes, if the i)rotrusion is sliced off, the cavity of one of the ventricles is laid open. It is more frequent in the young than in the old ; in the frontal than in the parietal region ; and it is more likely to occur when the opening is small than Fig. 292. — Hernia Cerebri. INTRACRANIAL TUMORS. 673 when the cranial bones are extensively comminuted. The appearance is unmis- takable. 'Inhere is a soft, dark-brown mass, covered over with lymph or pus, bleeding at the slightest touch, and ])ulsating synchronously with the brain. It may grow rapidly, becoming more and more oedematous as it protrudes from a narrow opening, or the increase may be very slow; and after a time it may cease altogether, shrink back of itself, and skin over. Recovery may take place even after large mas.ses have sloughed away, the space left in the cranium being filled with clear serous fluid ; more frequently the meningitis proves fatal. Hernia cerebri is always the result of inflammation ; if this is local and cir- cumscribed, and the products can escape freely, the hernia gradually sinks back and skins over ; if it is diffuse, nothing is of much avail. An ice-bag must be laid upon the head, and the ordinary treatment adopted for inflammation of the brain. The protrusion itself must be kept perfectly clean ; it is no use either applying pressure or shaving it off. The prognosis depends upon the inflammation. Intracranial Tumors. In 1884, relying entirely upon the clinical evidence of a focal lesion, Godlee exposed the surface of the brain and removed a tumor from beneath the cortex. Since then the same operation has been performed on many occasions by MacEwen, Horsley, and others with very considerable success. Unhappily the conditions are so stringent that the proportion of cases in which relief by operation is possible is very small. Localization must be exact ; the site must be accessible ; the size of the tumor must not be too great, or the lesion left may be practically as bad ; and there must be no other growth or disease. Success is naturally more probable when the tumor is surrounded by a capsule than when it is of an infiltrating nature, but this it is rarely possible to determine beforehand. The tumors that are grouped together under this class may grow from the bones, the membranes, or the brain. Some are primary, others secondary, the original lesion occurring elsewhere. {a) In Connection with the Bones. — Tumors (other than syphilitic or inflam- matory outgrowths) springing from the inner surface of the inner table of the skull are very rare. Myeloid sarcoma is not uncommon in the diploe, and ivory exostoses may grow from the frontal or other sinuses ; and both of these may cause a very serious inward projection of the bone ; but they usually admit of speedy recognition from the exterior, and in any case require to be dealt with on their own merits. (J)) In Connection with the Membranes . — Fibromata have been described in connection with the dura mater. Sarcomata are rather more common, sometimes causing absorption of the bone lying over them (the so-called fungus of the dura mater), and seriously compressing, but not invading, the brain beneath. Cysts, possibly originating in old extravasations, are met with from time to time in the arachnoid cavity, sometimes free, sometimes attached ; hydatids have been known to occur ; and occasionally other tumors, plexiform angeio-sarcoma or endothe- lioma (in which the walls of the vessels appear as if they were converted into sarcoma tissue), psammoma, cholesteatoma, etc., of little clinical importance. {c) In the Brain. — Three-fourths of the tumors that occur in the substance of the brain are either gummata or caseous masses of tuberculous material. The former, which nearly always occur in connection with the membranes or the vessels as they dip through the cortex, are very irregular in shape and size, and usually present on section surface marked by spots of caseation separated from each other by firmer tracts of fibrous tissue. So long as they are spreading, the surrounding brain-tissue is softened and hyperaemic ; after absorption there is merely a dense, indurated, star-like cicatrix, tying the brain down to the membranes, and spread- ing in its substance in all directions. Tubercular masses, on the other hand, are usually rounded and uniform in shape, and opaque and cheesy on section. Around them, so long as they are 674 DISEASES AND INJURIES OF SPECIAL STRUCTURES. spreading (and they may attain the size of a pigeon's egg) is a zone of gray granula- tions, spreading along the vessels ; later they may soften and form a caseous abscess, or develop into fibrous tissue, or dry up and undergo calcification. Naturally they are more common in the young, while gummata are generally met with in adult life. In many cases they are multiple (more than half, according to Gowers), and not unfrecpiently are associated with tubercular disease of the mem- branes and other organs. Gliomata are the next most common. They are composed of tissue resem- bling to some extent the neuroglia of the brain, but they vary very much in consistence, and the softer ones are often stained with old and recent extravasa- tions. They differ from the former and from other kinds of sarcomata in their infiltrating character, spreading among the nerve elements without any defined outline. Other forms of sarcoma are more rare. Carcinoma has been described as a primary affection of the brain, and occasionally other tumors and deposits of actinomycosis. Dermoid cysts have been known to occur, sometimes projecting on the exterior of the cranium through the bone. Hydatids and cysticerci are occa- sionally found both in connection with the membranes and the brain. Most of the serous cysts that have been described have originated in all probability either in the interior of sarcomata or in connection with old injuries and extravasations. Symptoms. — Some of these are general, occurring more or less with all tumors, whatever position they occupy inside the cranium ; others are localizing and are only present when certain parts are involved. {a) Headache, due in great measure to the tension upon the fibrous struc- tures ; vomiting, apparently without cause or object, and especially on waking; vertigo on suddenly rising up ; optic neuritis ; mental dullness, and lethargy are the most prominent and the most constant among the former. For a full account, special works, such as those by Gowers and Bramwell, must be consulted. {b) These may be due to interference with the cortex, the conducting paths, the nerves, or the walls. The more rapid the growth and the greater the amount of irritation and inflammation it causes in the tissues around it, the more distinct they are. Lesions of the cortex may lead to perversion or abolition of its function. If the part involved is motor there may be localized epileptiform convulsions (the most valuable sign of all), followed by loss of power in the muscles most concerned, without any loss of consciousness. Nearly always this is due to some coarse lesion, and most often a tumor. Greater pressure causes paralysis at once, extending in a definite order. When the part is not a motor one, the indications are much less distinct ; but as mind-blindness has been caused by a spicule of bone driven into the angular gyrus and has been cured by its removal, it is possible that similar evidence may be obtained of the growth of a tumor. The presence of a visual aura at the same time would render this much more probable. Lesions of the conducting paths are attended in the same way by abolition or perversion of function ; but in this case the former (manifested as paralysis or an- aesthesia, according to the part involved, without any sign of irritation) is much the more prominent. If the internal capsule is concerned there may be hemianaesthesia or hemiplegia ; if the lesion is lower, mixed or irregular forms, the muscles that are paralyzed on the same side as the lesion becoming atrophied and exhibiting the reactions of degeneration. If the paralysis is incomplete, and jjar- ticularly if it is variable, there may be only pressure on the fibres without destruc- tion ; but unless this can be clearly proved to be the case, it is very improbable that the lesion is within reach, or if it is, that it is not too large. Pres.sure upon the cranial nerves is often of great value in localization : neu- ralgia of all the branches of the fifth pair upon one side, for example, or anaesthesia limited to the same region, pointing definitely to intracanial pressure upon the trunk before its division. INTRACRANIAL TUMORS. 675 Affections of the walls have been already mentioned ; they are rarely present when the growth originates in the brain, until, that is to say, it has attained a size that precludes interference. Diagnosis. — Bright's disease and advanced forms of lead i>oisoning may both be attendctl hv ojitic neuritis, vomiting, headache, and convulsions. Anaemia and hypermetropia occurring together may occasion a momentary difficulty, a slight degree ofoi)tic neuritis and sometimes other symptoms being met with under these conditions ; but the presence of a disorder connected with vision and the absence of localizing symptoms are usually sufficient. It is not so easy with paroxysmal hemicrania, especially when it is associated with hysteria, for the pre.sence of one disease is not absolute proof that there is no other. Cerebral or cerebellar abscess very rarely occurs without a history of injury or evidence of diseased bone. Localized meningitis cannot always be distinguished, as it is present in many forms of tumor, especially syphilitic and tubercular ones, and furnishes some of the symptoms upon which the diagnosis rests. The diagnosis of the kind of tumor is much more difficult. Age, as already mentioned, is of importance, but at the best it only indicates a slight degree of probability. Definite evidence, either from the history or from lesions in other parts of the body, of a syphilitic or tubercular diathesis is very significant, and should influence the line of treatment very materially, but it cannot be regarded as conclusive. Pseudo-apoplectic attacks are more common in connection with glio- mata and gummata than with other forms. A positive diagnosis, however, especially in the early stages, is very often out of the question. Prognosis. — Syphilitic gummata may be absorbed, and all the symptoms disappear, if only the treatment is commenced sufficiently soon and carried out consistently. If they have already caused extensive destruction of the nerve-tissue around, that of course cannot be replaced ; and it is possible that the cicatrix left, dragging upon the brain and anchoring it to the membrane, may sometimes of itself lead to serious after trouble. It is probable, too, that tubercular masses are sometimes absorbed or dried up ; certainly they not unfrequently remain latent for long periods, but there is not nearly the same degree of control over them. Other tumors pursue their course relentlessly, sometimes leading to coma and compression, or destroying life by the intensity of the pain that accompanies them, sometimes leading to a condition of marasmus, or suddenly causing death by interfering with the respiratory centre in the medulla. Treatment. — From what has been already said it is clear that, except in the case of gummata and some tuberculous masses, there is little or no hope for diseases of this class except in operation ; and that even then the proportion in Avhich this is practicable is a very small one. Nor is there much prospect that, with only our present methods of investigation, it will be materially increased ; for the difficulty does not arise so much from the size of the tumor (although this has occurred) as from the impossibility either of localizing it or of gaining access to it. If the conditions are favorable, and it is decided to make the attempt, the direc- tions given by Horsley should be followed. The head should be shaved, washed with soft soap and ether, and thoroughly purified wdth an antiseptic, the site of the lesion having first been ascertained by measurement and definitely marked. A quarter of a grain of morphia is given before the operation, and the anaesthetic used is chloroform. This has the great advantage of causing contraction of the cerebral arterioles and so diminishing the amount of bleeding ; but very great care is required in the management of the anaesthetic, and a very small quantity should.be given. The flap reflected must be of sufficient size, carried right down to the bone at once, so as to bring the periosteum with it, and so arranged that while its main blood-vessels are kept intact, dependent openings are left for drainage. The bone is most easily removed by taking out an inch disc with a trephine to learn the thickness, and then cutting out the piece required with a circular saw mounted on a surgical engine, the separation being completed with bone-forceps • or two tre- 676 DISEASES AND INJURIES OF SPECIAL STRUCTURES. ])hine openings may be made, one at each end of the exposed area, and the inter- vening tissues divided with Hey's saw. All the fragments should be carefully jjre- served between warm carbolic sponges or in a warm dilute carbolic solution, for reimplantation. [The osteo-plastic resection is preferable in most cases, because by this method the bone disc is preserved.] The natural color of the healthy dura mater is difficult to describe. The fibres of which it is composed run in coarse interlacing bundles, so that its surface is irregularly fasciculated ; and showing up through them more or less distinctly is the purplish tint of the vascular brain. In cases of tumor it is sometimes reddened and vas- cular itself, at others adherent to the growth be- neath and more yellow. The line of incision should run round four-fifths of the circumference of the area exposed, at one-eighth inch distance from the margin of the bone, so that the edges can be stitched together afterward. The main branches of the meningeal artery, if they lie in the line of the incision, should be secured by ligature before division. Adherent portions of the dura mater must be removed. In cases of cerebral tumor, in which there is F.G. 293.-Osteopiastic Resection, showing i^^^^^^^d intracranial tension, the brain protrudes Scalp with Bone Flap. (After Esmarch.) into the wound as soon as the dura is divided. If the growth does not occupy the surface, an attempt must be made to ascertain its position by the difference in color or consistence of the parts of the cortex exposed. Horsley suggests that particular attention should be paid to the presence of any white i)atches along the course of the cerebral vessels, as indicating old mischief. In several cases an exploratory incision into the substance of the cortex has been necessary. The arteries that supply the brain are terminal, so that, where it is jjossible, every main vessel should be left intact; but, as Horsley points out, they can some- times be raised from the surface of the brain and even drawn out of the sulci without inflicting irreparable damage upon them. The incisions through the cortex must be exactly vertical, directed into the corona radiata, avoiding, as far as possible, any injury to other fibres, those, for example, running toward the internal capsule. The gaj) left by removal of a portion of brain fills up at once, the corona radiata bulging ujiward and the cut edges becoming slightly everted ; so that, owing to the mechanical rela- tions between the brain and the skull, there is normally a tendency to hernia cerebri. The edges of the dura mater are accurately secured by silk and horsehair sutures. In his earlier operations, Horsley used a drainage-tube for twenty-four hours : later, he discarded this, and merely leaves one inch, unsecured, at the most dependent part. The fragments of bone should be replaced /// situ in a kind of mosaic : tjiere is no question as to their vitality being retained or their power of contracting ad- hesions to the pericranium above and the dura mater below ; and so far there is no doubt they add greatly to the security of the flap ; but it is not certain how far there is any production of new bone. Horsley follows Lister's principles strictly, making use of the carbolic spray and carbolic gauze. At the end of five or six days the wound is covered with powdered boracic acid, cotton-wool, and collodion. The scalp usually tends to fall in a little at the seat of the operation, but the cicatrix becomes exceedingly strong. TREPHINING. G-n Trephining. Trephining is performed either as a precaution to prevent irritation and in- flammation of the dura mater by fragments of bone and to secure thorough cleansing, or to procure relief from symptoms that are already ])resent. In the former case, the prognosis, so far as the operation is concerned, is exceedingly good ; in the latter, it can scarcely be said to add very much to the risk. If, for example, there is compression of the brain, whether it arises from extravasation of blood, from pus, or from the presence of a new growth, or if a bullet has traversed the l)rain, and fissured the opposite side of the skull, or if insanity or ei)ilepsy follows an injury to the head, trephining may be the only chance of afford- ing relief; but when done under such circumstances as these, for the removal of a condition that has almost proved fatal already, it ought not to receive the whole blame of the result. The bone is exposed either by enlarging the original wound or by reflecting a flap of skin in such a direction as to secure a dependent opening for drainage (when the patient is lying down) without endangering the blood-supply. The pericranium is best preserved by reflecting it in the flap, laying the bone bare at once. In most cases where mere elevation is required, enough may be accom- plished by sawing off a projecting angle or cutting a channel with Hoffman's gouge-forceps without actually using the trephine. If, however, the original open- ing in the bone is not large enough for this, a portion must be removed to begin with. The centre pin of the instrument is screwed tight so as to project a little below the edge of the crown, and placed upon the centre of the part that is to be cut away. Then it is worked, with alternate pronation and supination, until a groove is cut in the bone sufficiently deep to prevent slipping. As soon as this is done, the pin is withdrawn to avoid injury to the membranes. The external table is exceedingly hard to saw ; the diploe, o-n the other hand, gives way with ease, and as soon as this is reached the groove becomes filled with soft debris mixed with blood. The inner table, again, is harder, but it is generally possible, when this is partially sawn through, to detach the circle by gently rocking the trephine from side to side, or by means of an elevator. It must, of course, be recollected that the skull is not of the same thickness all over ; that in some places the di];Ioe is wanting, and also that, owing to the curves of the vault, one part is usually sawn through before another. It is advisable, therefore, to test the depth of the groove from time to time with the flat end of a probe or with a toothpick, so as to be sure of the progress made ; and unless it is done intentionally, the region of the sinuses and the course of the middle meningeal artery should be avoided. If larger portions of bone have to be removed, so as to expose a considerable surface of the cortex, a trephine fixed to a carpen- ter's brace, or to a surgical engine, may be em- ployed. When the first opening has been made, it can be enlarged in any required direction, either by means of Hey's saws or by the gouge-forceps. The bone removed should be kept warm in a weak solution of carbolic acid and replaced, either bodily or after being broken up. In many instances, where the periosteum has been laid over it again and the dura mater is not sunken down, the vitality of the bones has been retained, and it has contracted adhe- sions to the parts near. When it is a mere question of removing splinters, and the dura mater has not been cut, the flaps are replaced and the wound sewn up (after being thoroughly washed out with corrosive sublimate solution) except at its most Fig. 294. 678 DISEASES AND INJURIES OF SPECIAL STRUCTURES. dependent i)art. (ieiierally a drainage-tube is unnecessary, unless there has been a great deal of bruising, or the cavity of an abscess has been laid open, so that union by the first intention is improbable. If the dura mater is incised to any extent, it should be thrown downward in a flap, as recommended by Horsley, rather smaller than the opening in the bone, in order that, when rej^Iaced, it may be readily fixed by sutures, and thus helj) to maintain the cerebral pressure until union is complete, and avoid the risk of hernia cerebri. [Prof. Senn, in common with most German surgeons, prefers the chisel and mallet to the trephine.] Cerebral Localiz.ation. An elaborate description of the relation between the surface of the scalp and the cerebral convolutions would be out of place in a work of this kind ; a fiiU ac- count may be found in the papers by Reid, Hare, Anderson, Makins, and others ; still, a few general statements are almost necessary. It must be premised that anything like mathematical accuracy is utterly out of the question ; to say noth- FiG. 295. — The Relation of the Sutures and the Chief Points on the Skull to the Cerebral Convolutions. The vertical depth of the teniporo-sphenoidal lobe is unusually great for an adult. ing of the differences at different ages and in different types, the same rules often will not hold good in more than a general way for the two sides of the same head. The fixed points of chief value are the glal)ella, the inion, the external angle of the orbit, the external auditory meatus, and the parietal eminence. The last mentioned, which at first sight ap])ears to be particularly vague, is really of very great value, as it bears a certain relation to the general development of the skull and is nearly always in close correspondence with the supramarginal gyrus. The most important boundary lines for the brain are the fissures of Sylvius and Rolando and the tentorium. Of these the last is easily marked by the superior curved line ; the two former are more difficult. The upper end of the fissure of Rolando is most easily defined by the measure- ment originally given by Thane, half an inch behind the mid-])oint between the glabella and the inion. supposing, of course, the fissure were continued quite into the great longitudinal division. The lower does not really admit of definition. The easiest way to arrive at it CEREBRAL LOCALIZATION. 679 is by means of ^\'ilsc)n's cyrtonieter. A strip of metal (graduated according to Hare's measnrenients to suit skulls of different shapes) is caiTied along the sagittal suture from the glabella to the inion ; on this glides a metal rod, about three and a half inches long, forming with the sagittal band a fixed angle of 67°. This when l)lace(,l in position corresi)onds api)roximately in length and direction to the fissure of Rolando as measured ujjon the scalp. The angle is more ojjen in some brains than in others ; possibly 67° is slightly more than the average, which other measurements place at 65°, but it is sufficiently near for practical purposes; nine times out of ten, it will allow a required point to be exposed with a trephine an inch and a quarter in diameter. Fig. 296. — Wilson's Cyrtometer in situ. G, glabella ; E A P, external angular process; R, fissure of Rolando — its position and direction marked by the lateral strip of metal. {After Bram-uwll.') The direction of the fissure of Sylvius is equally difficult. Hare takes a base line from the external angle of the orbit to the inion ; this passes rather above the external auditory meatus. The beginning of the fissure of Sylvius lies on this rather more than an inch from its commencement, and runs directly upward and backward from it to the parietal eminence. Practically the same line may be obtained by starting from the middle of the outer border of the orbit (the ex- ternal canthus or the sharp margin of bone that lies beneath it) and ending at the same point. The point of bifiircation is approximately three-eighths of the dis- tance from the edge of the orbit. 68o DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER VIII. INJURIES AND DISEASES OF THE BACK. SECTION I.— iMALFORMATlONS, Spina Bifida. In the strict sense of the term spina bifida refers to the condition of the spinal column ; but it is usually understood to mean a congenital tumor projecting through the ununited laminae of the vertebrae, and formed of the cord or its membranes, or of both together. It is nearly always on the back ; cases are reported in which the protrusion has taken place on the anterior aspect of the vertebrae through the bodies, but they are very rare, and are generally associated with other deformities. Three-fourths of the whole number are found in the lumbo-sacral region, where the medullary groove is open latest ; of the rest, the majority occur in the neck, but they may protrude through any part, from the occiput downward, or may even involve the whole length of the column. Symptoms and Diagnosis. — Spina bifida usually occurs in the form of a rounded, sessile (sometimes pedunculated) tumor, projecting in the middle line of the body, over the spine, with which it is closely connected. It may be of any size, larger even than the child's head. In some instances the skin over it is natural ; in most it is reddened, devoid of hair, and e.xceedingly thin : in a few it is vascular, like a naevus, and velvety, so far at least as the most prominent part is concerned, and occasionally there is a great growth of hair all round it, con- verging in a spiral fashion toward the central point. The swelling may be perfectly uniform in shape, or there may be a longitudinal groove running vertically down- ward over it in the middle line, beginning and ending with a little pit-like depres- sion, and sometimes in addition two lateral grooves can be made out, wide apart at the centre, but converging at their extremities toward the same small pits. The sac is very often translucent, and the nerve cords can be traced by trans- mitted light running obliquely across it. Fluctuation is distinct, and when the neck is wide the wave can be felt even at the anterior fontanelle. The tension varies according to the quantity of fluid present, increasing if the child cries or if the pelvis is allowed to hang down. Some of the contents can often be reduced by steadily compressing the sac, so that the edges of the cleft can be felt ; but the proceeding is a dangerous one, likely to cause convulsions. Complications are often present. Talipes, parajjlegia, and atony of the e.xter- nal sphincter are due, in all probability, to the condition of the sacral ple.xus, and point to the fact that the spinal cord, or the nerves coming from it, are involved in the sac ; meningocele, ectojjia of the viscera, and other malformations result from a similar arrest of development in other j^arts of the body. The diagnosis rarely presents any difficulty. The position of the tumor, its congenital origin, and its varying tension are sufficient to distinguish it from every- thing but naevus. Every now and then, however, other forms of congenital tumor closely resembling it are met with in this region. False spina bifida is the most deceptive. Strictly speaking, it is a single cyst in communication with the spinal canal, but not with the membranes or the cord, and probably it originates from the sac of a true spina bifida, the neck of which has become occluded. Kut con- genital lipomata, and even myo-lipomata, are known to occur, springing from the interior of the spinal canal and spreading out, either between the arches, or through an opening left by their imperfect growth, until they form large masses sessile upon SPINA BIFIDA. 68 1 the backbone. The true multilocular sacro-coccygeal tumors are, as a rule, in connection with a part of the sjjinal cohunn which is not the seat of spina bifida. Pathology. — There are three chief varieties of sjjina bifida, of which the second is by lar the most common. {a) Meningocele. — Protrusion of the membranes only; the skin covering it may be thinned and reddened, but in other respects it is perfectly natural. 'I'he cord lies in its proper situation, and there are no nerves in the .sac. (/^) Ale ningo myelocele. — Protrusion of the cord with its nerves and membranes. The skin around the neck of the tumor is natural ; over the most prominent part it is replaced by a thin, vascular layer, which shows no trace of corium, hairs, or sweat glands, and the line of transition is sharply marked. This layer is the flat- tened out spinal cord itself, which, in the most typical examples, leaves the spinal canal at the ujjper angle of the cleft, ])asses backward acro.ss the sac until it meets and fu.ses with its posterior wall, and then leaving it after a variable distance, regains the canal below. In some instances the cord is structurally complete, and although the normal arrangement of w^hite and gray substance is somewhat inter- %^-^ Fig. 297. — Meningomyelocele Laid Open. The centre is marked by a pit leading down to the spinal canal. Below this is a trifid groove. The whole of the posterior surface is composed of flattened-out spinal cord, the line at which the true skin stops being clearly marked off. In the interior the ligamentum denticulatum and some of the roots are stretched across from back to front. fered with, the central canal can still be recognized in transverse microscopic sections. In others the cord itself is flattened out from in front ; the posterior fissure has never been closed, and the central canal forms the median groove already mentioned, ending in a pit above and below, where it resumes its normal situation. Finally, in a few the pressure of the fluid in front of the cord has been so great that the anterior columns are separated, and between them there is a vascular, velvety protrusion of pia mater. The position of the nerves is, of course, con- siderably modified : the anterior roots spring from the concavity of the roof of the sac near the middle line ; the posterior ones arise from it further down the sides, with between them an enormously elongated ligamentum denticulatum. Sooner or later the roots fuse together to form a trunk, which, running partly in the wall of the sac, partly across its interior, passes between the margins of the cleft into the spinal canal, in order to gain its proper intervertebral foramen. The dura mater lies on the posterior surface of the bodies of the vertebrae, and can be traced into the wall of the sac as far as the covering of the true skin, never further. The sac, in other words, is an immensely distended subarachnoid space. 44 682 DISEASES AND INJURIES OF SPECIAL STRUCTURES. (r) Syrifigoccle. — The central canal of the spinal cord is dilated, forming the cavity of the sac ; the posterior wall is formed of skin, as a rule, with the expanded posterior columns of the cord, and perhaps the dura mater. In all of these there is a defect in the arches and laminae of tbe vertebrae (spina bifida) ; much rarer deformities are sometimes met with, chiefly in association with syringocele, itself \ery rare ; defective development of the bodies of the vertebrje, for example, so that they are either cleft vertically, or that one-half is wanting; growth of a Ijony process backward through the substance of the spinal cord and even complete division of the spinal cord into two for more or less of its length. From the fact that in sacral spina bifida the cord is found still occupying the sacral region (the nerves coming off horizontally without forming a cauda equina), while at birth it has normally receded far up the lumbar part, it is clear this defor- mity originates at the very earliest period, when the spinal cord and the vertebral column are practically of the same length. The defect is in the formation of the medullary canal. Spinal meningocele is the most simple. In this the neural canal has closed, FiG.^298. — Meningomyelocele, showing ihe vascular Pia Mater in the centre, the flattened cord on either side, and, above, the pit leading to the central canal (diagrammatic). Fig. 299 —Cured Spina Bifida, taken from a man xt. 26. SO that the cord itself is well formed ; but the mesoblastic elements which should grow around it and enclose it on the dorsal surface are imperfectly developed ; the bony laminre, the muscles and the substance of the true skin are deficient in various degrees (according to Recklinghausen, the dura mater is wanting in this as well as in the other forms) : and the protrusion is due to passive distention : fluid is secreted in the sac under the i)ressure of the blood, and the wall is too thin and weak to resist. In meningomyelocele the fluid collects in the .subarachnoid space in front of the cord ; if the neural canal is closed already, the cord itself is gradually flattened from before backward and pushed out from the cleft, until it joins and fuses with the epidermic covering developed from the epiblast, the sole trace of all the struc- tures that should protect the spinal cord behind. In this case a transverse section through the posterior wall of the sac reveals, on microscopic examination, the flat- tened out central canal, and there is no median groove or pit. In the other form the defect occurs at an earlier period still, l)efore the medullary groove is closed to form the cord and tlie layer of elementary nerve tissue is first flattened out, and then becomes convex backward, until at length it projects as the covering of a SPINA BIFIDA. 683 thin-walled cyst. In the most extreme cases the anterior columns are so far sepa- rated from each other by the pressure that a strip of pia mater, that which should line the bottom of the anterior fissure, forms a longitudinal velvety band on the most convex portion of the sac. The other malformations are due to the fluid collecting in the central canal, and to inequality of growth of various parts of the vertebral column. The bifur- cation of the spinal cord is probably an indication of the enormous power of re- production and repair posse.ssed by the embryo at the earliest period. If the neural canal is prevented from closing into a tube, each half may in some instances be capable at that time of life of forming one for itself. Treatment. — If the protrusion is small, covered over with healthy skin, and not inclined to enlarge, it should be carefully protected with cotton-wool and collodion in sufficient thickness to form a fairly rigid covering, or with a gutta- percha cap. There is a possibility of its gradually shrinking up. In most cases, however, the sac is increasing rapidly and threatens to give way sooner or later if left to itself. If the skin is already ulcerated or the wall is actually broken, it should be dusted over with iodoform and carefully packed with iodoform gauze or salicylic wool, in the hope that meningitis will not follow, and that the wound will cicatrize under the protection. The only treatment that has met with any success is the injection of Morton's fluid: this consists of iodine- gr. x, pot. iod. gr. xxx and glycerine 5J. A punc- ture is made with a fine trocar and cannula through the healthy skin near the bottom of the sac, and a certain quantity of the fluid, not more than half, allowed to escape. Then half a drachm to two drachms of the solution is injected, taking care that none escapes by the side in the cellular tissue, and the puncture sealed with collodion. The opening may be made valvular to prevent the contents drain- ing away. Afterward the sac must be carefully packed in cotton-wool with a sHght amount of pressure, and the child kept as quiet as possible, so that the in- jection may not diffuse itself too rapidly. In successful cases the sac soon begins to diminish in size, and at length shrivels up into a rounded solid excrescence ; but very often several injections are required, and it not unfrequently happens that after a while the skin becomes red and the opening begins to leak, or the child is attacked by convulsions and meningitis sets in.* Excision of the sac has been practiced successfully in cases of simple menin- gocele, but as it is impossible to prove that the spinal cord is not involved in the sac, this operation should very rarely be undertaken. The prognosis is rarely favorabk. Even in simple cases the child is seldom well nourished \ in the more severe ones — when, for example, there is a large thin- walled sac — it is nearly always small and puny ; and in many there is clear evidence from the first of paralysis or other nerve lesions. Growth, especially of the lower limbs, is usually stunted ; areas of anaesthesia persist ; some of the muscles of the lower extremity continue in a state of spastic rigidity, so as to limit the action of the joints ; and handling the cicatrix left may in some instances give rise to evi- dence of nerve irritation, passage of urine, defecation, and sexual emissions. [*Prof. Brainard, the originator of this method of treament of spina bifida, used the Lugol solu- tion. The solution used by him consisted of iodini .03, potass, i.jdidi .10, aquce destiliat c.c. -^t^. The rules laid down by Brainard for performing the operation were: First, to make the punc ture subcutaneously in the sound skin, by tlie side of the tumor ; secondly, to draw off no mure serum than the quantity of fluid about to be injected ; thirdly, to evacuate the contents of the sac, if symptoms of irritation supervene, and to replace them imme liately with distilled water. The patient should lie on his side or face after the operation, and if there be much heat, warm, evaporating lotions should be applied to the part on head. As sojn as the tumor becomes flaccid it should be covered with collodion, or supported by pressure continued for some weeks after the cure has been perfected; and lastly, the injection should be repeated ai often as may be n.cessary, care being taken that the previous irritation has completely subsided. The operation is performed with a very delicate trocar, the puncture being accurately closed with adhesive strips.] 684 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Congenital Sacral Tumors. A great variety of congenital tumors is met with in connection with the sacro-coccygeal region, and the origin of many is still involved in doubt. (^a) Spina bifida (true and false) may occur on the back of the sacrum. Its diagnosis and treatment have already been discussed. (Ji) Congenital liponiata and niyo-lipomata are also met with, springing from the interior of the spinal canal and protruding through an opening in its wall. Similar growths, due in all probability to the accidental transference of tissue germs at a very early period of embryonic life, are also met with higher up in the column. When small their diagnosis from spina bifida is almost impossible without a punc- ture. They have been excised with success. (r) Congenital sacral tiivior, in the limited sense of the term, is applied to a mass, often of enormous size, developed in the region of the coccyx, in front, dis- placing it ; or behind ; or hanging from it by a neck. It is made up of cysts of all sizes, from that of a pea to a horse-chestnut, communicating more or less freely with each other, and filled with a thick gelatinous material. When small the epithelium lining them is columnar, resting upon flatter cubical cells. In between is a variable amount of fibrous tissue with fat, hyaline cartilage, and sometimes even bone. It seems probable that this growth originates from Luschka's gland, which in its turn (according to Bland Sutton) is the rudiment of the post-anal gut of the embryo. Excision is the only line of treatment possible, but very careful examination is necessary, as not unfrequently the growth extends much further up the pelvis or the spinal canal than would be imagined from external appearances, {d') Dermoid cysts, containing the ordinary mixture of sebaceous material, hair, etc., are not uncommon. Sometimes they communicate with the rectum or bladder, and occasionally they are of very large size, extending long distances up the pelvis. As Bland Sutton has pointed out, there is an especial ten- dency to the production of these growths in those localities in which fusion of the germinal layers takes place in the embryo. {/) Finally, attached foetuses oi all grades of development may be met with. There may be merely a shapeless, formless mass of skin, containing fibrous tissue, bone, and fat, all mixed up together ; or a well-formed limb ; or even larger portions still. Excision is the only treatment practicable, flaps being formed from the part removed for the purpose of covering in the stump ; but full examination of the connections should be made in every case, as it is impossible to say how far growths of this kind may be incorporated with the bearer of them. Fif;s. 3C0 and 301. — Congenit.-il Coccygeal Tumors. SPRAINS OF THE BACK. 685 SECTION II.— INJURIES. INJURIES OF THE BACK. Injuries of the back, like those of the head, derive much of their importance from the danger to which the great nerve centres are exposed. Independently of this, the structure of the spinal column is so complex, its position as the axis of support for the trunk and the chief base for the movements of the body so im- portant, that no injury, however slight, can be inflicted upon it without produc- ing a serious, and often a widely felt, effect. Sprains and Wrenches. These are very common, especially in the flexible parts, the cervical and lumbar regions ; sometimes they are chiefly muscular, as in cases of overwork — lifting heavy weights, for example — or in sudden awkward twists ; sometimes, when due to external violence, they involve the fibrous textures, the ligaments, fascise, and synovial membranes as well, the muscles either being caught unawares by the unexpected jerk or being overpowered. The worst of all occur in rail- way collisions, when suddenly and without any warning, before a single muscle can contract, the body is wrenched and twisted, or thrown with overpowering force from one side of the carriage to the other, until every muscle or ligament that has an attachment to the spine is strained or hurt. For various reasons, the spinal cord itself escapes more frequently than might be expected ; it lies in the central axis, so that in all movements it occupies neu- tral ground ; it is separated by some distance from the walls ; around it there is a water-bed, probably always filled with fluid ; and in the lumbar region, where the range of movement is as great, perhaps greater, than anywhere else, its place is taken by the cauda equina. The extent of injury in these cases is very variable. No structure is always exempt, but probably the muscles and fibrous tissue are the greatest sufferers. The former may be thrown into a state of cramp ; they may be torn or wrenched away from the bone ; there may be hemorrhage into the sheath that invests them ; this may be torn and the muscular substance forced through the rent like a hernia; or, especially in the neck, where the long slender slips lie closely packed together side by side, there may be a real dislocation. The latter may be still more damaged ; the broad sheets that extend on either side of the spine may be overstretched, or the loose cellular tissue that fills up the irregular spaces around and between the bones crushed, and bruised ; or, what is much more serious, some of the ligaments that connect the vertebrae may be strained until they yield. This is especially dangerous, not only from the proximity of the membranes and the cord and the risk of their being injured at the same time, but from the danger of hemorrhage and inflammation. A certain amount of extravasation must always occur, causing an ill-defined swelling and tenderness, and giving rise to pain and inconvenience when any attempt at movement is made; but if the posterior ligaments, especially the ligamenta subflava, are torn, the bleeding may be very severe, owing to the size of the veins that surround them, and the blood may pour down the spinal canal. In other cases, the spinal nerves are hurt, stretched possibly as they pass out through the foramina, or compressed by extravasation, so that the effects are re- ferred to distant parts of the body. Even the bones and joints do not escape, for, though it is rarely possible to prove the existence of definite injury at the time, it is certain that inflammation may break out in them afterward. 686 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The complications that follow these injuries depend largely upon the state of the patient's health. Stiff neck, lumbago, and chronic rheumatism occur in some, particularly after middle life ; synovitis and osteo-arthritis, leaving the spine rigid, ankylosed, and i)erhai)s distorted, occur in others ; caries is exceedingly common, especially in children and young adults; and, what is still more serious, if the ligaments have been torn and hemorrhage has taken place in the vertebral canal, inflammation of the membranes or of the cord itself may follow. In most cases this is very insidious ; softening sets in slowly, and steadily grows worse and worse ; in a few rare instances it is acute, suppuration commencing externally in the broken-down blood-clot or in the joints, and spreading through a rent in the membranes or along the lymphatics, until the dura matral sheath is involved. This is not so frecpient as in the skull, owing to the wide separation between the dura mater and periosteum, and the lower vascularity of the former in the spinal canal ; but it has proved fatal in many cases of latent fracture. Sprains of the back have accpiired a peculiar significance from their frequency in railway collisions, and attempts have been made to distinguish them, when they occur under these conditions, from others. Except, however, for their severity and for the fact that they are always associated with a very grave degree of shock, which is certainly not without influence upon the subsequent progress of the case, there is no reason for such a step. Symptoms. — The chief ones are pain and stiffness ; these are never absent. The former may be immediate and severe, as when the head is twisted round to look in some awkward direction, and a muscle or tendon is caught or disj^laced ; or it may be dull and aching, not coming on for hours. The least attempt at movement makes it tenfold \vorse. Very often it is especially severe at night, when the patient is getting warm in bed ; and usually the skin over the painful part is exceedingly tender, as it always is over muscles that have been overstrained or overworked. If the nerves are injured in the foramina the pain runs round the trunk like a girdle, or extends into the limbs ; sometimes it is attended by for- mication. In one case, in which the lumbar region was severely wrenched, a l)atient described it as shooting like lightning down the legs, and very often it is referred to the distribution of the nerves — to the pubic region, for instance, when the injury is at the junction of the dorsal and lumbar vertebrae. The stiffness is to a great extent the result of this ; the neck and back are held perfectly rigid, and if the patient is asked to pick u]) anything from the floor, the knees and hips are flexed, and he lowers himself carefully down. Very often patients imagine they are paralyzed, mistaking the difficulty of movement arising from the pain for actual loss of power ; and this may be very misleading. I have recorded else- where a case in which, after a muscular strain of the neck, the patient believed that he could neither hold his head upright, without supi)orting it with his hands, nor open his mouth ; and it is not uncommon to find after a strain of the loins that defecation and micturition are attended with difficulty, not because the spinal cord has been injured (though it must never be forgotten that this may be the case), but because these actions depend so largely upon the integrity of the muscles that support the back. The same thing occurs in lumbago, when it is due to cold, without there being any suspicion of injury ; but it cannot be denied that, espe- cially after railway accidents, it is a very disquieting symptom. Swelling is not common in accidents of this kind, unless there is a consider- able extrava.sation ; it may follow the outline of the muscles, as in the neck, or simply from a smooth, rounded elevation. The skin, as already mentioned, is often very tender, but, as a rule, firm pressure gives relief. Redness is hardly ever seen, and it rarely happens that the temjjerature is raised. Htematuria is not an uncommon occurrence after s])rains of the lumbar region ; the urine is bright red for a day or two, and sometimes there is sufficient blood to form a clot in the ureter ; then it gradually becomes smoky, until, as a rule, the whole has disai)peared in about a week. It is seldom sej-ious, but I have known it fatal, probably from one of the larger arteries having given way. FRACTURE OF THE SPINE. 687 Treatment. — As in the case of sprains elsewhere, rest is the first considera- tion, to limit the amount of extravasation and hyi)era;mia that follows, and then gentle passive movement to assist in absorjttion and to restore the function and nutrition of the part. If there is one spot especially tender, or one particular movement that causes i)ain, immediate relief may sometimes be obtained by sud- denly throwing the muscles concerned into vigorous action. Subcutaneous injec- tions of morphia must generally be used, as the pain is often so severe that the patient has not the power to make the effort. In twists and ricks of the neck and loins this plan may be tried at once. Where the aching, stiffness, and pain on movement are more general, and it is clear that the symptoms are due to chronic changes in the joints and muscles, and that the spinal cord is not involved, counter- irritants, may be employed. Hot baths, shampooing, friction with stimulating liniments, ironing, blisters, acupuncture, and galvanism with slow interruptions of the current, are of the greatest value, but constitutional treatment must not be neglected, especially if there is any evidence of gout or rheumatism. Muscles and joints are intended for work ; if they are injured they require rest, it is true ; but as soon as the damage is repaired they become stiff and waste unless they are used ; and the longer they remain at rest the worse they become. In cases of more severe injury, when there is either shock or excitement, the patient should be placed in bed, and kept warm and as quiet as possible until it has entirely passed away. The urine may have to be drawn off, especially after rail- way accidents, or other severe injuries ; the bowels are almost sure to be constipated, and should be opened by a calomel purge ; stimulants, unless the pulse is very feeble or actually failing, do more harm than good. Then, as soon as the acute symptoms have subsided, when the patient begins voluntarily to change his position in bed, gentle passive motion, bending the spine backward and forward, and massage, may be commenced, to prevent the muscles becoming rigid. If the depression continues, or if some weeks after the accident the patient does not begin to rally, the prognosis becomes very grave. There is evidence then that the nervous system has been seriously affected ; and in patients of a neurotic temper- ament, or where there is any hereditary taint, it is impossible to predict what may happen. Perfect rest for mind as well as body is essential ; everything that can worry or annoy must be carefully kept away, and the attention must be diverted as much as possible by change of scene or occupation. Good food, fresh air, and a moderate amount of such exercise as the patient can be induced to take are the best remedies ; stimulants should be avoided. The only drugs of any service are those that improve the appetite and help to keep up nutrition ; bromide of potas- sium and sedatives or narcotics usually do harm. Fractures and Dislocations of the Spine. Fracture. The vertebral column may be broken either by direct or indirect violence. The former is the most rare, at least in civil practice : but a violent blow, or a fall, striking the back against a projection, may crush it in at any point. The extent of the injury is very variable ; if the force is slight, one of the processes only is broken off ; more frequently the laminae are driven in ; sometimes the bone is completely broken up. Fracture by indirect violence is generally the result of extreme flexion ; the head, for example, is caught in driving under an arch and forced down upon the sternum (sometimes breaking it) ; or the neck is fractured by diving head foremost into too shallow water ; more rarely it is caused by over- extension. When the fracture is the result of flexion the spine usually gives way either just above or just below the dorsal region, the seat of junction of the more movable parts with the more rigid ; and the injury is always very extensive. The muscles are torn ; the spinous processes are dragged asunder ; the ligamenta sub- 6S8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. flava are pulled away from their attachments ; the body is wrenched off the adja- cent disc and crushed in ; blood pours down the spinal canal, or is extravasated into the sheath ; and the upjjer part of the spine carrying the head is displaced forward, so that the edge of the vertebra below pins the spinal cord against the arches ; or, what is worse still, a triangular piece of bone is broken out of one of the bodies and driven backward like a wedge across the spinal canal (Fig. 302). Dislocation. True dislocation, without fracture, is met with in several parts of the verte- bral column. In children it may occur between the atlas and axis, from lifting them up by the head. In hanging there is usually a fracture running through the base of the odontoid ])rocess. Dislocation is most frequent in the lower part of the cervical region, especially between the fifth and sixth : here the articular pro- cesses look backward and forward, and are easily separated from each other by extreme flexion without any fracture taking place. Sometimes when the force is Fig. 302. — Fracture of Spine. Part of the body of the upper of the two vertebrae is driven back- ward into the spinal canal, causing hopeless disorganization. Fig. 303. — Dislocation of the Spine. spent, they fallback into position again, so that, though the spinal cord may have been completely disorganized, there is no permanent deformity ; in other cases they are caught and fixed, and then, generally speaking, the body of the vertebra is displaced as well (Fig. 303). The same thing has been known to happen be- tween the two last dorsal vertebrae, and also between the twelfth dorsal and the first lumbar ; in other parts it is very rare. Unilateral dislocation can be produced in the cervical region by rotation. If the head is suddenly twisted round while the neck is partially flexed, the movement may be carried a little too far and one articular process displaced from another. It may be the result of muscular action only, or of direct violence applied to the side of the head. The symptoms are usually characteristic ; the face looks down- ward and is inclined to one side ; the neck is slightly bent ; the muscles on the convexity are in a state of spasmodic contraction, in the concavity they are quite relaxed ; the spines are not irregular, but some projection can be felt to one side of the middle line ; and the least attempt at movement causes the most intense pain. Sometimes there is difficulty in swallowing, and a projection can be felt in FRACTURE OF THE SPINE. 689 the pharynx with the finger. Nervous symptoms may be altogether wanting ; more frequently there is intense pain, formication, or anaesthesia, corresponding to one or more of the roots of the cervical or brachial plexus ; in most there is evidence of i)ressure upon the cord, difficulty of respiration, weakness or paralysis of the extremities ; and even when these symptoms are not present at first, they generally make their api)earance later on, if the dislocation is not reduced, caused in all i)robability either by hemorrhage or by inflammation and softening. In the majority of cases of fracture, or of complete dislocation of the spine, the injury inflicted upon the cord is beyond repair. The dura mater, when the canal is laid open, may appear to have escaped, but only too frequently everything inside it is reduced to pulp. In exceptional cases the chances are better; if, for instance, a spinous process only is broken off, or an articular one displaced, there may be merely bruising or comjjression from hemorrhage into the sheath of the cord or into the spinal canal ; but if the fracture involves the laminae, or if the ligamenta subflava are torn, the effect is rarely limited to this. In the lumbar region there is better hope: the cord occupies a smaller space in the spinal canal ; the displacement is less, owing to the greater size of the bodies ; and the cauda equina, formed of nerves which are tough and firm, escapes more easily. In pure dislocation the prospect is a little better than it is in fracture, for though the dis- ])lacement may be no less, the risk of fragments being driven into the substance of the cord is certainly not .so great. If the patient survives the immediate injury there is always the danger of diffuse spinal meningitis and red softening of the cord. The former is more common after gunshot injuries, but even in simple fractures it sometimes begins around the bones and joints ; the latter is nearly always present in greater or less degree in cases that prove fatal after a few days or weeks, starting from the seat of injury and extending upward as well as downward. It is more likely to happen after severe injuries, but none are exempt. Symptoms, — {a) Those that Depend upon the Injury Sustained by the Bones and Ligaments. — Undue mobility ; deformity, and crepitus are present in fractures of the spine as in most others : but, so far at least as the first and last are con- cerned, no attempt should ever be made to elicit them. They are not required for purposes of diagnosis, and might, probably would in many cases, inflict still further injury upon the cord. With deformity it is different : the hand should in all cases be carried gently down the back, feeling each spinous process in turn without disturbing the patient, so as to ascertain if there is any irregularity. It may be necessary to reduce it at once. In addition, pain is always present, and is made worse by movement or by pressure. Generally it is limited, but sometimes it spreads down an arm or leg or round the trunk, owing to one of the nerves being caught at the seat of fracture. In a few cases these are the only signs ; the fracture may be latent, especially in the lumbar region. One or two vertebrae are exceedingly tender ; there is a sense of weakness or want of support when standing up; lying down, the patient can move his limbs with such freedom that I have known it necessary to put a cer- tain amount of restraint upon their action ; but there may be no other sign. Sudden displacement, however, may occur at any moment ; hemorrhage may spread into the canal ; meningitis or myelitis may set in ; even suppuration may follow and extend along the cord or lead to caries or necrosis of the bones. In the neck latent fracture is more rare, but a {q\n instances are recorded in which patients have continued to get about even for days without its being suspected. Weakness of the extremities ; a sense of insecurity in the movements of the head, so that it must be supported by the hands ; pain along the course of the occipital nerves ; even slight deformity may be present ; and yet the patient be unaware of the risk that he is running. In a few of these cases the symptoms have gradually sub- sided, a certain amount of stiffness only has been left, and the patient has re- covered ; in one a portion of bone, recognized as the odontoid process, was dis- 690 DISEASES AND INJURIES OF SPECIAL STRUCTURES. charged througli an abscess : more fre([uently death occurs either instantaneously from sudden displacement, or gradually from myelitis. {b) Those Due to Injury of the Spinal Cord or Nerves. — In most cases, even when no displacement is apparent, the cord is completely crushed and the power of conduction and reflex action lost. The former never returns ; a clean division of the spinal cord might i)ossibly be repaired, even in man ; hemisection certainly may ; but the injury sustained in accidents of this kind is much too grave. The latter, if the patient survives, returns to some extent as the shock wears off, and may in some cases become exaggerated. Recently l^owll)y has pointed out that, so far as men are concerned, there is a material difference in this respect between the behavior of the superficial and deep reflexes ; the former may return, whether the cord is crushed completely or not ; the latter never do unless some part still remains unhurt. If this is substantiated it must become a factor of very great importance both as regards prognosis and treatment. Another sign of great significance has been pointed out by Thorburn ; when the violence is extreme, the roots of the si)inal nerves are crushed and torn as badly as the cord itself, and the area of anaesthesia corresponds anatomically with the seat of the lesion. If, however, the force is not so great, the nerve-roots lying by the side of the cord may escape, even though the cord itself is crushed, and thus give rise to an apparent discrepancy, especially in the lower dorsal and lumbar regions. The prognosis in the former case is certainly much worse, and if ever surgical interference is justifiable, it can only be in the case of the latter. If the injury is not so severe, as for instance happens occasionally in the lumbar region, motion is always more affected than sensation, and although perfect recovery is rare, a certain amount of repair may take place, leaving more or less anresthesia and spastic rigidity. When due to hemorrhage the symptoms, as a rule, begin gradually ; there is an interval of a few minutes, or even of some hours ; and, as Horsley has pointed out in the ca.se of tumors pressing upon the spinal cord, the paralysis of motion spreads from above downward, the anaesthesia in the opposite direction. In the slighter cases, when the blood is absorbed, the symp- toms begin to disappear again, following the reverse order; but perfect recovery is uncommon, and not unfrequently after temporary improvement red softening sets in. Occasionally the symptoms occur in such a peculiar manner that it is difficult to believe they can be due merely to suspension of the activity of the cord. Lim- ited hyj)eriesthesia, for examjjle, is very common ; sometimes it becomes general, and is so intense that the slightest touch causes agony ; mu.scular wasting is the rule ; but every now and then cases are met with in which it is so rapid that it is difficult to believe that it is only the result of disuse. The most striking examples, however, are sloughing of the skin, and inflammation of the urinary organs. Both of these are common results of fracture of the spine, and in nearly every case admit of a local explanation ; but occasionally they are so intense, so rapid, and attended, with such an amount of congestion and extravasation that it has been suggested they must be the result of irritation of the cord. Symmetrical patches of skin on the inner sides of the thighs, for example, where there can be no pressure, have sloughed and beco;-',ie gangrenous in a few days ; suppurative nephritis has set in within forty-eight hours ; and weeks after the accident the most intense cystitis has suddenly broken out and proved fatal without the slightest evidence of any local cause. Moreover, in one or two cases, these lesions have occurred when there has been no fracture at all, but merely hemorrhage into the gray substance of the cord and red softening. The nature of the symptoms and the i)rognosis depend upon the seat of injury ; loss of sensation, for example, extending as high as the umbilicus, points to injury of the seventh dorsal vertebra; if it extends to the ensiform cartilage, above the sixth. The superficial origin of the nerves only corresponds to the point of exit from the canal in a very few instances; and, as Reid has shown, varies, FRACTURE OF THE SPINE. 691 immensely with regard to the spinous processes. The first dorsal, for instance, which passes out below the first dorsal vertebra and helps to form the ulnar, is nearly always destroyed in fracture of the seventh cervical ; the second, third, and fourth lumbar are at their origin opposite the eleventh dorsal ; while the whole of the sacral plexus corresponds roughly to the ujjper border of the first lumbar. Further, owing to the softening of the cord that follows injuries, it generally happens that a day or two after the accident the paralysis and loss of motion extend upward toward the head. Injuries of the Upper Cervical Vertebm. Dislocation of the head from the atlas is very rare, but can be produced by a violent blow upon the occiput while the patient is stooping forward. Fracture of the atlas is nearly as rare ; dislocation from the axis with fracture of the odontoid process is the common form. The check ligaments are stronger than the bone, so that this gives way either at the base, or more frecjuently below, through the body of the axis. Dislocation without fracture is seldom met with, but may occur in children, owing to the smaller size of the odontoid process, and, possibly in adults when the injury is the result of violent rotation, the check ligaments, as it were, being torn across in detail. Injuries of this character, are, of course, usually fatal at once ; the lower end of the medulla and the upper part of the cord are destroyed by the odontoid process being driven in. In a very few instances, however, life has been pro- longed, owing to the large size of the ring of the atlas and the thickness and toughness of the attachment of the dura mater to the margin of the foramen' magnum. Sometimes, in these cases, sudden displacement has taken place after hours, and even after days. Fracture immediately below this is equally fatal, owing to the phrenic nerve. The main root comes out with the fourth cervical. If the centre is destroyed death is practically instantaneous, as diaphragmatic and intercostal respiration are both interrupted. Injuries of the Lower Cervical Vertebrae. The most common seat of fracture as well as dislocation lies between the fifth cervical and the first dorsal ; and, as a rule, the cord is completely crushed. Motion and sensation are entirely lost in the trunk aud lower part of the body. In a few cases there is a want of symmetry at first ; the paralysis may extend one or even two nerves higher on one side than on the other ; but as softening sets in this .soon disappears. Immediately above the paralyzed region there is a zone of hyperesthesia ; when this is immediate it can only be explained by the mechanical irritation of the nerves above the seat of injury ; more frequently it does not make its appearance for some hours, not until the circulation in the parts round the injured area has become more active. Owing to the shock, reflex action is at first entirely suspended ; the cutaneous reflexes give no response ; irritation at the neck of the bladder, or at the anus has no effect ; the function of the part of the cord below is, for the time being, practically abolished ; the vaso-motor nerves are paralyzed, the blood-pressure falls, the secretion of nrine is diminished, the heart beats very feebly, and the pulse is rapid, small, and soft. In injuries through this region the fibres of the sympathetic that supply the dilator pupillse must be paralyzed, so that dilatation of the pupil cannot take place. It is, however, difficult to estimate, as it occurs on both sides, not on one only, as when the brachial ])lexus is torn away from the cord, and the degree of contraction is not very marked. The actual distribution of paralysis and anaesthesia depends naturally upon the seat of the lesion, but there is considerable difficulty in ascertaining the exact centre and nerve-root for individual muscles, and without this, of course, perfect 692 DISEASES AND INJURIES OF SPECIAL STRUCTURES. localization is impossible. [The following; table, founded almost entirely upon clinical data, is taken from Thorburn, doubtful muscles being excluded : — Supraspinatus, "1 ,- , . , -r ^ ^ ■ ,^^ \ rourlh cervical nerve, leres minor (?), J f l^icejjs, ..... \ Brachialis anticus, . Deltoid, ( Supinator longus . \ Supinator brevis (?), Fifth cervical nerve. Subscapularis, ~| Pronators, Teres major, Latissimus dorsi, j- Sixth cervical nerve. Pecloralis major, / Triceps, | \ Serratus magnus, J Extensors of the wrist, Seventh cervical nerve. Flexors of the wrist, Eighth cervical nerve. Interossei, ) t- . j 1 ^-..i • . • „ 1 r ti 1, 1 1 i'lrst dorsal nerve. Other intrinsic muscles of the hand, . . . . j — From Thorburn^ These, of course, as Thorburn points out, are only the chief points of origin, minor connections not being regarded. Thus, if the injury is above the sixth •cervical, the elbow is flexed and supinated, the arm abducted, and the wrist and fingers motionless — a most characteristic attitude ; if below this, abduction and supination are better performed, and a certain degeee of extension and adduction is possible, but there is still no power over the lower joints. The level of the anesthesia is not so difficult ; the fifth root, the first of the series supj)lying the fore limb, is distributed to the region of the deltoid and the outer aspect of the arm and forearm as far as the base of the thumb ; the eighth and first dorsal supply the inner side of the arm, forearm, hand, and little finger ; the sixth and seventh are distributed to the intervening spaces on the anterior and posterior surfaces. Respiration is embarrassed from the first. All the muscles that raise the ribs and help to enlarge the thorax are paralyzed ; only the diaphragm is left. Inspira- tion is carried on with difficulty ; instead of the chest expanding when the diaphragm contracts, so that at the end of the act it is distended in all directions, it collapses and sinks in, and the work of the diaphragm is in great measure lost. Expiration is worse still ; at the commencement, when the chest ought to be dilated to its utmost, ready to recoil from the elasticity of its walls as soon as the muscles relax, it is already contracted, and every expiratory muscle is paralyzed. The only forces left are the elasticity of the partially-distended lungs and the weight of the abdominal viscera which have been pushed downward and forward. Coughing is impossible; fiill expansion of the lungs cannot take place; the bronchi become plugged with mucus, and the blood gradually stagnates at the lower and back part of the lobes until, the respiration growing worse and worse each moment, and the action of the heart becoming feebler, hypostatic congestion or pneumonia sets in. Generally this proves fatal in the course of a few days. As the shock passes off, the character of the symptoms begins to change. The loss of motion and sensation remains unaltered, or possibly extends a short distance higher up, but the su])erficial reflexes gradually return. If their recovery is long delayed, or if, having once returned, they begin to fail again, the prog- nosis is very grave; in one case it points to injury so serious that it may prove fatal before reaction can set in ; in the other to progressive softening of the cord. The first sign is the recovery of the circulation : the heart begins to beat more firmly, the skin becomes warm, and the state of extreme prostration passes off. In FRACTURE OF THE SPINE. 693 fracture through this region, liowever, strange variations are not uncgmmon. In some cases, the pulse becomes aljnormally full, slow, and deliberate ; in others the temperature falls immediately after the accident, and, in spite of the shock passing off, continues to drop until in one instance it is said to have reached 80° 6' F. More frecjuently it rises rapidly ; I have known it to ascend from 93° F. to 109° F. within thirty-six hours ; and higher temjjeratures than this, persisting and sometimes even rising after death, have been recorded on many occasions. It is impossible to avoid comparing this with the results of curare-poisoning, but it cannot be said to explain in any way. As has been shown by Hutchinson, high temperatures are always associated with vigorous action of the heart and full, throbbing pulse. The secretion of urine is but little altered ; the quantity is scanty at first, owing to the general fall in the blood pressure ; but as the shock passes off it in- creases again. Sometimes there is haematuria without any direct injury to the lumbar region, possibly from extreme distention of the capillaries; and it is said that the urine, as secreted by the kidney, is not unfrequently alkaline in reaction. Micturition is always affected. At first there is complete retention ; the lum- bar portion of the spinal cord, has, for the time being, completely lost its power, and the urine simply accumulates in the bladder. If this is not relieved the result is merely a question of relative pressure ; the bladder becomes more and more dis- tended, until, if left sufficiently long, its muscle passes into a state of atony, the elastic resistance of the sphincter gives way, and the urine flows out drop by drop, leaving the bladder as full as it can be. If the patient survive, the subsequent condition is not always the same. Some- times, as the cord regains its power, micturition takes place involuntarily at regular intervals : the bladder becomes distended, a drop of urine flows into the neck, the stimulus passes up to the lumbar centre in the cord, and as the influence of the brain is not there to strengthen the sphincter, the muscles of the bladder contract and empty the cavity more or less completely. This appears to be the rule in the lower animals, but such perfect recovery of function is rarely met with in man ; either from atony of the wall of the bladder (arising from its over-distention), or from the spinal centre never regaining its full power of reflex action, a catheter has generally to be passed at regular intervals, or the bladder must be emptied by pressure over the pubes. Cystitis is exceedingly common ; in some few cases it may be caused, like bed-sores, by irritation of the cord — extreme congestion, followed by intense, inflammation, suppurating and sloughing setting in without any local cause, and attacking kidneys, ureters, and bladder together — but such must be very rare ; in by far the majority it is due to the extreme difficulty of taking proper precautions for such a length of time. There is everything to favor its occurrence ; the bladder and urethra are absolutely insensitive ; their walls, deprived of all oppor- tunity of working, are badly nourished and therefore prone to inflammation ; the cavity is never properly and naturally emptied ; the mucus which is secreted and which lines the urethra is not washed out, but remains as a tenacious alkaline coating ; the constant introduction of a catheter, even when it is perfectly clean, acts as an irritant ; the amount of mucus increases ; and the acidity of the urine diminishes until every condition that favors the growth of the specific urea fer- ment is present. If, in such circumstances, it finds its way in, whether by means of the catheter (which is usually the case) or along the mucus of the urethra, or through the kidney, decomposition immediately begins, the urine becomes am- moniacal, every drop as it falls into the bladder becomes an intense irritant, and the most severe cystitis, so bad as to cause sloughing of the mucous membrane, or perivesical suppuration, is sure to follow. In a large number of the cases in which the patient escapes hypostatic congestion, this proves fatal, either directly or through the secondary inflammation, suppurative pyelo-nephritis. Priapism is common in fractures above the mid-dorsal region ; sometimes it is immediate ; more frequently reflex, not beginning until a catheter is passed or 694 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the bladder becomes distended. It is rarely marked in degree ; and, if the patient survives, usually passes off of itself; occasionally, however, it is extreme and it may be followed by extravasation into the erectile tissue. .As a rule in these fractures the alimentary canal suffers very little ; obstinate vomiting has occasionally been noticed in injuries of the cervical region, and tympanites may occur, possibly from absence of the natural support to the intes- tines after the muscles of the abdominal wall are paralyzed. Wherever the fracture takes place constipation is the rule, so long as the motions are solid ; the peristaltic action of the intestine is in abeyance for some time, then it gradually recovers, and at long intervals passes on the contents into the rectum ; the sphincter is com- pletely paralyzed, and as soon as the lower part of the bowel is reached evacuation takes place involuntarily. Liquid motions, as when there is diarrhoea, flow away continuously without control. In those instances in which the patients recover the bowels usually act once or twice a week, the motions being very copious and solid ; and after a time the patient becomes aware, from the feeling of headache, or oppression, or from flushing of the face, when an evacuation is going to take place. In by far the majority, fracture of the lower cervical spine is fatal within the first four days : few last out the week ; a very small number is recorded as having survived for longer periods. Still it is possible for life to be prolonged for months and even for years, in spite of paralysis of the trunk and legs, and in one or two instances of the arms as well. The nutrition of the paralyzed part is very feeble ; bed-sores are liable to form upon the sacrum, the ischial tuberosities, and the trochanters. If they occur within the first few hours, they may be the direct result of irritation of the cord, but much more often they do not make their appearance until three or four days have passed, and are due entirely to local causes. The body lies absolutely motionless, hour after hour, pressing upon the same points, without intermission of any kind or sense of discomfort; the skin becomes red ; the epidermis is detached, the cutis exposed, and a slough soon forms, spreading perhaps until the bone beneath becomes necrosed, or even the spinal canal is opened. If the parts are allowed to become wet or sodden from faeces or urine, this is sure to occur, and the inflammation is verv likelv to end fatally. All over the paralyzed part the skin becomes harsh and branny, covered with desquamating scales ; the rounded outline of the limb disappears, the bones be- .come prominent, the muscles waste and become hard and unyielding, and the limbs are either fixed in a condition of permanent flexion, or are subject to con- stant twitchings, which may be so violent as to shake the whole body. As may be ipiagined, the health soon begins to fail, though in fractures through the dorsal region the nutrition of the rest of the body is sometimes maintained surprisingly well ; and even if the patient escapes the immediate consequences of the injury, he is very likely to succumb to the first trivial accident with which he meets, even a mere cold, especially if it attacks the lungs. Injuries of the Dorsal Region. The symptoms of fracture below the first dorsal vertebra are practically the same, making allowance for the difference in position and number of the muscles that are paralyzed. Owing to the small size of the canal, the cord is generally crushed completely; there is the same risk of cystitis and bed-sores; priapism, however, does not occur unless the injury is high up ; the temperature is rarely phenomenal ; and respiration is not so much interfered with. The extent to which this takes place depends upon the number of intercostals paralyzed. Temporary recovery is not unfrequent, but death follows sooner or later from bladder or renal trouble, from bed-sores, exhaustion, or from degeneration and softening extending further up the cord. FRACTURE OF THE SPINE. 695 Injuries of the Lumbar Region. The lower the injury the better the prognosis : the shock is not so great, the respiratory muscles escajje, and owing to the flexibility and toughness of the nerves that form the cauda equina, the loss of motion and sensation in the parts below is often incomplete. In fractures through the last dorsal or first lumbar vertebra, the centre that governs the act of micturition is destroyed, and the effect on the bladder is the same as if all the nerves going to it were cut across. At first there is retention of urine, and, unless relief is given, overflow, just as when the cervical cord is hurt ; but in a short time the muscles begin to degenerate and contract ; they become hard and lose their elasticity ; the capacity of the bladder diminishes until its cavity is almost obliterated ; and a condition of true incontinence is produced, the urine flowing out from the urethra as it passes down the ureters. The eff"ect on defecation is not so marked, as the action of the intestine is to a much greater extent independent of the spinal cord When the fracture occurs below the second lumbar the symptoms are often obscure. The cord itself, of course, escapes, being above the seat of injury ; so may the long flexible roots of the cauda equina, which slip to one side or the other out of the way ; and there may be either no nervous symptoms of any kind, or partial loss of motion and sensation, with violent pain shooting down the limbs, owing to some of the nerves being crushed or torn by the broken fragments of bone. If the fourth sacral is injured, there is true incontinence, as when the micturition centre is destroyed. These cases of latent fracture not unfrequently escape diagnosis; there is no crepitus or undue mobility, nor of necessity is there any deformity ; merely local pain and tenderness, and a great sense of weakness and insecurity when an. attempt is made to stand or move. The prognosis of course, is much more favorable ; but, as in fracture of the spine elsewhere, there is always the risk of chronic inflammation setting in and extending along the membranes until the cord becomes affected. Treatment — In many cases the cord is completely crushed at once, beyond all hope of recovery ; sometimes the injury is made very much worse by the ill- advised efforts of assistants. If therefore there is the barest suspicion of such an accident, the patient should merely be laid perfectly straight upon his back on level ground and not raised or moved until there is some one to superintend his being placed upon a stretcher. A water or air-cushion, circular or horseshoe-shaped for choice, is essential for the sacrum, and is better than a water-bed ; and the mattress and draw-sheets must be arranged so that the bed-pan may be used without dis- turbing the patient. The outer clothes and boots may be removed while the patient is on the stretcher ; the others should be left until he is lifted on to the bed and everything is ready for a complete examination. Active treatment is impossible in the majority of instances ; if, however, defi- nite displacement can be made out, if there is a distinct irregularity in the spines, or a projection where there ought to be a hollow, and if the patient's condition admits of it, reduction should certainly be attempted, and as soon as possible; delay only increases the risk of hemorrhage and softening of the cord from pres- sure ; but, particularly in the cervical region, it should be explained to the friends that the proceedings may prove immediately fatal. In unilateral dislocations of the neck, when one articular process only is dis- placed, and when the accident is the result of sudden twist, reduction is often attended with conspicuous success. The patient should be cautiously placed under an anaesthetic, so as to relax the muscles ; the head, which already inclines toward the opposite shoulder, bent over as far as can be to disengage the processes ; and then rotated so as to carry the under side forward. Slow extension with rotation has succeeded even without an anaesthetic, the patient being seated and the operator standing behind, grasping the head while the shoulders are fixed ; some- times a sudden snap has been heard ; more often the improvement is gradual. Bilateral dislocations are very much more serious, owing to the displacement 696 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the body ; but even here a sufificient degree of success has occurred to warrant the proceeding. Hiiter recommends the same method as in the unilateral form, one side being reduced first, and then the other, on the ground that extension when all the ligaments are so much torn would expose the cord to undue risk ; and in one case out of three he succeeded in saving life. Ashhurst, however, gives par- ticulars of several in which permanent improvement followed gentle extension combined with rotation, and in one instance with pressure upon the displaced body from the interior of the pharynx. When the displacement is not reduced, the result is almost sure to be fatal within the week. It must always be rememl^ered in manipulating that the upper fragment is displaced forward, and that if it is carried ever so little further in this direction the cord must be crushed. As soon as the displacement is rectified, the head must be fixed by weight-extension, and the arch of the neck supported from below, either by a sand-bag (others being used to prevent lateral bending) or a collar made from softened mill-board, or, better, from sheets of absorbent cotton dipped in thin plaster-cream. Extension under anaesthetics, combined with pressure, has also been successful in injuries of the lower dorsal and lumbar regions ; but the displacement is seldom com])letely rectified, owing to the i)resence of fracture and to the locking of the articular i)rocesses. Crepitus has been felt on several occasions while it was being done. Weight-extension should be applied to the legs before the patient comes round, in order to prevent any recurrence. Where there are no nerve symi)toms the trunk may be encased at once in plaster-of-Paris, as the best method for ensuring rest and guarding against injury to the cord ; and the same plan has been adopted with great benefit in injuries of the lumbar region in which the displacement has been rectified. Berkeley Hill has done it within thirty hours of the accident ; in most of the other cases two to four days have been allowed to elapse. In the earlier cases the vertical position was tried, the patient either being supported under the arms, or, better, laid upon a table swinging upon a central axis like a toilet glass, and then carefully slung up from Sayre's tripod. In the more recent ones the jacket has been applied with the patient lying down. A bed is prepared with folded blankets and a mackintosh, and two bandages are laid upon it, crossing at right angles to mark the ground plan : one must be long enough to reach from the occiput to within an inch of the trochanters ; the other must be one-fourth more than the girth of the patient's chest. On these are placed, first, a many-tailed bandage made of coarse house-flannel to go on the outside of all ; then a layer of crinoline bandages, three-fold thick, soaked in mucilage and plaster (the proportions are generally an ounce of mucilage to a pound of plaster). The upper strijjs must be laid in position first, and each must overlap the one above it at least two-thirds. Then, over this in a similar manner, a second and a third layer, the ends of the strips being prevented from sticking to those above and below by laying a piece of ordinary bandage over these down each side. Overall is laid a sheet of absorbent wool, especially thick on either side of the spine, so as to pro- tect the processes as far as possible ; and a small water or air-cushion may be fixed opposite the sacrum, so that when the jacket is set its contents may be let out, and may be withdrawn without disturbing the rest. If the jacket issufticiently long to come well over the gluteal region, and clasp the crests of the ilia, it will hold the trunk firmly enough. The patient must be lifted up from either side, carried over the foot of the bed while extension is still being kept up, and laid gently down in the exact posi- tion that has been prepared for him ; and then commencing from below, each strip must be carefully folded round, crossed over, and smoothed down as rapidly as possible. In a very large proportion of cases all that can be done is to protect the patient from the various complications that may set in. The effect of the pressure on the back must be avoided as far as can be by water-cushions and ])illows, and by pads of elephant plaster. The skin must be kept as dry as possible, and whenever there INJURIES OF THE SPINAL CORD. 697 is an opportunity, should be sponged over with spirit to harden it ; Ijut care must be taken that the shoulders are not rolled over first, to dry that part of the back, and the hips afterward. Even the position of the extremities must be carefully watched, and the weight of the bed-clothes preventetl from pressing them down, or sores may form upon the external malleoli and elsewhere. The bladder must be emptied by means of a catheter three times a day ; of course the greatest gentle- ness must be used, especially as the part is absolutely insensitive ; but this is not enough, the catheter must be of the softest description, and must be kept in a solution of carbolic acid ; it is not enough to dip it in before using. If there is the least sign of cystitis, gr. xv of benzoate of ammonia should be given three times a day, to try and keej) the urine acid ; the bladder should be very carefully washed out with Condy's fluid, boracic acid, or a very dilute acid solution of corrosive sublimate ; and a grain of sulphate of quinine dissolved in an ounce of water may be injected afterward and left in. Phosphatic calculi of enormous size have formed in the bladder after fracture of the spine. The bowels are better left alone, at first, at any rate ; the amount of food the patient takes is generally very small, and the inconvenience of constipation is not to be compared with the risk of movement and the danger to the skin. Care, however, should be taken that the anus and the parts around it are kept dry. If the bowels do not act of them- selves after a few days, an enema may be given. Pain shooting down the nerves is sometimes relieved by continuous extension ; the hyperesthesia th^^t sets in on the second day and occasionally extends over the non-paralyzed portion of the trunk is more difficult to treat. Probably it is the result of hypersemia of the cord, and points to the commencement of red soften- ing or myelitis. Iodide of potash in large doses has been recommended, and leeches have been applied with advantage when the injury was in the lumbar region, so that the bites would not afterward be pressed upon ; but the prognosis when this sets in is very grave. In cases of fracture by indirect violence the operation of trephining offers little or no hope. It is probable that in the majority of cases the cord is only subjected to momentary compression, but yet it is so reduced to pulp that recovery of function very rarely follows. If it were possible to diagnose the persistence of compression and to relieve it by operation, the condition would be no better and the probability of recovery not in the least greater. This has been confirmed by actual trial in a sufficient number of instances ; in fractures of this description the injury to the nerve structures is either so slight that an operation of such a nature is not justifiable, or so severe that it could do no good. In fractures by direct violence, on the other hand, the question is altogether different. The lamina or a spine may be driven in with just sufficient violence to compress the cord without destroying it ; and if anything of the kind is suspected, the operation should certainly be performed at once. It has proved its merit. Still more is this the case with cauda equina. The nerves that compose it may be compressed by displaced bone or by cicatricial tissue, and although they possess a power of adapting themselves altogether unknown in the spinal cord, there are limits even to this ; and if improvement does not take place, or if in a few weeks it begins to flag, it is open to argument whether it would not be better to expose the seat of injury and, if possible, release them. Injuries of the Spinal Cord. The spinal cord may be injured by itself without the vertebral column being hurt. It may be bruised from a violent blow upon the back, or torn from forced bending ; it may be compressed from hemorrhage, from bone that has been driven in, or from inflammatory products thrown out by the meninges ; it may be so shaken by concussion that its activity is partially suspended, or it may be wounded by stabs or punctures between the arches of the vertebrae. The symp- toms are essentially the same as when it is crushed in fractures of the spine ; and 45 698 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the same sequela2, softening and inflammation, may set in, but they differ con- siderably in their extent and in the time of their occurrence. Contusion of the Spinal Cord. — Hamatoinyelia. — Hemorrhage into the sub- stance of the cord is nearly always the result of forced flexion, and occurs naturally in the region in which fracture by indirect violence is most common. Sometimes the similarity of origin is shown by their occurring together, but independently of each other. It is possible, however, that it maybe caused by direct violence al.so. The hemorrhage nearly always lies in the gray substance of the cord, because this is the softest and the most vascular part ; and it may occui)y an indefinite length. The effect is immediate, becoming intensified later as the hemorrhage extends. Motion and sensation are lost over a corresponding area ; reflex action is suspended for a time, but rarely so completely as when the cord is crushed ; and then later, as the circulation around the injured area becomes more active, hyperaesthesia sets in ; motor disturbances are rare. The subsequent course depends chiefly upon the degree of the primary injury. The extravasated blood may be in great measure absorbed, leaving a certain degree of anaesthesia, with paralysis or spastic rigidity of the muscles, corresj)onding to the part of the cord that has been destroyed ; or, on the other hand, red softening and ascending myelitis may follow, the paralysis extend higher, bed-sores and cystitis set in, and, if the injury is in the cervical region, phenomenal temperatures, just as when there is a fracture. According to Thorburn it is probable that cases of hemorrhage into the cord are much more common than is usually suspected. Wounds of the spinal cord are rare in civil practice, but they may be produced by stabs, the weapon passing between the arches of the vertebrae, possibly notching or incising them as it does so ; or by gunshot injuries. The symptoms in either case depend upon the seat and the extent of the injury, and only differ from those of crushing of the spinal cord in fractures by their proneness to inflammation and suppuration. There are several authentic cases on record in which men have re- covered completely after symptoms that pointed to at least partial division of the cord ; so that it is probable that, though it may not be so perfect as it is in animals, a certain amount of repair may take place, whether this consists in actual reunion of the divided fibres, or in a re-arrangement of conduction in the cord. Compression. — This is much more rare ; it may be caused by a lamina driven in, though when this occurs the delicate nervous tissue is almost sure to be utterly crushed ; or by hemorrhage, either inside the theca or between it and the bones (it is impossible to distinguish one from the other) ; or later it may result from inflam- mation, as in Pott's disease. If due to bone the symptoms are immediate ; if to hemorrhage, there is a distinct interval before they commence, and they progress from below upward, affecting the leg first, and then the trunk, until the respira- tory muscles are involved. The loss of motion is more marked than that of sen- sation, but it is rarely so definite as in contusion ; pain along the course of the nerves, hyperaesthesia extending round the trunk, and muscular tremors are more frequent. In many instances the blood is absorbed again and the symptoms sub- side ; occasionally it accumulates to such an extent as to prove fatal, either from its pressure or from secondary softening and degeneration. Concussion. — The position of the spinal cord, surrounded by a water-bed and suspended by the nerves and the ligamentum denticulatum in the centre of a flex- ible column of bone, which nowhere presents any large surface exposed to injury, is such that concussion, by itself, must be very unusual. If the term is used in the same sense as in speaking of the brain ; it can only be caused by direct violence ; the symptoms must be immediate ; there must be no gross lesion, merely suspension of activity for a time, and then, after a itw minutes or some hours, gradual re- covery. Practically, therefore, it occurs under the same conditions as contusion, and can only be distinguished from it by the symi)toms being general, not confined to any one portion of the spinal cord, and by their passing off within a few hours. Such cases do occur, though it very rarely happens that there is an opportunity of proving them. Gull (Guy's Hospital Reports, 185S) mentions one of peculiar INJURIES OF THE SPINAL CORD. 699 interest : a man, 40 years of age, fell on his back from a moderate height ; im- mediately after the accident there was partial |)aralysis of the upper and lower extremities with collapse, but no insensibility. Later in the day,- as reaction set in, and the skin became warm again, the paralysis gradually disappeared. The next morning symptoms of injury to the cervical portion of the cord came on ; paralysis of upper and lower extremities ; anaesthesia ; priapism ; tympanites ; high temperature; and paralysis of the respiratory muscles followed. He died at the end of the third day. Post-mortem the membranes of the cord and the cord itself api)eared entirely uninjured ; so that the earlier symptoms can only have been due to concussion : outside the theca, caused by a fracture through the body of the fourth cervical vertebra, was a large extravasation of blood which had gradually extended down the canal and compressed the cord. There was slight displace- ment of the body of the fractured vertebra, but not sufficient to press ui)on the membranes. Afterward, when the immediate symptoms have disappeared, hyperaemia may set in, as in concussion of the brain. If there is no contusion this may be merely transient, and under proper treatment subside without leaving behind any serious result ; but if the part is not kept at rest, or if there is severe contusion, it may increase, and either run on to inflammation or lead to softening and degeneration. Railway accidents are not unfrequently followed by a peculiar train of symptoms which have been -grouped together under a name, "railway spine," justly stigmatized by Page as absurd. The symptoms do not set in immediately and are not those of any gross lesion of the cord, such as contusion or inflammation. As a rule they do not appear for three or four days ; then, after lasting some time, they either begin to subside or steadily grow worse. The chief difficulty is to distinguish them from locomotor ataxy and chronic meningo-myelitis, both of which may undoubtedly follow injuries to the back. If, however, sufficient attention is paid to objective symptoms, to the distribution of areas of antesthesia, for example, and the electric reactions of muscles, it can usually be surmounted. Railway accidents are always accompanied by an extreme degree of shock. Sometimes this takes the ordinary form of profound collapse from the first ; more frequently there is a peculiar phase of unconsciousness associated with excitement ; pain is not felt ; an enormous amount of energy, often strangely misdirected, is displayed ; and then suddenly, some time later, the patient, as it were, wakes up and is entirely unable to account for himself, or what he has done, or explain how he came to be where he is. This is generally followed by violent reaction, the more intense perhaps for being so long postponed. The temperature falls ; the pulse becomes small and feeble ; the face is pale ; the forehead covered with cold perspiration ; there is retention of urine ; often the secretion is scanty ; in short, the patient lies in a state of complete prostration. This may end in various ways. Occasionally, but fortunately not very often, it grows worse and worse ; the patient becomes more feeble, and without being able to assign any definite reason for it, or find any gross lesion, death ensues after a few weeks or months, just as sometimes happens after a severe mental shock. More frequently there is a certain amount of improvement for a time, but not perfect recovery. The extreme depression passes off, but the patient remains weak and feeble, unable to control himself or to exercise deliberate judgment, with mental capacity and bodily vigor alike impaired. The symptoms are of the most varied character. Some, such as palpitation, flushing, alternate sensation of heat and cold, and menorrhagia, may be accounted for by the disorderly working of the vasomotor system ; others, like sleeplessness, dreaming, headache (often posterior), irritability of temper, emotional display, noises in the ears, and failure of sight, are due to interference with the blood supply of the brain and the organs of special sense. Dyspepsia is always present and makes the other symptoms worse. The breath is foul ; the bowels are constipated ; the bodily strength fails ; 700 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the j)atient becomes worn and emaciated ; the cerebral symptoms grow more pronounced, and at last he becomes utterly broken down in health, feeble in mind as well as body, and aged before his time. This is not in any way peculiar to railway accidents. It may be induced by injuries of all kinds, especially those who from heredity or for other reasons are in any way predisjiosed to the occurrence of nervous disorders. It is not uncommon, for example, after severe and prolonged mental trouble ; it may even follow a single shock ; and I have met with minor degrees of it in several of those who were exposed to the earthcjuake in the Riviera, and in one person after a dynamite explosion. Occasionally it persists for the rest of life ; as a rule, it passes away by degrees ; and, as Page has clearly shown, even when there is no suspicion of fraud, there is often rapid improvement as soon as the irritating question of com- pensation is settled. Too little is known about the working of the central nervous system to hazard a suggestion as to what really happens in such cases ; but there can be no doubt that the brain is involved at least as much as the cord, and very possibly a great deal more. In another class the symptoms resemble those ordinarily grouped together as hysterical. There may be epileptiform attacks from time to time, with insanity, melancholia, or suicidal impulse. Aneesthesia and hyperesthesia may occur, affecting the special nerves as well as those of ordinary sensation. There may be, for instance, contraction of the field of vision, achromatopsia, or hyper- gesthesia at various points ; one-half of the body may be anaesthetic, or one limb, the line of limitation being circular, not corresponding to the anatomical distri- bution of the nerves ; and occasionally hysterogenic points, pressure upon which causes epileptiform spasms, are associated with these. In other instances muscular paralvsis, affecting physiological groups rather than anatomical ones, or spasmodic contraction is present, the electric reaction remaining unaltered. Retention of urine and aphonia are very common ; and numerous other symptoms are met with from time to time — pains in the joints, for example, of the most excruciating character, without any objective sign, dysphagia, torticollis, closure of the jaws, etc. Thorburn has ingeniously attemi)ted to explain these results by a comparison with what takes place by " suggestion " in hypnotic sleep. There is certainly to all appearance a verv close resemblance between the condition of unconscious excitement that so often occurs after these accidents, and some phases of hyj)- notism ; and there is nothing impossible in the idea that the violent shock and emotion at the moment are capable of producing either this condition or one closely similar to it. Now Charcot has shown that in hypnotized ])ersons light blows are often followed by paralysis and anaesthesia, and it is quite possible that trivial injuries in railway accidents, or even suggestions of them, when there is this condition of profound mental shock, are capable of doing the same. If in either of these groups of ca.ses there is in addition a severe sprain of the muscles or ligaments of the neck and back, so that every movement is attended with pain, the difficulty of proving that the whole mischief is limited to external structures, and that the spinal cord is not involved as well, may be imagined. The local symptoms, the stiffness, rigidity, and pain, grow worse and worse as time goes on. U the hypnotic state continues, each suggests some further trouble, and it is almost impossible to distinguish between the real and the functional disorder. The desire to get well is often not genuine, even when it is present, and it is impossible to obtain any assistance from the patient. If there is even a suspicion of chronic inflammation of the spinal cord, it is a serious matter to propose active measures. And thus it comes about that time passes by ; the muscles become more rigid from disuse ; the extravasated blood becomes organized ; adhesions are formed in all directions ; and it ends in leaving a permanently crippled condition. The diagnosis from chronic inflammation of the spinal cord rests chiefly upon the absence of definite local signs. Stiffness and rigidity of the back are not leading characteristics of chronic meningitis. When this sets in there are DISEASES OF THE SPINAL COLUMN. loi other symptoms, usually of an unmistakable character : there is pain along the course of certain nerves ; or anaesthesia and hyperoesthesia of definite regions ; special groups of muscles are wasted or paralyzed ; the electric reactions are abnormal ; the cutaneous reflexes are enfeebled or lost ; in short, there is definite evidence of injury to nerves or centres in the cord, such as does not occur in sprains of the vertebral column alone, however severe the mental depression and bodily weakness may be. SECTION 111.— DISEASES OF THE BACK. DISEASES OF THE SPINAL COLUMN. Osteitis. Inflammation of the vertebrae is nearly always tubercular, in children almost without exception, although it is not impossible that the immediate starting point of the disease is some slight injury causing an extravasation of blood into the sub- stance of the cancellous tissue. In exceptional cases it may be due to syphilis (perhaps more frequently than is suspected, in the case of adults), and late in life to rheumatism, osteo-arthritis, and osteitis deformans. Tubercular Osteitis. This is essentially a disease of childhood, although it may occur at any period of life. Sometimes it is excited by injury and affects one part of the spine only ; more rarely several vertebrae are involved together. Like tubercular osteitis else- where, it nearly always begins in the cancellous tissue, where growth is most rapid and the blood supply most abundant. The upper or under surface of the bodies of the anterior border is the favorite seat ; the spinous and transverse processes are never involved at the first, although later they become welded together as the inflammation extends to them ; and the articular processes only when, as in disease of the atlas and axis, synovitis precedes osteitis. The most common situation is at the junction of the lumbar and dorsal regions ; here the bodies are large, and strains are felt most severely. The cervi- cal vertebrae enjoy much greater immunity, and the two highest, in children at least, the greatest of all. There is some reason to think that disease of the atlas and axis is proportionately more common in adults. Usually the intervertebral discs are destroyed with the bones between which they lie, the granulation tissue eating into them and causing their gradual absorp- tion. Sometimes they disappear at a very early period, as if the force of the disease was spent on them rather than on the bodies ; very rarely they persist, as when the vertebrae are absorbed by the pressure of an aneurysm. Pathology. — This does not present any special feature. The disease begins as rarefying osteitis, the bone becoming softer, more open and vascular, and the bone corpuscles undergoing fatty degeneration. According to the intensity and number of bacilli on the one hand, and the strength and resisting power of the tissues on the other, resolution, caseation, or liquefaction follows. In the most fortunate everything is restored ; the bacilli are killed or re- moved by the tissues and recovery is complete. In others not so good the process steadily advances without any caseation (caries sicca or fungosa) until the solid structure of the spine is replaced by masses of soft granulation tissue, which yield and give way beneath the weight of the trunk. In others again the centre slowly degenerates, caseates, and becomes liquid, forming a so-called caseous abscess, filled with serum, mixed with broken-down particles of bone and 70 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. cheesy debris. Sometimes, when the inflammation is severe, fair-sized sequestra are found as well (caries necrotica). Even then recovery is jjossible, with more or less deformity. Part of the debris is absorbed, the rest undergoes calcification ; the vertebrae fall together, and ankylosis occurs (Fig. 304). On the other hand, however, the caseous focus may extend, grow larger and larger, until somewhere it approaches the surface, breaks, and unless due precautions are taken, becomes infected with pyogenic germs as well. Disease of the upper two cervical vertebrae nearly always commences as syno- vitis and extends from the articulation to the bone beneath, spreading along the most vascular lines, and therefore, if it involves the axis, separating the odontoid process from the body. The deformity depends upon the amount of destruction. If the caries is superficial, involving only the anterior surface of the body, and if repair begins at once, it may be entirely wanting. If the bodies are softened or destroyed, even if only part of one, the spine above sinks forward, the spinous processes project A Fig. 305 — Tubercular Osteitis with Caseation under the Anterior Ligament and in the Bodies of the Vertebrae. A triangular sequestrum has been driven back so as to compress the spinal cord. Fig. 304. — Ankylosis of Dorsal Vertebra, with great De- formity Consequent on Caries of the Bodies. backward, and compensatory curves in the opposite direction are developed above and below. This is most distinct in the dorsal region ; the lower cervical rarely becomes convex backward, only a little thickening is perceptible, and the lower lumbar practically cannot. Disease between the axis and atlas is ]3eculiar again in this ; for, owing to the shape of the articulation on the former, the latter when the ligaments are softened by inflammation, or the odontoid process is detached from the base on which it rests, slips bodily forward, carrying the head with it, so that when the patient is looked at from one side it appears as if the head were placed in front of the spine. The eflect of this displacement (when it is below the third cervical vertebrae) on the diameter of the spinal canal is exceedingly slight ; often it is actually enlarged ; exceptionally a wedge-shaped portion is driven backward (Fig. 305) into the substance of the cord. When the upper two, however, are concerned the atlas slides forward, and the antero-posterior mea.surement opposite the odon- toid process may be reduced to less than half an inch. This, if it is efi"ected gradually, is not incompatible with life, and the odontoid process may even DISEASES OF THE SPINAL COLUMN. 703 become ankylosed in its new situation as much as half an inch in front of its natural one (Fig. 306). The deformity cannot, of course, remain limited to the s])ine. When the cervico-dorsal region is affected, the chin is brought down on to the sternum so that the movements of the neck cannot l)e carried out ; and similarly when the curvature is lower down the thorax is crushed together, respiration is carried out by the diaphragm only, and the heart and the abdominal viscera are placed at great disadvantage. Repair may commence at any time ; the ca.seous material, if any has formed, and the debris being absorbed, dried up, or discharged externally. The vertebrae above and those below fall together ; the spines, laminae, and in the dorsal region even the ribs, become welded into a solid mass, the sinuses gradually close up, and bony splints are thrown out around in proportion to the degree of strength required. Suppuration is visible, according to Oolding Bird, in about five-and-twenty per cent. Probably caseation and licjuefaction are present in many more, but do not come to the surface. The fluid may make its way into the spinal canal and spread down it, outside the theca vertebralis ; but much more generally it comes to the front, under the anterior common ligament, and then spreads out- ward. If the cervical vertebrae are diseased, the abscess may point in the pharynx (retropharyngeal) ; in the posterior triangle of the neck just above the clavicle ; or, especially if the lower one or two are concerned, it may extend down into the posterior mediastinum. From the dorsal vertebrae it usually makes its way behind the pleura into the sheath of the psoas, destroying the muscle, dissecting out the nerves of the lumbar plexus, and pointing below Poupart's ligament, on the inner side of the femoral vessels. Sometimes, however, it turns round, accom- panying branches of the intercostal vessels, and passes between the transverse processes to the skin of the back. In the case of lumbar vertebrae it may either follow the same route or work its way into the pelvis, from which it escapes either above Poupart's ligament in the iliac region, or along the rectum in the ischio- rectal fossa, or accompanying some of the branches of the internal iliac, out through the sacro-sciatic foramen. In the later stages, especially after licjuefaction has occurred, the inflammation not unfrequently extends to the dura mater and even to the spinal cord. Some- times a mass of granulations, developed from the posterior surface of the vertebrae, j)resses against the theca; more frequently meningitis sets in, and the membranes become thickened, caseous, and adherent to each other and the cord beneath ; occa- sionally the cord itself is involved, and the degeneration spreads upward and down- ward in its substance, until it is practically disorganized. The most common cause of death is septicaemia, hectic, or amyloid disease, consequent on suppuration ; but it may occur from tuberculosis, affecting the men- inges, or disseminated ; from pressure upon the cord itself (especially in atlo- axoid disease) ; or from the secondary consequences of paraplegia. In other cases it follows indirectly from the distortion of the thorax caused by the angular curvature, long after the disease itself has come to an end. Symptoms and Diagnosis. — It is of the utmost importance to diagnose caries of the spine before it has caused deformity. There is then fair prospect of recovery, and if taken in time repair may be perfect. Deformity, once estab- lished, is irremediable. The most prominent symptoms are pain, tenderness on pressure, rigidity of the back, and a sense of weakness which, even when the child cannot describe it, can usually be recognized from its actions. Fain is rarely local ; nearly always it is referred to the distribution of the spinal nerves, not their origin ; thus, in atlo-axoid disease it is felt over the back of the head, or, when the dorso-lumbar region is concerned, over the pubes. Sometimes there is a sense of constriction round the thorax, and children often describe it as stomach-ache. Usually it is worse after standing or any exertion ; 704 DISEASES AND INJURIES OF SPECIAL STRUCTURES. lying down, it may not be felt at all. It is a rough but a sure test for the absence of si)inal caries to stand a child on the seat of a chair and tell it to jump down ; if it comes down readily and fairly on its feet from a height of only a few inches, osteitis is out of the question. Tenderness on percussion is very imjjortant, especially in adults; a smart tap with the finger on the tip of the spinous processes will generally show whether there is any inflammation. Not unfrequently the skin covering the same region is hyper- cesthetic, especially to temperature, owing, in all probability, to the distribution of the posterior divisions of the spinal nerves, for the .same thing may be noticed over the insertions of strained and overworked muscles. Muscular rigidity is highly characteristic : every movement of the segment of the back for some distance al)Ove and below the seat of mischief is avoided with the greatest care. If the cervical spine is involved, the whole trunk is turned around instead of the head when the patient wishes to look to one side, and it is done with the utmost deliberation. If it is the back, and the child is told to pick up anything from the floor, the hips and knees are bent, the head is thrown back, and the si)ine kept absolutely rigid. Sometimes it voluntarily goes on hands and knees. For the same reason the walk is very jjeculiar, entirely different irom the natural mobile gait, and wry-neck and other distortions are not unfrequently present. Where children are concerned the weakness of the back must be judged of by their actions. They cease to play and run about ; they wish to be left alone quietly ; and if they must stand, they try to support the weight of the head and shoulders by resting their hands upon the furniture or even upon their knees, propping them- selves up in a crouching attitude. With adults it is more easy, as they can explain the peculiar difficulty they experience in holding themselves upright'. Early diagnosis is often a matter of real difficulty, particularly in the case of children. In many cases it is advi.sable to act upon the safe side and confine them to bed for a few days. Wry-neck, for example, arising from strains, inflamed glands, cold, or reflex irritation, may simulate the beginning of cervical caries very closely ; but, as a rule, a few days' rest is sufficient to make the distinction clear, and can do no harm. The danger is that the earlier symptoms may be overlooked and regarded merely as growing pains or stomach-ache. With young adults, particularly girls, hysteria is the chief difficulty ; and it must always be recollected that even when some of the symptoms are transparently exaggerated, there may be real disease behind. The projection of the lower cervi- cal vertebras is a frequent source of alarm, especially as it is sometimes greatly in- creased by muscular weakness or from some habitual faulty attitude. Fortunately, the symptoms generally exhibit such discrepancies that, if not at the first exami- nation, at least after two or three, the existence of caries may be negatived without fear. The diagnosis is much easier when deformity is present ; but the disease may be far advanced before it makes its appearance ; and, as just mentioned, care must be taken not to mistake natural projections for i)athological ones (see Angular Curvature') . Caseation and liquefaction may occur, even though deformity is never present, and no case of spinal disease should be allowed to pass without investigating all the ordinary situations. Retro-piiaryngcal abscess usually first attracts attention by the difficulty it causes in breathing and swallowing. Generally it lies rather to one side of the middle line and is accompanied by an ill-defined swelling near the angle of the jaw ; in some cases fluctuation can be felt across from one point to the other. Left to itself, it may burst into the back of the pharynx (it has been known to cause suffocation from entering the larynx) ; or work its way into the mediastinum ; or point on the side of the neck. Large fragments of the atlas and axis have been discharged through the opening in the pharynx in many instances. Z>^ ^^ tubercular osteitis. With very few ex- ^Vk, '-'F^'^ ceptions local removal of the diseased *■} l)ortion is out of the question ; all that can / be done is to improve the general health /^ and subdue the local inflammation, in the hope that the tissues may be able to cope successfully with the disorder. Rest is the first consideration. In most cases it is advisable to confine the Fig. 306. — Separation of the Odontoid Process by ^- , r ..• ^ 1 ^ ^ ^1 \ ^ Caries, Ankylosis of the Detached Part to the patient, for a time, at least, to the recumbcnt Atlas, and Reduction of the Spinal Canal to a position, on a well-iTiade hair iiiattress with Narrow Chink. ^ ' sand-bags as splints. In disease of the upper cervical vertebrae it is absolutely essential, a bag being placed on either side, coming well down against the shoulder, and a third smaller one under the arch of the spine. If the patient's circumstances are favorable, this maybe kept up for many months without the least deterioration of health ; indeed, distinct improvement is not uncommon, especially when the pain has previously been severe. Later, when the acute symptoms have subsided and the tenderness on pressure has disappeared, the back may be encased in some kind of splint, and the patient allowed very gradually to begin to move about. Unfortunately, this is not practicable in the majority of cases, although an attempt should always be made to secure a prolonged rest at the commencement. Even with a splint, however, very great success may be obtained, if only the patient can be kept quiet, supplied with good food and fresh air, and made to lie upon a reclining chair the greater part of the day ; but with children, particularly in the poorer classes, in whom this disease is so common, the difficulty is almost insuperable. The splints in common use are made of plaster-of- Paris (Sayre's jacket), poro- plastic felt, or metal. Of these the first is by far the cheapest, and is especially useful for children, in whom the weight of the body is light and the bony promi- nences well defined. For older patients, and particularly women, it is not nearly so suitable ; the weight of plaster is too great, and the fit is not so accurate or close. The disadvantages are that it cannot be used where there are suppurating sinuses, and that it cannot be taken off. A well-made jacket will always last three months and sometimes six, although for the sake of the development of the thorax it is never advisable to leave it on so long ; but the objection, to many people, is quite insuperable. Poroplastic felt is more expensive and does not fit so well ; but it is much lighter ; it can be taken on or off with ease ; and if very great strength is required at any spot, strips of metal can be fastened to it. Its chief use is in the later stages, when only general support is required ; and it is best to obtain it roughly fitted to the shape of the trunk already, so that there is no difficulty in moulding it. Moist or dry heat may be used to render it flexible for the time ; but if any parts are required permanently soft, as, for example, over the breasts, they must either be left so in the manufacture or the resin dissolved out afterward. It is fastened in front with straps and buckles, one side overlapping the other consider- ably ; and in taking it off it must be rotated through a quarter circle first, so that the thorax may slip out sideways. Metal supports are very much more expensive, requiring skilled labor and DISEASES OF THE SPINAL COLUMN. 707 constant attention afterward ; but particularly in the case of adults, and of short but stout and heavy i)eople, they are the only ones of real service. They consist of a metal girdle which can be buckled round the pelvis ; two uprights, one on each side, carrying crutches, })artly for the support of the shoulders, partly to pre- vent the drooping forward of the up|)er part of the trunk, and to give a point of fixed resistance for straps; and of a single or double support in the middle line Fig. 307. — Apparatus for Applying Sayre's Jacket ; Consisting of Tripod, Pulleys, and Suspension Supports for Arms end Chin. behind, fitted to the spine, and capable of being made to press either forward or to one side, by means of a ratchet arrangement. In many cases it carries lateral plates as well, so that when the patient stands upright and the body sinks down against them, a large part of the weight is transmitted directly to the pelvis. These do not, of course, secure the same amount of rest as a well-made plaster splint, but special modifications suited to individual cases may be devised much more easily. Fig. 308. — Double Thomas's Splint for Caries of the Neck. Sayre's jacket is applied to the patient while in the vertical position, slung from the head and shoulders (Fig. 307). A specially made collar is fitted under the chin and the occiput, and two well-padded straps under the arms. These are fastened at a proper height and at a proper distance from each other to a horizontal cross-bar, which in its turn is suspended in the centre of a tripod stand, and is so arranged that it can be raised or lowered at once without any jerk. The patient is 7oS DISEASES AND INJURIES OF SPECIAL STRUCTURES. first fitted with a sleeveless merino vest, fastened on top of the shoulders and com- ing down well over the crests of the ilia. Except in children with very flaccid and jirominent abdomens, a pad of suitable size should be slipi>ed in from below, between the vest and the stomach, and withdrawn when the jacket is dry ; and in females similar smaller ones may be used for the breasts. Any special bony prominence should be protected by surrounding it with a ring-pad outside the vest, to be left permanently. The bandages are made of very coarse crinoline muslin torn into strips about four inches wide ; and the ])laster is well rubbed into the meshes as they are rolled. If it is not perfectly fresh it should be re-baked, or a little alum may be added to the water. The bandages are placed under water, standing on one end, one at a time, a second being put in as the first is taken out. As soon as everything is ready the patient is gently raised until only the toes rest upon the ground ; there is no object in swinging clear, and sometimes it causes considerable alarm. As a rule, if there was any pain before, it disajjpears at once, and if the straps are properly arranged most patients describe themselves as per- fectly comfortable. The effect is not to straighten out the curve, that would be most undesirable, but to fit the jacket to the trunk while in its best position, with the thorax expanded. When the patient is lowered the ribs and the scapulae sink down and are fixed by the weight of the body against the inner wall. The first bandage is applied round the hips ; and then successive turns are carried round the abdomen and thorax, without making any reverses, until the body is encased suffi- ciently strongly, from the armpits to three-quarters of an inch below the iliac crests. x\n assistant in the meanwhile smooths the surface down, and if there are any inequalities rubs a small quantity of plaster in. In adults, where great strength is required, strips of tin may be inserted here and there. When the casing is finished the patient is gently lowered to a horizontal position by bringing up behind him a vertical table swinging on a central transverse axis and provided with cushions, so that there may be no strain until the plaster is thoroughly set. Afterward it may be trimmed down under the arms and over the iliac crests if it descends too low. The movable pads are pulled out as soon as the casing is firm. In disease of the cervical or cervico-dorsal vertebrae absolute rest is essential, until it is certain that the acute symptoms have subsided and the period of con- solidation is well established. The patient lies perfectly flat with the head and shoulders fixed by means of sand-bags ; and, as already mentioned, care must be taken to preserve the contour of the spine. Afterward some kind of appliance must be fitted to keep the head and neck at perfect rest. The most useful is the modification of a double Thomas's splint devised by Krohne (Fig. 308). In this there is an upright on either side, coming from the thoracic crescent and supporting a pad When the head is fastened to this and the trunk is well secured, the immobility is comj)lete. The patient, of course, must have either an exceedingly soft feather-bed or a water one for lying down. This form of ajjparatus may be used with great advantage in disease of other parts of the spine as well. Furneaux Jordan recommends plaster bandages ar- ranged in a figure-of-eight for cervical caries. The centre of the upper loop is on the forehead ; from this the band- age passes on either side above the ears, downward on to the opposite scapula, and beneath the axilla, round the thorax. The jury-mast arrangement of Sayre (Fig. 309), however, is better than this, especially when the disease is below the axis, as it for the occiput. Fig. 3C9. — Sayre's Jury-mast. DISEASES OF THE SPINAL COLUMN. yog permits a sli-lit degree of rotation, and exerts a little steady extension. It con- sists of a metal rod, fastened below in the meshes of a plaster jacket, exactly op- posite the spine, and curved so as to follow the outline of the neck, pass round the occiput, and end on the top of the head. To this is attached a collar which supports the chin and the occiput, the degree of tension exerted by the metal being controlled by straps and buckles ; a similar apparatus may be secured to a poro- ])lastic jacket. Suppuration in Connection loit/i Spinal Caries. As a rule, abscesses should be opened early and freely ; leaving them, in the majority of cases, only enables them to become larger and more complex in shape, and an imperfect incision is a premium on putrefaction. Aspiration is of little service, although occasionally in young children, when the condition is in other respects improving and the abscess is not increasing, it may be tried once, or even twice, in the hope that by reducing the tension, absorption may be set up. No attempt should be made to empty the abscess, and very slight suction should be employed, for fear of causing hemorrhage from the granulations. As a rule, if it is used more than once or twice the opening fails to close, a little serum drains away, the skin becomes ulcerated, and the contents discharge themselves slowly and intermittently. [In these abscesses, lavage of the sac with iodine water, followed by injection of iodoform emulsion, is of great benefit. The trocar and cannula used for evacuation should be large enough to prevent clogging during the outflow.] Where it is practicable, a spinal abscess of any size should be opened in two places, one of which should be at the lowest point. If the interior is very irregular in shape, divided into numerous pouches by stout bands of fascia passing across it (such, for example, as Poupart's ligament), it is of great advantage, wherever it is possible, to make an opening into each. The object is not only to empty it of its contents, but to keep it empty, and this is impossible with a complicated cavity, altering in shape with every movement of the body, if only one opening is made. If such an abscess is thoroughly drained, so that there is no accumulation of putres- cible fluid possible, the caseous material that clings to the wall is thrown off by the granulations, the amount of discharge is reduced to a few drachms of serum, and all the outlying parts close up, leaving only one sinus leading down to the diseased bone. The drainage-tubes must be of the largest size, with walls sufficiently rigid not to collapse under pressure ; and they must reach at first at least to the bottom of each pouch. If this is not feasible, either antiseptic dressing must be applied after Lister's plan, in the hope that putrefaction may be prevented for an indefinite length of time, and that the abscess will empty itself of its contents by slow degrees and con- tract into a sinus, or the interior must be washed out either continuously or at frequent intervals, with some antiseptic, which, if it is retained by any accident, in an outlying pouch, will not cause poisonous symptoms. Treves has employed continuous irrigation with water in one or two cases of psoas abscess with good results. A retro-pharyngeal abscess may break of itself before attention is drawn to it. If it is diagnosed, it may be opened either through the mouth (with a guarded bis- toury, and taking care that pus does not enter the larynx), or externally by incision through the skin of the neck. The choice of locality is determined by the direc- tion the abscess takes. Sometimes a sequestrum is found. Abscesses in the dorsal and lumbar region should be opened freely and explored with the finger to ascertain if there are any outlying pockets to be drained or fragments of carious bone to be removed. Sometimes the focus of disease can be reached directly, the softened bone scraped away, and iodoform applied. Psoas abscesses should always be opened in the lumbar region. Poupart's ligament divides the cavity into two, the upper half being usually much the larger ; 7IO DISEASES AND INJURIES OF SPECIAL STRUCTURES. it is imi)ossil)le to drain this \)n)\)cv\y from ;i single opening in Scarpa's triangle. The incision is longitudinal, by the side of the erector spinee ; all the structures are divided until the quadratus lumborum is reached ; the fibres of this are incised oi)posite the tip of the third lumbar transverse jjrocess, and with them the anterior layer of the transversalis fascia ; and then the finger is passed along the anterior surface of the muscle until the psoas is reached. The line of safety is the trans- verse process : a lumbar artery lies above and below. In someca.ses an incision of this kind can be utilized to get directly at the seat of the disease. In most instances a second (and sometimes even a third) oi^ening is required. Tills must be made in the situation in which the abscess points, either above Poupart's ligament (with an incision similar to that for tying the e.xternal iliac artery), or below it in Scarpa's triangle, or on the outer side or behind. I have, on several occasions, passed a large drainage-tube (half-inch internal diameter) through the whole length of the psoas, from the lumbar region to the thigh, with very great success, the temperature remaining practically unchanged ; and after a time have divided this in the middle, so that the central portion of the absce.ss should collap.se first. Usually it results in the inferior opening closing completely, and the upiJcr one contracting into a small sinus, which, owing to its being {practi- cally straight, scarcely retains any discharge. Paraplegia. — As the inflammation subsides and the caseous deposit shrinks, the paraplegia not unfrequently undergoes material improvement without direct treatment of any kind ; and occasionally rapid recovery of power follows the ap- plication of a Sayre's jacket. This is due, in some instances, to the weight of the upper part of the body being removed and the pressure on the soft tissues relieved ; but more frequently it only means that the trunk is better .supported and the centre of gravity brought over the feet again. Counter-irritation is sometimes of service. The actual cautery, for example,, may be applied either in lines radiating from the central projection, or a row of points may be placed in a circle around. The iron should be of a dull red heat, and the whole thickness of the skin should not be destroyed. An anaesthetic is advisable, and if the burns are covered over at once, so that the access of air is prevented, the subsequent pain is very slight. McEwen, of Glasgow, has, on several occasions, resected the spines and laminae of the vertebrae, exposed the sheath of the cord, and excised the dense, thickened, peri-meningeal connective tissue pressing upon it, with very great suc- cess ; and this example has been followed by others. There is no doubt that where there is no pyrexia, where the symptoms ])oint to pressure upon the cord without myelitis, and where, although the inflammatory process has ceased, the paraplegia does not improve, and is not influenced by treatment, an operation of this kind is not only justifiable, but strongly to be recommended. The incision should lie in the median line, and the periosteum with the muscles on either side should be stripped back, so that when the flaps are replaced a tolerably firm casing may be formed over the canal. Curvature of the Spine. The spine may become bent, either from primary disease of the bones and joints (caries, osteo-arthritis, new growths, etc.) or from weakness of the muscles whose function it is to maintain the erect j)osition, the vertebra; only becoming affected secondarily after the deformity has already lasted some time, owing to the unequal distribution of the weight they bear. The direction may be either antero- posterior or lateral, although the latter rarely occurs by itself. The former is known as excurvation or kyphosis when the projection is convex backward, incurvation or lot'dosis when it is convex forward ; the latter as scoliosis. I. A ntcro- Posterior Curvature. Of these there are two-well-marked varieties, distinguished from each other by the shape of the curve : the one is sharp and angular, due to some local disease of SPINAL CURVATURE. 711 the bone; the other is uniform and gradual, caused, as a rule, Ijy a general affec- tion of the whole or part of the spine. ((/) Aiii^n/ar. — in by far the majority of cases this is the result of caries ; but it may arise from myeloid sarcoma affecting the body of one of the vertebra;, from aneurysm, carcinoma (secondary), and in infants from rickets. The prujection, as its name implies, is sharj) and angular, and it is exaggerated by the presence of compensatory curves in the opposite direction above and below. The-se are the natural result of the attempt to retain the erect position ; if the sjjine is bent for- ward at any one spot, owing to a defect in the bone, the head and the upper part of the trunk must be thrown back in order that the centre of gravity may lie over the base line of the feet ; in other words, one or more compensatory curves must be developed in the opposite direction. When this cannot take place, oris imper- fect, as when the disease involves the last lumbar vertebra, the patient is compelled to stoop forward. The diagnosis rarely presents any difficulty. In progressive caries the rigidity of the muscles, the tenderness over the spinous processes, and the care with which the patient avoids moving, especially in any way that might jar the back, are nearly always conclusive. These signs are lost to a certain extent, it is true, after the inflammatory stage is past and repair is complete; but the diagnosis is assured then by the fact that, with the exception of rickets, the other diseases that lead to the formation of angular curvature have little or no tendency to get well. Myeloid sai-coma, except for the rapidity with which the curvature is formed, cannot be diagnosed from caries. The age is the same, and the symptoms are the same, especially as it is always attended by a certain amount of inflammation. Fortunately it is much more rare. Rickets in infancy may be a source of considerable difficulty for a time, as the presence of this disease does not exclude caries as well. The spine of a rickety child retains for a long time the normal infantile curve, and if it is allowed to sit up the weight of the upper part of the body, acting on the softened bone, may cause a very sharp bend to take place at the junction of the dorsal and lumbar region, where caries is most common. In most cases the diagnosis may be made by laying the child upon its stomach across the nurse's knee ; a rickety curve can usually be straightened out by a little manipulation as soon as the weight is taken off, while in caries this is, of course, impossible, as the muscles retain their rigidity ; but very often in the really severe cases of rickets this fails completely, as the bones are as tender and the muscles as rigid as in actual inflammation. Fortunately, in such cases, rest, cod-liver oil, and good food effect a complete transformation within a week. {F) Gradual. — This may be caused either as a compensation for other defects, or by some affection of the back itself. Compensatory curves have been already mentioned in connection with caries, but they are the natural result of many other deformities. Congenital dislocation of the hip, for example, and ankylosis of the hip joint in a flexed position, are of necessity attended by lordosis ; and where this is at all extensive there must be a compensating degree of kyphosis above. The same thing occurs in abdominal tumors and even to a slight degree in pregnancy. Weakness of the muscles of the back, such as commonly occurs in rickety children, or in those who have outgrown their strength, is a very frequent cause of kyphosis. Sometimes the body retains its symmetry and the spine remains in the middle line ; more frequently it yields to one side or the other, and lateral curva- ture results as well. Infantile paralysis and progressive muscular atrophy occa- sionally lead to the same result. At first the bodies of the vertebros are unaffected, but after a time they become wasted and thinned in front ; the thorax is crushed together and the deformity is permanent. If rickets is present the change is much more rapid, owing to the softness of the bones. In old age the normal curves of the spines are often lost and replaced by a single general one, especially marked at the junction of the neck and thorax ; and 712 DISEASES AND INJURIES OF SPECIAL STRUCTURES. a similar deformity is produced when the spinal column is affected by osteo-arthritis or osteitis deformans. 2. Lateral CuT^oature — Scoliosis. Lateral curvature may result either from want of symmetry in other parts of the body, the spine bending to one side to compensate for some other defect, and enable the head and centre of gravity of the trunk to be kept vertically over the base line of the feet, or simply from weakness, the muscles which ought to keep it straight not being equal to the work ; in this case it is nearly always associated with antero-posterior curvature as well. {a) Asymmetry. — Owing to its position in the central axis of the body, the spine is necessarily influenced by the least alteration in symmetry. Whether it is •O^ '?s Fig. 310. — The Ordinary Form of Lateral Curvature, Lumbar to the Left, Dorsal to the Right, with growing out of the right shoulder and a depression beneath the ribs. the legs, or the arms, the thorax, or even the head, if one side predominates unduly over the other the effect is visible on the spine. Inequality in the length of the lower limbs, for example, whether it arises from congenital defect (and the legs are unequal in length in many people, without its being suspected), fracture, disease of the hip, or any other reason, must cause curvature of the spine. The base line of the pelvis is oblique ; the last lumbar vertebra must be perpendicular to it ; and, consequently, if the person is to stand erect, the spine above must be bent back to the opposite side. Inequality in the strength or the development of the upper limbs produces a similar though less marked result. The most striking examples are seen in con- genital absence of one of the arms ; but in people who are very distinctly right- SPINAL CURVATURE. 7,3 haiuleil, the tlorsal spine is always slightly convex to the right, and sometimes very decidedly so. Asymmetry of tlie thorax is eye. Errors of Refraction. For oi)hthalmic work, the student should be provided with the following : a refraction ophthalmoscope (of which there are many varieties, the one designed by Mr. Stanford Morton being perhaps the best), and a large convex glass lens having a diameter of two inches and a focal length of about three inches. In addition to these, for estimating refraction, a " keratoscopy mirror " is useful, and a pupillo- meter should be added to the ophthalmoscope case. By " oblique illumination " of the eye is meant the projection of light from a lamp at the side of and somewhat in front of the patient's head through the convex lens into the eye, the lens being held at about its focal distance from the latter. Oblique illumination is especially valuable for detecting opacities or " nebulce " in the cornea, foreign bodies on the latter, or commencing cataract. By " indirect oi)hthalmoscopic examination" is understood the following: The patient is seated in a dark room with a light behind and to one side of his head ; the observer uses the plane mirror of the ophthalmoscope at a distance of about eighteen inches, and reflects the light into the pupil of the patient's eye ; then interposing the convex lens, held in -the left hand at rather less than its focal distance from the latter, the patient is directed to look at the observer's right ear if the right eye is being examined, at the left ear if the left eye is under ob- servation. By this means an inverted image is obtained of the optic disc, and the whole fundus can be explored by making the patient look upward, downward, and to either side. It must be remembered that the image obtained is an inverted one, and hence, for instance, a hemorrhage seen apparently above the disc is really situated below it. In the " direct method " of examination, on the contrary, the image obtained is not inverted. The oblique mirror of the ophthalmoscope is used, the light being as near as convenient to the patient's ear ; the surgeon, using his right eye when examining the patient's right one and vice versa, approaching his eye and instru- ment until the latter is just in front of the cornea, whilst reflecting the light steadily into the pupil. If the patient looks straight forward, the optic disc will be seen ; if straight at the observer, the region of the macula or yellow spot can be explored, etc. Since reflecting the rays on to the latter region j^roduces reflex contraction of the pupil, it is a great convenience if the contractor pupilla; be paralyzed by homatropine. In estimating refraction, too, the previous use of this drug is often necessary, especially in young subjects and in those with hyperme- tropia or "long sight." An aqueous solution of homatropine hydrobromate (four grains to the ounce) is employed, two or three drops being applied within the conjunctival sac every ten minutes. After this has been repeated three or four times, practically complete paralysis of the ciliary muscle and contractor pupill^e is obtained, both muscles recovering within twenty-four hours. For ophthalmo- scopic use, homatropine has largely displaced atropine, since the paralytic effects of the latter often persist for nearly a week. Further, if atropine be used in patients of advanced age, there is a certain risk of causing glaucoma. The student should practice the use of both direct and indirect ophthal- moscopic examination, since both are indispensable. We may now briefly notice the methods of detecting and estimating errors of refraction by the ophthal- moscope. EXAMINATION OF THE EYE. 723 In hypcrmctropia, otherwise known as long sight, the eye is shorter than usual, and if the ciliary muscle be at rest, parallel rays are brought to a focus behind the retina. Rays proceeding from an object at a distance of twenty feet or six metres may be regarded as parallel ones. Hence a hypermetropic eye, if the ciliary muscle be for the time not in action, has a certain amount of defect in distant vision, a defect which the patient can overcome by contracting his ciliary muscle, rendering the lens more convex, and thus bringing the rays to a focus on the retina. Rays proceeding from a near object, e.g., the type of a book, can also be brought to a focus on the retina with extra use of the ciliary muscle, and it is in near vision that the hypermetrope nearly always notices his defect, the strain upon the accommodation causing aching in the eyes or head. Hypermetropia may Ije detected by the surgeon by the following means : — 1. In using the indirect method, if the image of the disc be obtained and- then the surgeon gradually withdraw his mirror and lens whilst keeping the disc in view, the size of the image will be noticed to decrease. 2. If the direct method be employed, as the observer approaches the patient whilst reflecting the light into his eye, an image of the retinal vessels will be obtained at a distance of some inches from the eye. This image will appear to move (from side to side or vertically) in the same direction as the observer's eye. The distance at which the vessels can be distinguished varies with the degree of hypermetropia. 3. The observer uses the keratoscopy mirror (or the plane one in his ophthal- moscope) at a distance of at least one metre, and reflects the light from the lamp placed above and behind the patient's head into his cornea, making a shadow pass across the latter by inclining the mirror. If the shadow passes across the cornea in the direction opposite to the one followed by the mirror, the eye examined is either hypermetropic or emmetropic (of normal refraction). The test being repeated with a lens * of -f- i D (40") focal length immediately in front of the patient's eye, if the latter be emmetropic there will be no moving shadow. If hypermetropic, lenses of increasing strength are used until the shadow movement ceases, when the deduction of about i D from the lens required to effect this will give the amount of hypermetropia. 4. By using the direct method the details of the disc can be clearly seen in a hypermetropic eye when -|- glasses are used in the ophthalmoscope. The highest lens with which the smaller vessels can be distinctly seen represents the total amount of hypermetropia. The observer's eye in this test must be brought close to the patient's. It must be remembered that these methods of estimating the amount of hypermetropia are only available if the patient be relaxing his accommodation, and most easily if tht ciliary muscle be temporarily paralyzed by homatropine or atropine. In myopia or short sight precisely the same tests are employed : in (i) the size of the image increases as the lens and ophthalmoscope are withdrawn ; in (2) the image moves in the opposite direction to the observer's head ; in (3) the shadow moves across in the cornea in the same direction as the mirror is tilted ; and in (4) the details of the disc cannot be clearly defined unless a — lens equal to the amount of the patient's myopia is used in the ophthalmoscope. A myopic eye is one in which the length of the globe is greater than normal, and therefore parallel rays passing through the cornea are brought to a focus in front of the retina. Hypermetropia is a congenital condition, does not tend to *The unit of the Dioptric System, which is now universally employed, is a lens of about 40 English inches focal length ; -f- 2 D signifies a convex lens of V' ^= 20^'' focal length, — 5 D a con- cave lens of ■M' = %" focal distance, etc. To convert the French into the English system, divide the number of dioptres into 40. The standard of normal acuteness of vision is represented by |, i. e., letters which subtend an angle of 5° at the distance of 6 metres (about 20 feet) are used and can be read at this distance. V ^ ^'^^^ implies that the patient can only read at 6 metres type which subtends this angle and should be read at 12 metres distance, etc. 724 DISEASES AND INJURIES OF SPECIAL STRUCTURES. increase as age advances, but, on the other hand, occasionally Ijeconies less. Myopia usually comes on when the eyes begin to be used much for near vision — /. e., at school or during early adult life — and tends to increase with more or less rapidity. Overwork of the eyes (especially in a bad light), the habit of stooping and bringing the book, etc., very near to the eyes, and reading small or bad print, favor the progress of myopia. Twelve inches is about the best distance for near vision, and if the amount of myopia be so great as to compel the i)atient to hold his books, etc., nearer than this, concave glasses should be given of a sufficient strength to enable him to read comfortably at about this distance. For good distant vision a myopic patient may be ordered the full correcting glasses, and if these do not exceed — 4 D or — 5 I), they may be used for both near and dis- tant vision. A hypermetropic patient has no difficulty in distant vision, as a rule, but the extra strain thrown ui)on his ciliary muscle in near work tends to produce pain in the eyes and headache (especially frontal), and these symptoms may be entirely relieved by ordering the full correction to be worn for near vision. Complications of Hypcrinctropia and Myopia. — The chief complication of hypermetropia is convergent strabismus, the form of squint most often met with in practice. In this, whilst one eye is directed upon a near object, the axis of the other i)asses to its inner side (/. e., between the object and the non-squinting eye). Generally the squint affects the same eye always ; it is then said to be constant, and the vision of the affected eye is often defective {e. g., /^). The image is men- tally ignored, and hence the patient does not complain of double vision. Con- vergent strabismus comes on in childhood, and if the case is seen early and the squint be not of very high degree, it can be cured by the continuous use of fully correcting glasses (/. . .-x J r ii T J • ^1- • 4. J on the Lower Eyelid, commencing in With at the edge of the eyelids is the pigmented amoie. mole, forming a small, lobulated excrescence. It is of importance from the risk of melanosis starting from it in later life, and hence should be excised. Alolluscum contagiosum is treated in the section on Diseases of the Skin. A favorite starting-place for rodent ulcer is the inner part of the upper or lower eye- lid. It commences as a small, smooth infiltration of the skin, and tends to have a crescentic outline and to ulcerate sooner or later, then steadily advancing both in depth and on the surface. It may occur as early as thirty years of age, but is most common in more elderly patients, and, as is well known, causes no glandular enlargement, however long it exists. The best treatment is excision, scraping or cauterization being more likely to be followed by recurrence, unless very thoroughly done. Dermoid cysts occur as rounded, subcutaneous tumors, especially over the external angular process of the frontal bone, which is often slightly indented beneath them. They are always congenital, and due to peculiarity in develop- ment, and do not, as a rule, increase much after the first year or two. They have a fibrous wall lined with epithelium, their contents being chiefly sebaceous matter, cholesterin, and abortive hairs. If prominent enough to be unsightly, the cyst should be excised (without opening the cyst-wall during the operation, if it can be avoided), the wound being made parallel to the eyebrow, and carefully sutured with fine silk. A spirit lotion or iodoform should be used in the dressing. Pulsating Orbital Tumor. This term includes several conditions, producing the following symptoms : (i) protrusion of one eye (occasionally of both), with dilatation of its superficial vein ; (2) pulsation to be felt in the orbit, generally best through the upper lid ; (3) a continuous bruit, which is not only readily heard by the surgeon, but gives great annoyance to the patient ; (4) frequently paralysis of one or other oculo- motor muscle. Although the pathology of this affection is still not completely ascertained, it is certain that the most usual condition is a great dilatation of the ophthalmic vein (due in most cases to a communication with the internal carotid artery in the cavernous sinus). More rarely a true aneurysm of the carotid or ophthalmic arteries is present. Pulsating orbital tumor, like arterio-venous aneurysm elsewhere, is generally the result of injury — a fall or blow on the head involving fracture of the base, a punctured wound of the orbit with a sword or stick, etc. — and is, therefore, most common in males. It develops gradually within a iQ.\\ weeks of the injury, the 738 DISEASES AND INJURIES OF SPECIAL STRUCTURES. symptoms increasing in severity until sometimes vision is lost, owing to the ex- treme protrusion of the globe and stretching of the optic nerve. In some cases, it arises independently of any injury, and this spontaneous form is usually of sudden onset, and is most common in females. It is an interesting fact that, however great be the protrusion {proptosis) the vessels of the optic disc present but little that is abnormal, beyond pulsation of the veins. As already mentioned, however, the veins of the conjunctiva and lids are usually much dilated. The progress of the disease is variable ; a gradual diminution of the protru- sion and spontaneous cure is possible, though most of the cases are submitted to treatment. This consists in : (i) digital compression of the common carotid, which unfortunately can only be carried out for short periods, owing to the pain it causes; (2) the use of ice or graduated compression over the globe and eye- lid ; (3) ligature of the carotid artery. Attempts have been made more than once to ligature the dilated vessel in the orbit, but have almost always failed. Tying the common carotid has been followed by cure in a fair proportion of cases, but it is a proceeding attended with serious risk, and should not be resorted to, unless milder measures have failed, and the symptoms are steadily increasing in severity. OPERATIONS. The introduction of cocaine has greatly limited the use of ether and chloro- form in ophthalmic surgery ; general anaesthesia is now only required, as a rule, for excision of the globe, tenotomy in young children, advancement of a rectus, and iridectomy for glaucoma. Extraction of cataract can nearly always be effected under local anaesthesia, and thus the risk of after-vomiting avoided, but occasion- ally it is necessary to give ether or chloroform if the patient be very restless or l)ossess no self-control. To obtain local anaesthesia of the cornea and ocular con- junctiva, the best way is to drop on to them a 2 per cent, solution of freshly pre- pared cocaine (made with some boracic acid in it for the purpose of antisepsis) several times during the ten minutes which precede the operation. It must be remembered, however, that the cocaine does not anaesthetize the lid-borders nor the iris, hence the introduction of a speculum and iridectomy cause slight pain. In doing extraction of cataract with iridectomy, it is well to warn the patient ot this before introducing the iris forceps, for fear that a sudden movement should endanger the success of the operation. Hypodermic injection of a few drops of cocaine solution may be used in per- forming tenotomy or excising part of the eyelid, etc.; and, for the removal of a meibomain tumor or applying astringents to the conjunctiva, anaesthesia is best procured by applying powdered cocaine and allowing it to dissolve locally. I. Excision of the Globe. Instruments required : spring speculum, fixation forceps, scissors curved on the flat, strabismus hook. Standing behind the patient, introduce and fix the speculum, pick up the conjunctiva just al)Ove the cornea, and divide it all round close to the sclero-corneal junction. Having opened Tenon's cai)sule, introduce the hook under each of the recti muscles in turn and divide them. Then open the speculum as widely as possible, press it backward and make the globe pro- trude. Steadying it with the fingers of the left hand, introduce the scissors behind the globe from the right-hand side, open them to receive the optic nerve within the blades, and divide it with a single cut. One or both oblique muscles and some connective tissue may still require to be divided. A small sjjonge should be at once applied and kept in place by a pad and firm bandage. The wound heals usually within a week, and about a month after the operation a glass eye may be worn. It is well to use some boracic lotion and ointment daily for a week or two after the operation. OPERATIONS ON THE EYE. 739 Lately the introduction of small celluloid, glass or silver globes within Tenon's capsule, to take the place of the excised eye, has been extensively tried. The capsule and conjunctiva should be sewn up separately with fine silk, and it is well to use a drain of horsehair for a day or two. If the operation succeeds, the move- ments of the glass eye are generally imi)roved by the presence of the globe behind it, but, unfortunately, there is a strong tendency on the part of the latter to work out. A glass eye should be removed every night and cleansed, and it needs to be renewed, as a rule, once a year. 2. Tenotomy. (The common operation — division of the internal rectus — will be described.) The operator stands at the right side of the i)atient, introducing the speculum, and seizes a little fold of conjunctiva with the fixation forceps — the point aimed at being the junction of the inner and lower corneal tangents. With a small pair of straight scissors he makes an opening in the conjunctiva and Tenon's capsule at the same time. If this is not done, the capsule should be picked up separately and incised. The strabismus hook (which should always be blunt-ended) is now passed with its head directed backward toward the apex of the orbit, then brought under the rectus tendon, and the latter slightly raised on the hook, whilst one blade of the scissors is introduced under it, the other passing between the con- junctiva and tendon. The latter is now cut through, and the hook may be reintro- duced if it is thought some part of the muscle has remained undivided. A pad and bandage are usually applied for a few days — the conjunctival wound is so small that no suture is required. It is never advisable to perform tenotomy on both eyes at a time, for fear diverg- ence should result. Squints of 25° or more will not be cured by a single tenoto- my ; but it is best to perform the second operation after a considerable interval ; of course, all errors of refraction should be corrected. Sometimes tenotomy of one muscle is combined with advancement of its opponent, e.g., for divergent strabismus the external rectus is divided and the internal one advanced. The operation of advancement is too complex to be described here. 3. Iridectomy. As already described (p. 728), in cases of wound of the globe with prolapse of the iris, an iridectomy may be required. Apart from this it is performed Fig. 318. — Iridectomy Downward Fig. 319. — Iridectomy for and Inward for Artificial Pupil. Glaucoma. {^De Wecker.) either for optical purposes (/. ) Local. — All forms of injury, inflammation (whether specific or not), and new growths, may be attended by epistaxis. It rarely haj)i)ens, however (except in the case of naso-pharyngeal polypi, and occasionally as a result of injury), that the loss from these causes is of the same serious and persistent character as from the former. It may be smart for the time, but as there is no constitutional dis- order, no serious affection of the blood or blood-vessels, it can usually be checked without difficulty. Treatment. — Raising the corresponding arm above the head ; compressing that side of the nose with the finger ; cold-sponging of the face ; applying cold to the nape of the neck, and other simple remedies should be tried first. If they do not succeed, the patient should lie down and an ice-bag be applied over the nose, but watch must be kej^t that the blood does not trickle down into the ]jharynx. All muscular eftbrt, and especially blowing the nose, must be forbidden. Washing out the nose with ice-cold water, or with water tinged with perchloride of iron, is more effectual. The internal administration of such drugs as acetate of lead, gallic acid, and ergot, is of little use, though more may be said in favor of opium. Finally if the hemorrhage persists or returns again and again, the nostrils must be plugged. There are two ways in which this may be accomplished. The best is with a thin dilatable rubber tube, which may with advantage have two bulbs upon it about an inch apart, for the better closing of the apertures. This must be passed by means of a long probe along the floor of the inferior meatus, until the further of the two bulbs lies in the posterior nares ; then distended to its utmost with air or water, and the contents prevented from escaping by clamping or tying the project- ing end. It fits accurately into all the recesses, exerting an equable degree of pressure, and fills the cavity so closely that very little blood collects. At the end of twenty-four hours the contents may be allowed to escape, and the bag quietly withdrawn. Where this is not at hand and cannot be improvised, Bellocq's sound, or, failing this, a gum-elastic catheter, must be used. The sound is i)assed down the nostril ; the end protruded, and caught in the mouth ; it is then threaded with stout silk and withdrawn, leaving a double ligature passing along the inferior meatus, behind the soft palate and out through the mouth. Two plugs are then prepared, of compressed sponge or cotton-wool, about the size of the last jjhalanx of the thumb. One of these is tied tightly round the middle and fastened to the threads hanging from the mouth. The ends should not be cut off, but left, so that when the plug is car- ried on the tip of the finger to its jjroper site, the pos- terior nares, they may hang down in the pharynx. As soon as this is adjusted the other ends, projecting from Fig. 325 — Bellocq's Sound. ^1 ^ -i • <- "". the nostril in front, are drawn tight and knotted securely together over the other plug, which is placed INFLAMMATION OF NASAL MUCOUS LINING. 753 between them in the anterior opening. At the end of twenty-four hours the string that hangs down the pharynx shouUl be fished up, the knot that secures the anterior phig divided, and the two gently drawn away. If they are left longer they are very likely to cause ulceration ; and, as the whole cavity of the nose is filled with blood, which soon decomposes, this may lead to very severe inflam- mation and necrosis, or even worse. Inflammation of the Mucous Lining. Acute catarrhal iiiflammation is easily caused by exposure to cold or by irritating dust or vapors. The mucous membrane becomes swollen, there is a profuse watery discharge with sneezing (coryza), the respiration through the nose is obstructed, smell and taste are lost, and, if the lining of the frontal sinuses is affected, there is usually frontal headache with a certain amount of fever. In most i)eople this subsides as soon as the irritant is removed, or yields at once to ordinary remedies, such as Dover's powder or a Turkish bath ; but, occasionally, either because the tissues are peculiarly delicate and unable to regain their strength at once, or because of the persistence of some irritant, the inflammation continues, spreads over the adjacent mucous surface, and becomes chronic. Chronic inflammation is either the result of frequent repetition, the congestion and exudation of one attack not having time to subside before they are niade worse by another ; or of some constitutional disorder such as tubercle, syphilis, or gout. In many cases it is associated with outgrowths from the mucous mem- brane (polypi and adenoid growths) caused by the persistent irritation. Numerous varieties have been described, some well characterized. One, for example, is frequent in syphilis, especially the hereditary form, causing what is known as snuffles. Another, the hypertrophic variety, is almost as common in scrofulous subjects about puberty. The mucous membrane (chiefly that covering the inferior turbinate bone) is enormously thickened ; the surface is red and gran- ular, secreting a thick muco-purulent discharge ; the nasal passages are blocked, the hypertrophied mucous membrane fills the posterior nares, and projects so far into the anterior that, in spite of the color and rough appearance of the surface, it is often mistaken for a polypus ; the wall of the pharynx becomes affected, the Eustachian tubes are closed, and the tone of the voice completely altered. In a third {atrophic catar7li), which may possibly be a further development of this, the change is exactly the opposite ; the mucous membrane becomes atrophied, the glands disappear, and the nasal cavities are enlarged. With this is often asso- ciated a form of ozaena, due apparently to the decomposition of discharge retained in outlying dilatations or prevented from esca])ing by the crusts and scabs that form. In many instances, however, particularly when there is no specific irri- tant, no definite classification is possible ; the mucous membrane simply becomes rough and granular, the layers beneath hard and fibrous, the glands enlarge, their secretion alters, the veins, and probably the lymphatics, become varicose, and the smooth, soft, natural surface is completely lost. Treatment. — Syphilitic coryza quickly disappears under mercury ; and, though the prospect is less hopeful, a very great deal of improvement can be effected in scrofulous cases by iron, cod-liver oil, and especially residence at the seaside. Local treatment, however, is usually required as well. Temporary relief, especially from the attacks of sneezing, which are often very painful, can be ob- tained by brushing the mucous membrane over with a 5 per cent, solution of cocaine. The spray or the nasal douche is more effectual for checking secretion and diminishing congestion. Tannic acid, sulphate or chloride of zinc, carbolic acid, tincture of eucalyptus, and many other astringents and antiseptics are recom- mended ; the chief thing is the thoroughness of their application. If the spray is used, it must be directed up the posterior nares by means of a properly curved nozzle, as well as up the anterior ; if the douche, the stream must be of full volume and allowed to flow back through both nostrils. Afterward an astringent 754 DISEASES AND INJURIES OF SPECIAL STRUCTURES. powder (tannic acid, for example, with subnitrate of bismuth, or ahim and oxide of zinc) should be applied, but care must be taken not to make the inflammation worse by constant irritation. In cases in which the hyjjertrophy is extreme, it may be necessary to reduce the swelling by caustics or by removing some of the redundant tissue. Nitric acid has ])een applied with benefit, and so has the actual cautery ; and portions of the turbinate bones may easily be removed with forceps (this is often done in the case of polypi), but the most effectual method is the galvano-cautery, the loop of wire being adjusted over the projecting part and gradually tightened up ; the margin of the septum and of the ala must be protected with an ivory speculum. Inflammation ok thk Bones of the Nose, leading to caries and necrosis, is usually the result of syphilis, hereditary or ac- quired ; but it may be due to tul)ercle or glanders, to injury, the presence of foreign bodies, septic decomposition, mercury, and occasionally the fumes of bichromate of potash. ']1ie septum may be attacked, so that the bridge of the nose sinks in (although, in an adult, a great deal may be lost without any appa- rent alteration in shape), or the turbinate bones, or the roof, and in the latter case there is always the risk of meningitis. The symptoms are those of inflam- mation of the mucous membrane, but the discharge is always profuse and foetid, the breath exceedingly foul, and nothing, so long as any dead bone is there, gives more than temporary relief. In many cases the diagnosis is clear at the first Fig. 326. — Nasal Speculum. glance ; either there is a perforation of the hard palate, or a probe introduced into the nasal cavity strikes the .sequestrum at once ; but sometimes, especially when it lies toward the upper and back part, detection is a matter of very great difficulty. Treatment. — The dead bone must be removed as soon as it is loose, careful attention being paid at the same time to any constitutional taint that is present. In most cases it can be extracted, under an an?esthetic, through the anterior nares ; .sometimes it is easier to push it back into the pharynx (the two forefingers can usually be made to meet in the inferior meatus of the nose, the one introduced from the front, the other from behind, when the patient is anaesthetized), but the operator must be prepared for free, though not usually serious, hemorrhage. Where, owing to the size of the fragment, this cannot be done. Rouge s operation may be performed, /. e., an incision made through the mucous membrane, where it is re- flected from the under surface of the upi)er lip on to the gum, the cartilaginous septum detached from the anterior nasal spine, and, if necessary, from the maxil- lary crest ; the alai detached at the margins, ami the upper lip with the nose lifted up and reflected on to the forehead. The nasal cavities are thoroughly opened up to view by this, the whole interior can be examined, and then the nose and lij) replaced without a suture being re(iuired, or a mark left. If the dead bone, without being loose, is fairly accessible, as frequently hap- pens in hereditary syphilis, it may be partially dissolved away by a suljjhurous acid spray (which also heljjs to check the foetor), and occasionally can be chipped off" in little pieces with a fine chisel, but care must be taken that the instrument does not slip and penetrate the roof. TUMORS OF THE NASAL PASSAGES. 755 OZ^NA. By this is understood a persistent, offensive discharge from the nose, caused either by necrosis (syphilitic, tuhercuhir, or traumatic), or by the atrophic form of catarrhal inflammation. The smell, which is often not perceptible to the patient (differing in this respect from ozaena of the antrum), is infinitely more offensive than that of ordinary putrefaction. Possibly, in necrosis cases this is due to the presence of dead bone (which, it is well known, possesses this property) ; in others, however, it must arise from some si)ecial kind of fermentation, for which there is every facility. Opinions differ very greatly as to the relative proportion of cases in which dead bone is present. According to some it is never wanting, although there may be great difficulty in finding it ; sometimes it has not been discovered until Rouge's operation has been performed. Probably it is present in the majority, especially as there is very often evidence of syphilis, and certainly its absence should never be assumed until after the most thorough exploration. Treatment. — Constitutional treatment is always needed ; even when there is no necrosis, there is very frequently ulceration depending upon some constitu- tional taint, such as syphilis or tubercle. Locally, the first thing is to reduce the foetor as far as possible by means of the nasal douche, using Condy's fluid and very dilute carbolic acid af first, and, later, when the patient is more accustomed to it, chloride of zinc (one-eighth of a grain to the ounce), and corrosive sub- limate (i in 10,000). The chief difficulty is to make the lotion penetrate into the recesses, and this is hardly possible unless the bore of the tube is as large as the nostril will admit. In many cases, the spray and volatile antiseptics, such as iodine vapor, sulphurous acid and eucalyptus, are more effectual. As soon as this is to some extent overcome, the interior of the nose must be thoroughlv examined, both by sight and touch, from in front and behind. If any dead bone can be found, it should be removed or chipped away, so as to reduce the size of the offen- sive surface ; lupoid ulceration must be thoroughly scraped out, the bleeding being stopped with the actual cautery, and syphilitic sores touched with the acid nitrate of mercury. If the disease is too extensive to be dealt with through the interior nares, or if no cause can be found, and the ozaena still persists, in spite of all that can be done, the interior must be further exposed by operation. Not only is the patient's ])resence almost intolerable to others, but his own life is seriously endangered by the constant inhalation of the poisonous odors. One or both aire may be re- flected without leaving any conspicuous mark if the line of incision is carried along the junction of the nose with the face, but in most cases Rouge's operation is preferable, as being more thorough and leaving no deformity. Tumors of the Nasal Passages. The majority of tumors that grow in the interior of the nose tend to assume the polypoid shape. Some (adenomyxomata, the so-called mucous or gelatinous polypi) spring from the submucous tissue covering the turbinate bones, especially the middle, but occasionally the superior. Like the polypi that occur on other mucous membranes, they are essentially local hypertrophies, caused by constant irritation. Others, which are very much more rare, are formed of fibrous or fibro- sarcomatous tissue in varying proportions, and grow from the roof and occasion- ally the septum. These belong to the same order as the naso-]jharyngeal polypi which are attached to the roof and other parts of the pharynx, and spread from them into the nose. In addition, a few cases of papilloma and columnar epithe- lioma are recorded, but they do not require special mention. Mucous polypi are composed chiefly of mucous or myxomatous tissue, covered over with columnar ciliated epithelium ; but portions of glands (sometimes newly formed), cysts, and even widely dilated vessels, giving them an almost cavernous 756 D/SEASES AND INJURIES OF SPECIAL STRUCTURES. structure, are met with as well. They form soft, gelatinous, semi-translucent masses, pale pink or yellow in color, projecting from the surface of the mucous membrane, and sometimes reaching far into the anterior and posterior nares. At first they are small and sessile, and in any advanced case numbers in this stage can be seen between the larger ones. Those that project toward the front can usually be seen at once (or if the jjatient expires forcil)ly), forming smooth, ])edunculated ma.sses very soft to the touch, and moving up and down with each breath. The deeper ones may require a speculum, and those that grow into the posterior nares can only be detected by introducing the finger round the margin of the soft palate. Occasionally, when one has been exposed to the air for any time, the surface becomes dry and rough, and then it may possibly be mistaken for an overgrowth of the mucous membrane over the inferior turbinate bone ; otherwise it is difficult to see liow such an error can arise. Symptoms. — Chronic catarrh is always present. The breathing is obstructed (especially in wet weather, when the polypus swells up)'; the mouth is held open ; the voice is altered and becomes nasal ; the sense of smell, and often that of hear- ing, is lost ; and nearly always there is constant frontal headache. In severe cases the shape of the nose may become altered by the internal pressure ; the lachrymal duct obstructed ; the septum displaced to one side ; and the Eustachian tube blocked up. As a rule, there is no bleeding and no offensive discharge, both of Avhich symptoms are com- mon in the case of malignant growtlis. Treatment. — There are various ways of removing po- lypi. The simplest is to grasp the neck as high up as possible with a pair of slightly curved forceps, having long serrated blades, and twist it round and round until it comes away (Fig. 327). Mitchell Banks recom- mends that in bad cases the patient should be antcsthetized upon a sofa, and, when fully insensible, brought to the edge and placed so that the head hangs over. The surgeon then, kneeling on the floor, pulls out whole masses of the middle turbinate bone with the polypi upon them. If there is a very distinct pedicle, the ordinary wire ecraseur may be employed, or the galvano-cautery, cocaine being used to allay the pain and prevent sneezing. Polypi that lie far back, in or near the posterior nares, can only be snared if the forefinger of the other hand is carried round the back of the soft ])alate to guide the loop. The bleeding is free, but stops at once upon the ajiplication of ice-cold water. The chief dithculty is to make the removal thorough ; and the operator should not be satisfied until the route between the two nares is completely freed. Even then many small growths must be left behind, and these, released from the pressure of the larger ones, and, stimulated by the inflammation that follows the operation, are almost sure to spring up rapidly. To prevent this, tannic acid or sulphate of zinc may be used as snuff, or the cavity may be washed out with boracic acid and alcohol, or with other astringents ; but constant care is needed. In the worst cases it may be necessary to i)erform Rouge's operation. Naso-pharyngcal Polypi. — These include all the varieties of fibroma, sarcoma, and fibro-sarcoma, which grow from the roof of the nose, the jjharynx, or the pterygo-palatine region. They are met with chiefly at puberty, and in boys, form- FiG. 327. — Method of Grasping Mucous Polypi TUMORS OF THE NASAL PASSAGES. 757 ing roundish, lobnlated masses, covered over with a vascular mucous membrane. Some grow slowly and are firm and dense; others (which in all probability are round or spindle-celled sarcomata) are much softer and increase in size very rap- idly. 'I'hey are all exceedingly vascular (the walls of the vessels being very thin), so that they bleed with the least i)rovocation and very profusely ; and they spread in all directions, forming secondary attachments wherever they exert any pressure upon the mucous surface. The favorite locality is the basilar process, spreading forward into the nose and down into the pharynx ; but they grow sometimes from behind the superior maxilla (simulating a tumor of the antrum, except that the hard palate and the alveolar border are not depressed) ; from the ethmoid and sphenoid bones ; and even from the sei)tum. Occasionally enchondromata are met with. The symptoms depend upon the direction the polypus takes. A fcetid, blood- stained discharge is nearly always present, as the surface of the growth breaks down and ulcerates; sometimes the epistaxis is so severe as to threaten life; the nostrils may be obstructed ; the Eustachian tubes closed ; deglutition may be im- peded, and the most repulsive deformities (exophthalmos and frog-face) caused by the displacement of the features. Sometimes there is constant headache with a tendency to coma and convulsions, suggesting that the meninges are implicated. It is said that naso-pharyngeal growths sometimes atrophy, and they have been known to slough away of themselves, but, as a rule, progress is steadily from bad to worse, the profu.se hemorrhage in particular reducing the patient's strength. The only treatment is free removal with thorough destruction or ablation of the surface from which it springs. Otherwise it is certain to return. Small growths might probably be sometimes caught and twisted off, with prop- erly contrived forceps introduced through the nose, while the finger directs them from behind the soft palate. If a loop of wire can be adjusted round the neck, the bulk of the growth can be removed with the galvano-cautery, or, if this is not at hand, with an ordinary wire ecraseur ; but in either case the base must, in addition, be thoroughly seared. Hemorrhage is sure to be profuse, and, particularly if the growth is a large one, springing from the base of the skull, there is very consider- able risk of causing meningitis. Electrolysis has succeeded and deserves a further trial. Both needles must be inserted and a current used as strong as the patient can bear, with the view of causing sloughing. In most cases, however, a preliminary operation is required, in order to get sufficient space ; the origin of the growth is not accessible without. Where this should be done depends upon what can be found out with regard to the position of the pedicle and the direction the growth has taken. {a) If the polypus is situated low down it may be enough to divide the soft palate in the middle line (the flaps have been known to unite together again of themselves without a subsequent operation) ; or, if this is not sufficient, to reflect the periosteum and mucous membrane from the under surface of the hard palate and remove some of the bone as well. This, however, is a serious addition. (l)) When it grows forward toward the nose, Rouge's operation with free division of the septum might give sufficient room ; and in a case of frog-face a median longitudinal incision between the separated nasal bones has been prac- ticed. Langenbeck reflected upward the nasal bone and the nasal process of the superior maxilla, using as a hinge the skin, periosteum, and mucous membrane, connecting them with the frontal. Two incisions were made through the bone ; one vertical through the nasal, the other from the anterior nares to the margin of the orbit. (^) Retromaxillary growths can only be reached by excision or reflection of part of the upper jaw. Excision of the whole seems unnecessary ; the orbital plate should be left, a saw-cut being made through the bone parallel to it and w^ell below it. Temporary resection has been practiced in various ways, of which the best 7 5 8 DISEASES ANP INJURIES OF SPE CIA L S TR UCTURES. known is that of Langenbeck. It consists in reflecting inward, toward the middle line, a flap consisting of part of the malar bone and the whole of the superior maxilla, bounded by the pterygo-maxillary fissure behind, the floor of the orbit above and the roof of the palate below, with the soft parts covering it. The hinge is the suture between the sui)erior maxilla and frontal. Incisions down to the bone are made: (i) from the nasal j^rocess along the inferior margin of the orbit on to the middle of the malar bone, or even the zygoma ; and (2) from the ala of the nose parallel to the former, as far back, and then turning upward to join it. The origin of the masseter must be carefully detached as far as exposed. An elevator is then pushed through the posterior end of the incision down to the zygomatic surface of the superior maxilla, and carried onward until it enters the pterygo-maxillary fissure, and can be felt under lOjUu^-' Fig. 328. — Plan of Incision for removal of por- tion of upper jaw. (After Esmarch.'S Fici. 329. — Plan of Bone Section, Removal of upper jaw and malar bone. (A/ler Es7iiarch.) the mucous membrane with the finger passed into the mouth. In a case of polypus there does not appear to be any difficulty in this, as the pressure of the growth widens out the fissure. The incisions are then made through the bone from behind forward, in the line of the superficial ones, the upper passing through the malar bone, the malar process, and facial surface of the sui)erior maxilla to the inner angle of the orbit, the lower parallel to this above the alveolar border. A straight, narrow saw must be used for this, the depth of the cut being guided by a finger in the mouth. As soon as this is done the included portion of the bone, with the soft parts covering it, is freed behind, above, and below, and can be levered out from the pterygo-maxillary fissure, turning on its hinge in front. This exposes the orbit, the temporal fossa, the nasal cavities, and the pharynx, into all of which the retromaxillary growth may have advanced ; after the tumor has been removed the bone can be replaced and secured in position with sutures. CLEFT PALATE. 759 CHAPTER XL INJURIES AXD DISEASES OF TIJE MOUTH AND FAUCES. MALFORMATIONS. Cleft Palate. Cleft i)alate is caused by the imperfect development of the i)alate process grow- ing inward from the superior maxillary. It may involve the soft palate only, or even the uvula by itself (bifid uvula) ; or the soft and part of the hard \ or the whole length of both, and then it is always associated with hare-lip on one or both sides. When the intermaxillary portion is separate it usually carries three incisor teeth, sometimes only two; and very often in these cases there is a pre-canine incisor developed, more or less perfectly, on the posterior margin of the cleft. Whether this is due to the (possible) development of each intermaxillary bone from two centres, the cleft running between them ; or to a reversion under condi- tions of abnormal development to the original number of six incisors ; or whether it simply indicates a general disarrangement of the dentinal papillae, is uncertain. Nothing is known as to the cause of the arrest, which must take place at a very early period of fcetal life. It 'is sometimes hereditary, and it is said that there is a distinct tendency to it, when one of the lateral incisor teeth is wanting in the parent. It is, however, more to the point that the arrest is only complete in a very small number of cases ; the palate processes are seldom altogether deficient ; very often one side (usually the right) is fused with the vomer ; and they continue to grow for the first few years of life, so that not unfrequently the cleft actually becomes narrower, especially in front. Syphilis often leaves median perforations, both in the hereditary and the acquired form ; but the soft palate is never symmetrically defective, and there is always a large amount of scar tissue. Infants with this defect are unable to suck in the ordinary way ; sometimes they can manage it if there is a flap attached to the teat, closing the aperture into the nostril, or if the teat is very large and thin with a hole on its under surface ; in other cases they must be fed with a long-necked bottle, so that the fluid is poured quite to the back -of the throat. After a time the difficulty diminishes, the tongue becoming hypertrophied and somewhat altered in shape. The growth of the palate and the ultimate success of the operation may both be seriously endan- gered by imperfect feeding during the first few months of life. The time for the operation depends upon the extent of the deformity and the condition of the child ; five or six years is the usual age ; by that time the parts are fairly well grown and the child should be able to stand an operation. If, how- ever, the defect is unusually great, it is better to wait a year or two than run the risk of an unsuccessful attempt. The soft palate is generally operated upon first, but Smith recommends that, unless there is some exceptional difficulty, the whole should be completed at once. The patient is placed in the dorsal position with the shoulders raised and the head rather thrown back. An anaesthetic is not absolutely necessary, but if care is taken to watch the breathing and prevent blood passing down into the larynx, chloroform may be given through the nose by means of Junker's apparatus. Smith's gag, opening both sides of the mouth, and combining with it a tongue- depressor, is the most satisfactory, but Mason's or Coleman's should be at hand. The rings of the gag are held behind the neck by a responsible assistant, whose sole duty it is to attend to the position of the head and the breathing, especially as the continued depression of the base of the tongue may cause a little difficulty. Fig. 330. — Smith's Gag with Tongue Depressor. 760 DISEASES AND INJURIES OF SPECIAL STRUCTURES. (a) When the soft palate only is involved. As soon as the gag is in position and the patient anaesthetized, the tip of the uvula on one side is caught with a long jjair of mouse-toothed forceps, and a flap cut from the margin of the cleft from below upward. The other side is then seized and pared in the opposite di- rection. The whole of the mucous edge must be removed and care taken to obtain as wide a raw surface as possible, espec- ially at the angle, where union fails most fre- quently. Fine silver wire or horse-hair is used for the sutures. If the edges fall fairly well together, the former can easily be passed with one of Smith's tubular needles (Fig. ^S^). taking both sides in a single sweep. If horse- hair is preferred, a short curved needle may be threaded on each end and passed separately through each half of the flap with a needle-holder ; or Avery's method may be employed. In this a loop of silk is passed through one side of the cleft with a needle on a handle, caught with a pair of forceps, and drawn out sufficiently far to project from the mouth. Then a single horse-hair is passed opposite to this, through the other side and threaded through the loop. When this is pulled back again it draws the hair through the second side with it. In the ca.se of the uvula a rectangular needle on a handle can generally be used. The lowest suture is passed first. By drawing on this the palate is made tense and the passage of the next is easier ; the same process can be continued the whole Fig. 332.— Cleft of the Soft Palate, way, the a.ssistant keeping the ends of the sutures separate. dotted lines showing line ot t r .■• j ^ ^\ j-i 1 <- ^ • i. incUion. li the cdgcs come together readily, the fastening can be Fig. 331. — Coleman's Gag. Fig. 333 — Smith's Tubular Needle. CLEFT PALATE. 761 completed at once ; if not, the loops must be just drawn together, so that the operator may see where the tension is greatest, and lateral incisions made to relieve it. The levator palati is the chief cause of the difficulty, but free division of the mucous membrane, especially on the nasal surface of the palate, is almost equally essential. A puncture is made with a sharp-pointed knife (like a tenotomy knife on a long handle) inside the hamular process, midway between the teeth and the cleft, and on a level with the highest suture. A similar instrument, but with a blunt, rounded i)oint, is then passed through this, and an incision made downward and backward through the tissues of the .soft palate, as far as may be necessary. The wounds gape im- mensely at once, the edges come together readily, and the sutures can be tightened up, a twister or a pair of torsion forceps being used for the wire ones. If the tension is very great, the incision may be half the length of the soft palate, but a shorter one is usually sufficient. One of the palatine branches is always divided, but the hemorrhage is seldom serious. (F) When the hard palate is involved as well : „ c <■ d 1 . ^ ■ u i V / ' 1 • 1 Fig. 334. — Soft Palate sutured, with lat- the gap in this case is closed by detaching the mu- eral incisions for the relief of tension. I /-J T r iU • .. In the hard palate, site of puncture. cous membrane (and as much 01 the periosteum as midway between teeth and edge of will come with it) from the under surface and inner ,'='^'''- ^'^^ ""^ of incision along the ,,.,.. , latter. side of the palate process, and displacing it toward the middle line. In front and behind the flaps are left attached, so that they hang down like two horizontal curtains. To separate these flaps, a puncture is made down to the bone in the centre of one side of the hard palate, midway between the teeth and the cleft, and midway between the anterior angle of the latter and the posterior margin of the bone. A curved raspatory is thrust in at this spot and worked toward the middle line until it projects into the cleft, detaching the periosteum before it. It is then withdraw^n, a more curved one inserted into the puncture through which it protruded, and all the structures covering the hard palate, out as far as the puncture, forward to the teeth and backward to the junction of the hard and soft palate, completely detached. The same thing is done on the opposite side. The next step is to divide the connection between the upper surface of the soft palate and the floor of the nose, where the fascia is especially firm. Scissors curved on the flat are used. The palate is drawn forward, one blade passed between the flap and the bone, the other above the upper surface of the palate, and the mucous membrane cut through as far as the wall of the pharynx. The flaps now meet together easily, particularly if the palate is a high one. Wire sutures are passed and drawn together, taking care that the edges are everted ; the original puncture in the centre of the hard palate is prolonged sufficiently to remove all tension, and then the sutures are twisted up. Hemorrhage may be free for a moment or two, but it generally stops of itself. In the case of the soft palate, it is very rarely of any consequence, and sponging is hardly required ; the more this can be dispensed \\\\.\\ the better, as it delays the operation and tends to make the patient sick. If the lateral incisions bleed, the head can be turned to one side and the mouth syringed out with ice-cold water. Detaching the periosteum is occasionally attended with a good deal of bleeding, but a sponge on a holder, pressing the flap against the bone, stops it at once. Secondary hemorrhage from the palatine arteries, w-hich may be very serious, must be stopped by plugging the descending palatine canal. Respiration requires careful watching, not only on account of the anaesthesia, the position of the head, and the pressure upon the base of the tongue, but because of the danger of blood trickling down the larynx. Later, severe broncho-pneu- monia, which is almost fatal to union, may arise from this. 49 762 DISEASES AND INJURIES OF SPECIAL STRUCTURES. After-Treatment. — The child must be kept as quiet as possible after the operation, and only a few droi)s of ice-cold water allowed for some hours, for fear of causing sickness. All food must be fluid, or semi-fluid, and taken very slowly. If possible, the child should be kept in bed, at any rate for the first few days; and if it is fretful and inclined to cry, small doses of chloral may be given. The mouth should not be looked at for a fortnight ; the sutures, if there is no tension upon them, may be left longer still. Union fails most frequently at the junction of the soft with the hard palate; sometimes the whole breaks down, but it rarely happens that the flaps slough. If union is not perfect, a considerable time, six months at least, should be allowed to pass before a second operation is tried. Occasionally a third or even a fourth is necessary ; but in many of these a more satisfactory result can be obtained by wearing an obturator. Afterward no jjains should be spared to improve the articulation and educate the muscles. In the slighter cases, which admit of early operation, phonation may be almost perfect ; but when the defect is very consid- erable, so that the palate, even though it is restored, forms merely a tense septum extending partially across, the accent is never lost. The fibres of the superior constrictor, extending from one hamular process to the other, become hypertro- phied, so as to close the communication more completely, l)ut the flap never can vibrate properly, and not unfrequently. after some time, the cicatrix contracts and makes matters worse than they were immediately after the operation. INJURIES OF THE MOUTH AND FAUCES. Lacerated wounds of the tongue are of frequent occurrence in epileptic fits and from falls u])on the chin ; and the hemorrhage is sometimes serious. The wounds always heal by granulation, although the attempt may be made to draw the surfaces together by means of deeply placed catgut sutures. The soft palate, the tongue, or the tonsils may be very seriously injured by foreign bodies, such as the stem of a tobacco-pipe or a piece of stick being violently driven into the mouth. The internal carotid, or the ascending pharyn- geal artery, has been torn open in this way with fatal consequences. In some cases the extraction of the foreign body has been followed by a torrent of blood ; in others suppuration has taken place, usually because of some fragment left behind, and the artery has not given way for some days. In the latter case there is nearly always a warning first. If the bleeding is slight an attempt may be made to control it from inside the mouth by means of ice, or, if this fails, by tur- pentine or solid perchloride of iron held against the spot ; but, if it is severe or if it returns, ligature of the common carotid should be performed at once. It has been proposed in these cases to tie the external as well, so as to prevent, as far as possible, the blood finding its way round through that part of the collateral circulation. Fish-bones, pins, and other pointed structures are occasionally driven into the mucous membrane in deglutition ; and at times they cause a considerable amount of inflammation. Very often they can be felt with the finger better than they can be seen. DISEASES OF THE MOUTH AND FAUCES. Inflammatory Affections, Acute inflammation of the mucous membrane of the mouth is common in infancy and childhood, and is occasionally met with later in life, about the time of eruption of the molar teeth. It is often associated with disordered digestion, the two being dependent to a great extent upon the same cause : and it is espec- ially frequent among the children of the poor and those who live under bad STOMA Tins. 763 hygienic conditions. \'arious forms of it are described, but they seldom occur independently of each other. Catarrhal stomatitis K?, \.\\Q mildest; the mucous membrane swells up and becomes a brighter red ; the epithelium has a sodden white appearance, and after a time is detached in patches ; the tongue is raw and red, indented by the teeth ; the gums are soft and spongy ; and here and there the surface is marked by shallow erosions. In what is known as follicular stomatitis the orifice of each mucous gland is marked by a swollen, bright red areola. Aphthous stomatitis is difficult to distinguish from the last. It makes its first appearance as a group of yellowish vesicles, which break and leave superficial ulcers, about the size of a pin's head, covered with a yellowish slough and sur- rounded by a bright red areola. Frequently they come out in successive crops, so that all stages can be seen at the same time. They are exceedingly tender, and if on a part where they are exposed to friction they may seriously interfere with mastication. Aphthous stomatitis must not be confused with thrush, which is an entirely different affection. Ulcerative stomatitis, which occurs at the same time of life and under the same conditions, is more serious. The whole thickness of the mucous membrane is involved (though not the, substance of the cheek, as in norma) ; it becomes swollen, dusky-red, or even purple ; then a foul grayish slough forms upon the surface ; and later, when this is detached, a distinct although superficial ulcer is left. Very often the opposing surface of the gum or cheek, as the case may be, becomes infected too, so that various stages of the disease may be seen at the same time. The symptoms depend upon the severity of the attack and the extent of sur- face involved. In the catarrhal form the mouth is hot and dry, the breath offen- sive and every movement of the tongue attended with pain ; there is constant thirst and the sense of taste is altogether lost. After a time the secretion becomes more profuse, sometimes excessive, and very tender spots make their appearance, corre- sponding to the places from which the epithelium has been detached. In the ulcerative form these symptoms are greatly exaggerated ; the gums are swollen and bleed with the slightest touch ; the teeth are exceedingly tender, and movement so painful that mastication is impossible. Not infrequently there is a consider- able degree of fever, and there may be conspicuous swelling of the floor of the mouth, involving the lymphatic glands and the loose cellular tissue around ; but there is never the hard brawny feeling in the centre of the cheek which marks the onset of noma. Treatment. — Chlorate of potash rarely fails to effect a cure : it should be given locally in the form of a gargle or wash, and internally as well. In younger children borax with glycerine (well diluted) may be painted over the raw surface several times a day ; or, if the case is very obstinate, alum or nitrate of silver .10 ad 30 c.c. (gr. ij ad 5J) may be used instead. The condition of the bowels always requires attention — it rarely happens that they are acting properly ; but mercurials should be avoided ; and as soon as a certain amount of regularity is established, tonics, iron, cod-liver oil and quinine should be given freely. Partly as cause, partly as consequence, these forms of stomatitis are always associated with debility and malnutrition. Other forms of stomatitis are due to specific causes. Thrush is a superficial inflammation of the mucous membrane of the mouth and tongue caused by the growth in the epithelial cells of the fungus, the o'idium albicans, in all probability the same as the o'idium lactis. It is met with chiefly in children who are brought up by hand, and in adults suffering from exhausting illnesses. The mucous membrane of the mouth and tongue is red and swollen ; its secretion is acid instead of alkaline ; but the characteristic feature is the presence at the angles of the mouth of a number of minute white dots, without any red areola as in the case of aphthce. These enlarge until they meet and fuse, so that sometimes in bad cases the whole of the interior, with the pharynx and even the 764 DISEASES AND INJURIES OF SPECIAL STRUCTURES. oesophagus, is covered over with a thick creamy-white layer. Diarrhoea with greenish offensive stools sets in ; the child is unable to take any food ; the emaci- ation becomes extreme ; sores make their apjiearance round the anus, and the result is not unfrecpiently fatal. This disorder is due to the fungus that causes the acid fermentation of milk, and can be produced anywhere by neglect of proper precautions, especially scald- ing thoroughly every time they are used all the vessels which contain food and come into contact with milk. In large institutions, such as foundling hospitals, it is constantly making its ap])earance unless special precautions are taken, and fre- quently helps to cause the death of weakly children by the digestive disturbances that accompany it. The treatment is very simple : with thorough cleanliness it soon dies out. All suspicious spots within reach should be brushed over with very dilute carbolic acid, or with borax and glycerine, and the child's mouth cleansed thoroughly after every meal. At the same time the complications that are present with it, and are in great measure due to it, the diarrhoea, loss of appetite, and disordered digestion, require the strictest attention. Mercurial stomatitis is rare at the present day : a faint red line, or a slight swelling of the gum round the necks of the teeth, particularly where there is an accumulation of tartar, is all that is seen. It may occur from inhalation, inunc- tion, or absorption from the alimentary tract, and no doubt, though the number must be very small, certain people are peculiarly su.sceptible. The flow of saliva is increased ; the gums, as already mentioned, become red and swollen ; the breath is foul ; the tongue furred and a little enlarged ; the teeth feel too long ; and mastication of anything hard is very painful. If this is persisted in the most fearful consequences may ensue ; the mucous membrane may slough, the gums ulcerate away, the teeth fall out, the bones perish, and the gangrene spread to the floor of the mouth and nose, causing the most terrible destruction. In days gone by there is no doubt the result was often fatal, partly from the constitutional disturb- ance and the inability to take food, partly from the continued inhalation of particles from the foul and decomposing sloughs. At the earliest sign the administration of mercury should be stopped, and strong astringent gargles used frequently. Usually this of itself is enough. Chlorate of potash is said to be of as great service in this as in other forms of stomatitis, preventing in particular the peculiar foetor of the breath. S\J>hilitic Stomatitis. — The same forms of eruption that occur upon the skin are met with also in the mouth, modified by the conditions under which they exist. They occur in the hereditary as much as in the actpiired disease, and furnish a very large proportion of the cases of mediate contagion. Rhagades and the ex- ceedingly painful fissures at the angles of the mouth have been mentioned already. Superficial sores, closely similar in appearance, are of common occurrence upon the inside of the lips. Mucous plaques and tubercles are more frequent upon the tongue, the tonsils, soft palate, and pillars of the fauces. Where the epithelium is thin, and the friction smooth and constant, they are scarcely raised ; there is simply a grayish-white patch with a smooth surface, and well-defined, slightly reddened border ; or the epithelial covering has already been detached and a raw surface left. Symmetrical jjatches of this kind are often seen upon the margin of the soft palate on either side of the uvula, and may be regarded as distinctive. In other places they grow out into warty or cauliflower excrescences, often of some size; and in others, again, where they are irritated by the teeth, they cut into deep and angry ulcers. Secondary tubercular syjjhilides are more rare ; the epithelium, which is thrown off as scales upon an exposed surface, becomes soft and macerated in the mouth, so that the appearance they present is closely similar to that just described. In the tertiary stage, superficial and deep gummata, involving the mucous membrane, the submucous tissue, or the periosteum, are of common occurrence. Sometimes they are absorbed under treatment, and disappear without leaving a scar ; more PERIOSTITIS AND OSTEITIS. 765 often they break clown and leave deep and irregular ulcers. The favorite locality appears to be the palate. Central gummata, leading to necrosis and median per- foration, are frecjuently met with (the presence of congenital clefts in the hard and soft palate, and occasionally of foramina in the pillars of the fauces, must not be forgotten), and it is not uncommon to find the uvula and soft palate either destroyed altogether or united to the posterior wall of the pharynx in such a way that there is only a small aperture left. The constitutional treatment does not present any special features ; the local is very important. Gummata disappear rapidly under iodide of potash ; ulcers occa- sionally require the application of acid nitrate of mercury. Secondary affections, however, may prove very obstinate. The first thing is to get rid of every kind of irritant, whether it is the sharp edge of a tooth, or tobacco-smoke, spirits, or highly seasoned food. So long as these continue to act, it is almost impossil)le to effect a cure. Rhagades and exuberant condylomata may be touched with nitrate of silver, or brushed over with a 10 per cent, solution of chromic acid. Simple mucous patches usually get well with a wash of chlorate of potash and lotio nigra, or a very weak one of bichloride of mercury; in more obstinate cases the inha- lation of calomel maybe tried, or brushing the surface over, night and morning, with a solution of bicyanide of mercury (gr. xv ad 5J), and sometimes iodoform lightly dusted on proves very beneficial, the taste and odor being concealed by mixing it with freshly ground coffee. Tubercular stomatitis is not a common affection. Occasionally, when the tongue is involved, it occurs on the under surface of the soft palate, appearing in the form of minute vesicles which enlarge, break down, and leave superficial sores with sharply cut edges. More rarely it begins independently. There is very little inflammation as a rule; the sores slowly and steadily increase in size and depth, multiplying and fusing together until at length they develop into irregularly shaped ulcers with sinuous edges, often lying upon carious bone. There is no in- duration ; the course at first is very chronic, and there are no large sloughs or necro- sis, as in syphilis, but, in spite of this, the destruction maybe very considerable; I have knowui the whole of the soft palate eaten away. The prognosis, especially wdien the disease is secondary to mischief elsewhere, is very unfavorable, and the course tow^ard the end often very rapid, in a measure ownng to the pain on deglu- tition, and the difificulty of taking food ; but, occasionally, a certain amount of benefit is derived from constitutional treatment combined with scraping, iodoform, lactic acid, and similar remedies, and more rarely spontaneous (but unfortunately only temporary) cicatrization occurs. Other forms of stomatitis are occasionally met with. Lupus may extend from the lips to the gums and palate, and has been known to occur independently ; in the latter case the diagnosis from tubercular disease must be almost impossible. Anaesthetic patches occur in the early stages of leprosy, and deep ulceration is not unfrequently the immediate cause of death in the tubercular form. A very acute variety has been described in connection with gonorrhoea; in scurvy, hemor- rhagic stomatitis is one of the prominent symptoms, and in leucoplakia, when the tongue is extensively diseased, the mucous membrane of the sides and floor of the mouth is usually affected too. Periostitis and Osteitis. Inflammation of the superior or inferior maxilla may be caused by extension from neighboring structures, such as teeth ; by injury after extraction of teeth or compound fracture ; by mercury or phosphorus ; by suppurative disease in all its forms (noma, acute suppurative periostitis, or, especially after the acute exanthe- mata, pysemia), or by the action of specific organisms, such as those of actinomycosis, syphilis, tubercle, or leprosy. It may be acute or chronic, ending in necrosis or caries, according to the cause, the intensity of the attack, and the character of the bone. Necrosis, for instance, is more common in the lower jaw than in the upper, 766 DISEASES AND INJURIES OE SPECIAL STRUCTURES. owing to its peculiar density ; caries in children, in whom the bones are more vas- cular and less compact. When due to acute suppuration, the sequestrum may be detached within a few days ; on the other hand, in phosphorus necrosis, it often does not separate for years. The amount of new bone thrown out is usually very small, but in necrosis of the lower jaw from phosphorus poisoning it is often enor- mous for a time, and then disappears almost entirely. In acute, suppurative osteitis, whether arising from local or constitutional in- fection, the symptoms are exceedingly severe. Owing to the vascularity of the part and the looseness of the tissues around, the swelling is usually excessive, spreading far over the face and down the neck. The fever is often very high and the pain intense, continuing until the pus is let out by incision or finds some means of exit for itself. Then the symptoms slowly subside, the pus escapes ex- ternally or into the cavity of the mouth, and the discharge continues until either the bone recovers (for even extensive portions of the alveolar margin may be de- tached from the periosteum by acute suppuration, without necessarily undergoing necrosis) or the secpiestrum is cut off. Mercurial stomatitis when carried far enough to affect the bones is no less acute, judging from past accounts, for happily such cases are seldom seen at the present day. Syphilitic inflammation, on the other hand, is more chronic, and the tubercular form more so still. Phosphorus necrosis is peculiar in many ways : it does not affect those whose teeth are sound, but as soon as a spot of caries appears the inflammation spreads down into the alveolus, detaches the gum, loosens the tooth, and steadily advances until the whole ramus is involved. The symptoms are often very severe : the soft tissues around swell up and become inflamed ; there is a constant discharge of most offensive pus welling up around the teeth and poisoning the breath ; fresh abscesses are always forming ; and partly from the continued fever anci inability to take food, partly from perpetually inhaling and swallowing the foul discharge, the patient is cpiickly reduced to a condition of extreme anremia. (See Diseases of Bone.) Treatment. — Syphilitic periostitis and simple acute inflammation are checked at once by iodide of potash, or by painting the inflamed surface of the gum with the liquid iodine. If there is the least reason to suspect supjiuration, an incision should be made inside the mouth with a sharp-pointed bistoury, the edge of which is protected up to within half an inch of the end by wrapping it round with a strip of plaster. If this is done in time the disfigurement of an external opening can nearly always be avoided. Even when there is already a soft fluctuating swelling upon the face, the incision should always be made in the groove between the cheek and gum. Afterward the cavity of the mouth must be washed out fretjuently with some hot antiseptic solution (carrying it outside the teeth by means of a rubber tube), and the vessels of the skin made to contract by keeping it constantly wet with lead lotion. When dead bone is present, very little can be done until it is loose enough to come away. The teeth may be extracted if they are detached and surrounded by suppuration ; incisions made to facilitate drainage ; and the mouth kept as clean as possible. Carious bone may be scraped, but care must be taken, especially wath children, not to disturb the germs of the permanent teeth. If any extensive defect is left, it must be bridged over with a suitable plate so as to pre- serve the outline of the mouth. Alveolar Abscess. — Suppuration in connection with the fangs of carious teeth is known as alveolar abscess, or parulis. Throbbing pain, with protrusion of the tooth from thickening of the periodontal membrane, and swelling of the soft structures around the jaw, are the chief features. If left, it may discharge around the tooth ; more often, it works its way out through the side of the jaw on to the gum (the ordinary form of gum-boil) ; but, when connected with the lateral inci- sors, it may spread back between the layers of the hard palate, and gain the sur- face first at its posterior margin, or burst into the nose, and, especially when the molars are involved, it has a marked tendency to open upon the face. In this case it is not unlikelv to leave a chronic sinus, the orifice of which is surrounded SUPPURATION IN THE ANTRUM. 767 by pouting granulations. Sometimes, owing to the tension, the consecjuences are even worse ; necrosis is not uncommon, and even pyaemia has l)een known to occur. The mouth should be washed out with water as hot as can be borne, and the gums freely lanced, or leeched. Poultices should not be used. If this fails, and the tooth is much diseased, it should be extracted, or, if there is any stopping, this should be removed ; but, unless this gives free exit, or the whole abscess sac comes away attached to the diseased fang, it is advisable to make a free incision through the swollen portion of the gum, keeping the edge of the knife turned toward the bone, and open the abscess there. The thickening along the side of the sulcus, sometimes extending under its floor, can usually be made out at once by running the finger round the inside of the cheek. If a discharging sinus persists, it will usually be found on j^robing that there is either a small .sequestrum, or, more frequently, an old fang left, keeping up the irritation. Suppuration in the Antrum. This may result from injury, from dental caries and alveolar abscess (the fangs of the first molar project into the cavity, and those of the second bicuspid are only separated by a thin plate of bone), or from disease of the mucous membrane of the nose. In this case the teeth are sound and free from pain, or are only involved secondarily, occasionally becoming loose and dropping out of themselves, from absorption of the alveoli. The natural orifice of the antrum is rather high up on the floor of the middle meatus, and is rarely closed. Even when it is the inner wall is so thin that it usually gives way elsewhere. Sometimes, however, the secretion is pent up ; the tension rises ; suppuration sets in, and the attack becomes very acute. When this occurs the pain is most intense ; generally it is deep-seated ; often it is referred to the teeth, and usually it radiates all over that side of the face and head. The walls of the cavity yield and bulge outward in all directions, as in the case of rapidly growing tumors. The side of the face is tender and swollen ; the skin is reddened and pits on pressure ; the nostril is blocked up ; the teeth are loosened and exceedingly painful, very often they feel too long ; and the floor of the orbit maybe pushed upward, until vision itself is seriously interfered with. If the finger is passed under the upper lip, the anterior wall can be felt projecting into the mouth ; and occasionally the bony plate is so thin that it crackles. Some- times there is a rigor, and always there is serious constitutional disturbance. Such cases, however, are certainly rare ; nearly always the wall gives way at some spot, and the acuteness of the symptoms is relieved at once ; and it does not seem un- likely that most of the cases of acute suppuration of the antrum are really deep- seated periosteal abscesses in connection with the roots of the teeth, and are in the thickness of the wall. In chronic inflammation, on the other hand, the occasional discharge of fluid from the nostril, when the patient lies down with the affected side of the face uppermost, is sometimes the only sign. If it is merely catarrhal, associated with polypi, the fluid is of a clear, watery character ; if there is suppuration it is thicker and generally offensive ; but it differs from ozaena in this, that the smell is per- ceptible to the patient, but not, unless by blowing the no,se the cavity is emptied of its contents, to the bystanders. Moreover, there are no crusts of dried and inspis- sated mucus. Occasionally, the discharge finds its way through the posterior nares and is swallowed. In one case quoted by Heath, the cavity was filled by thickened caseous pus, and the bone was enlarged, hard, and tender, so as to simulate a solid tumor of the jaw; as a rule, however, there is no distention. Attacks of neuralgia, with a constant, dull, aching pain, and sometimes frontal headache, as, when the frontal sinus is involved, are nearly always present. The teeth and the bone around are tender, and the former may become loose and drop out ; the side of the face, and 768 DISEASES AND INJURIES OF SPECIAL STRUCTURES. especially the eyelids, are swollen and puffy from time to time ; and, not uncom- monly, the patient's health suffers severely from the constant swallowing of an offensive discharge. When the suppuration is chronic, the diagnosis rarely presents any difficulty, though it is i)rol)al)le many of the cases are overlooked and regardetl merely as inflammation of the mucous meml)rane of the nose. The acute form resembles in some respects a rapidly growing sarcoma, especially as this is often attended with pain and a considerable rise of temperature ; but the symptoms are much more severe. In any case of doubt, an exploratory puncture should be made under the lip. The treatment consists in letting out the pus, draining the cavity thoroughly, and, if necessary, washing it out with an antiseptic or mild astringent. In some cases, the cavity can be readily cleared from the middle meatus of the nose by means of a Eustachian catheter. If this does not succeed, an additional orifice must be made elsewhere. If any of the teeth which are ordinarily in relation with the antrum are decayed and carious, the stumps should be extracted, and, if the cavity is not opened, a trocar driven through the remaining i)ortion of the bone, care being taken that it does not slip in too far. Afterward a drainage tube, that can be stopped at will, must be inserted in the opening to prevent its closing and to keep the food from passing up into the cavity, where it would decompose. If, however, the teeth are sound, or if they have already been extracted, and the alveolar margin has become thickened and dense from sclerosis, the opening must be made either through the anterior wall, under the upper li}), behind the canine, or through the nose. The former of these is to be preferred when the wall is at all bulged or is inclined to yield beneath the finger. The latter is better under other circumstances, provided there is sufficient room in the nostril. The open ii'^g is most easily made in the lower meatus, just under the middle of the inferior turbinate bone, where the inner wall is fairly thin. There is no difficulty in per- forating the bone, and, if there is a necessity for it, the patient very soon learns to wash out the cavity through the opening, for himself. As a rule, however, if a second opening is made, and the interior is once thoroughly cleared of its decom- posing contents, the secretion soon regains its natural character. Hydrops Antri, or Dropsy of the Antrum. The facial surface of the upper jaw occasionally becomes immensely distended by a collection of clear yellowish serum containing a few crystals of cholesterin. The enlargement is very gradual, quite painless, and sometimes involves the palate and nasal surfaces as well. The bone becomes so thin that it crackles like parch- ment, and it may even be completely absorbed in some places. If the fluid is evacuated, the swelling subsides, the maxilla resumes its normal relations, and the opening very soon clcses in. It was formerly held that this dilatation was due to an accumulation of the natural secretion of the mucous lining of the cavity, the opening into the nose having in some way or other become closed. According to Heath, however, it is certain that some of these cases, and very probably all, originate as cysts in the anterior wall of the antrum ; and that either they grow to such a size as to be mistaken for the cavity itself, or that the intervening wall is gradually absorbed by the pressure, and the two cavities thus placed in communication with each other. Closure of the Jaws. Inability to open the mouth may ari.se from muscular spasm, from acute in- flammation of the bones or soft structures, or from cicatricial contraction and other organic changes caused by previous attacks of inflammation. {a) Muscular. — The simplest example is the contraction of the muscles of mastication, which not uncommonly attends the eruption of the wisdom teeth ; CLOSURE OF THE JAWS. 769 « sometimes apparently it is hysterical, and, occurring as trismus, it is one of the early symptoms of tetanus. The contraction disappears at once under an anaes- thetic, allowing the interior of the mouth to be thoroughly examined ; and then, if the wisdom tooth is found to be growing forward against the next, or if it is covered in, steps may be taken to release it. Generally it requires removal, but occasionally this is impossible, and the next has to be taken away before it is sufficiently accessible. Hysterical contraction is characterized by the peculiar manner in which it returns after the anaesthesia is past, not slowly and quietly, beginning with the return of consciousness, but quite suddenly, long after all the reflexes, and not until the patient's attention is drawn to it. (/O Inflamviatory. — All forms of acute inflammation, whether involving the lower jaw itself, the tonsil, parotid gland, or other structures in the neighborhood, are attended by a certain degree of inability to open the mouth, partly owing to the pain, i)artly to the mechanical difficulty caused by the inflammatory exudation poured out in the loose cellular tissue. The treatment, of course, depends upon the i)rimary cause. {/) Permanent Closure. — This may arise from cicatricial contraction of the soft parts, consequent on noma or gunshot injury destroying a large portion of the cheek, or from affections of the joint. In one or two instances the coronoid pro- cess has become ankylosed to the upper jaw after long-continued inflammation. Unreduced dislocations, after a time, acquire considerable mobility, although the incisor teeth cannot be brought into apposition. If the cicatricial contraction involves both the mucous and cutaneous sur- faces, the only satisfactory way of dealing with it is by plastic operation after ex- cision. Stretching the bands and simple division are quite useless. A double flap must, of course, be used — the inner one, if possible, being composed of mucous membrane. In cases in which the whole thickness is not involved, Heath recom- mends that the cicatrix should be freely divided and a metal plate or shield adjusted on the teeth so as to fit in between the gum and the cheek, and prevent the for- mation of fresh adhesions. A kind of mucous membrane is gradually developed in the groove, but this mode of treatment is naturally only practicable in a very limited number of cases. Ankylosis of the lower jaw is caused either by chronic suppurative arthritis (consequent on injury, pyaemia, suppurative osteitis, or tubercular disease) or by a peculiar form of rheumatism, often the relic of an acute attack, which leads to the production of dense fibrous adhesions, and not unfrequently obstinately returning again and again, ends at length in synostosis. Naturally, it is a condition of con- siderable importance, not only from the interference with mastication, but from the grave danger of asphyxia in case of vomiting. Treatment. — The joint may either be excised or an artificial one made in front of the fixed point. The former operation is only of limited value. An incision an inch and a half in length, not deeper than the subcutaneous cellular tissue, is carried downward and slightly forward from the supraglenoid root of the zygoma. The temporo-facial branch of the seventh nerve must be found and pulled downward, the lobules of the parotid gland pushed aside, and the neck of the condyle divided with a chain saw, without opening the buccal cavity. The head may then be detached with a chisel or cutting-forceps, and levered out ; but, especially in those cases in wdiich the bones are dense and sclerosed as a result of chronic osteitis, the operation is exceedingly difficult. Linear osteotomy has been performed through the condyle itself; below this through the neck ; further down at the base of the coronoid ; and, according to Rizzali's method, through the mucous membrane, without an external scar ; but all of these labor under the same objection, that osseous union is almost certain to occur. Esmarch's operation (excision of a wedge-shaped portion of the ramus) is more satisfactory. An incision is made along the lower margin, in front of the angle, the soft parts separated, and a triangular portion of bone with its apex 770 DISEASES AND INJURIES OF SPECIAL STRUCTURES. t upward, and the base, about an inch in length, corresponding to the lower border, detached and removed. A deep groove is cut on the external surface with a saw first, and then the section completed with cutting forceps. Bennett, who per- formed this operation on both sides in a case of rheumatic synostosis, in which all milder measures had failed again and again, recommends that, at least in cases of this disease, the insertion of the masseter should be detached from the bone on the distal side of the incision, or the two fragments are certain to be drawn together, The patient recovered with very good upward and downward action. TUMORS. I. In Connection with the Soft Structures. Navi are not uncommon ujion the gums, lips, and inside of the mouth. In one case under my care the whole thickness of the cheek was involved. Congenital hypertrophy of the gums is a very rare affection, requiring free excision. It must be distinguished from local hypertrophy, growing out in a polypoid form, the result of constant irritation, for which a much more limited operation will suffice. Papillomata may occur upon the gums in the neighborhood of the teeth, upon the lips, or upon the inside of the cheek. In some cases they are low and can scarcely be distinguished from ordinary warts ; in others, however, they are compound or branched and covered over with exaggerated filiform papillae, similar to those that are occasionally seen in what has been called ichthvosis linguae. It is probable that they are the product of constant irritation (I have known them develop symmetrically upon the upper and lower lips, from perpetual smoking) ; and they should always be freely removed for fear of something worse developing as age advances. Adenomata are rare, but they are occasionally found on the lips, palate, gums, and, in short, in all parts in which mucous glands are abundant. They form soft, irregularly-shaped, but flattened swellings under the mucous membrane. Their growth is slow, but it is generally difficult to ascertain how long they have been present. In microscopic structure they present a close resemblance to the gland growths that are found in the parotid, and sometimes, like these, are cystic and contain bone and cartilage. For the most part they are made up of irregular masses of acini and ducts. Mucous cysts are often met with upon the inside of the lip (labial) or cheek (buccal) developed from the mucous glands, and forming rounded, tense swellings, rather dark in color. The contents are translucent, but very viscid ; and occa- sionally undergo calcareous degeneration. It is sufficient to remove a portion of the wall, but in many cases the whole can be excised without difficulty. Ranula is the term applied to a cyst of the floor of the mouth, in many respects resembling those just described. It forms a soft, lobulated, fluctuating swelling, usually of a bluish-purple color, and lies immediately under the mucous membrane, on one side of the frsenum linguae. When small it gives rise to little inconvenience, but as it grows it pushes the tongue on one side, interfering with deglutition and articulation, projects in the submaxillary region, and may even reach down into the neck. The wall is composed of fibrous tissue lined with epithelium which is sometimes ciliated ; and the cavity is filled with a clear viscid fluid that bears no relation to saliva. Ranula is probably developed from a mucous gland (that of Blandin or Nuhn) which is present in this situation ; it has nothing to do with the duct that runs by the side of it. It has been known, however, to originate in connection with the sublingual gland, and it is probable that in many doubtful instances it is the product of cystic dilatation either of normal mucous glands occupying this region or of outlying portions of the larger ones which have been in some way detached TUMORS OF THE MOUTH AND JAW. 771 in the course of development. It is very questionable whether ranula in the strict sense of the term ever develops from the sublingual bursa, although it is cjuite possible that this may become cystic. The treatment of ranula is a little difficult on account of the obstinac)' with which it returns. Excision of the whole cyst is a serious operation, involving a considerable degree of dissection among very vascular structures. Removal of a portion of the wall only is seldom of any use unless further steps are .^yj^— [^^•;, v ^on^uc taken to secure its obliteration. So much may be cut away that it tannot close ; the interior may be wiped out with caustic, so as to excite a certain degree of inflammation ; a V-shaped flap may be made and the apex ,».'i. 1 ^A J„ ., i.« i-U a • -ii Fig. 335. — Ranula, or Sublingual Cyst, with Stitched down to the floor; or a wire or silk Saiivary buct lying upon it. seton may be used. The milder measure should be tried first, as severe inflammation may result if the sac wall is made to slough. [The injection of Tincture of Iodine is recommended. After the excision of the V-shaped flap a hard-rubber syringe with a long curved nozzle should be pushed into the cavity, which should then be filled to distention with the iodine. A second and even a third injection is sometimes required.] Dermoid Cysts. — Cysts containing sebaceous matter and hairs are occasionally found in the floor of the mouth, chiefly in the middle line, and in the substance of the tongue. They are always of congenital origin, although they may not enlarge until adult life, and are due either to accidental implantation, or to the persistence and cystic degeneration of fcetal structures, such as the hyoglottic canal, which commences at the foramen ceecum. Their position, the absence of inflammation, and the exceedingly slow enlargement are the chief diagnostic features, but it is rarely possible to be certain without a preliminary puncture. Other forms of cysts are very rare, although one or two instances of hydatids are on record. Epithelioma (squamous) is the only form of malignant disease that is at all common. It develops not unfrequently from the continued irritation of ill-fitting plates, and requires the freest removal. The diagnosis from simple ulceration is not difficult if the part is examined carefully, but the chief interest of this disease is the relation that it bears to a variety of cystic degeneration of the jaws. 2. Growing from the Bones and Periosteum. Partly owing to the great variety of the tissues that compose them, partly to the constant irritation to which they are subjected, the jaws are exceptionally liable to become the seat of new growths and cysts. All the tumors that develop in connection with bone may occur, and, in addition, others that form from the teeth, the fibrous tissue of the gum, and the epithelium. The term epulis is applied to those that grow from the aheolar margin at the neck of the teeth, springing from the periosteum or the periodontal membrane. Strictly, it should be limited to the hard fibromata which are common in this region, and which often extend so far down the socket of the tooth that a considerable portion of the alveolar margin has to be excised in order to insure its complete removal. Fibromata, composed of peculiarly dense fibrous tissue, with often spicules of bone, and sometimes islets of cartilage in their anterior, are the most common. For the most part they grow from the periosteum and form pedunculated tumors, projecting under the mucous membrane. More serious ones, however, are met with occasionally, springing from the interior of the antrum, or from the inferior dental canal, or from the sockets of some of the teeth, and attaining an enormous 772 DISEASES AND INJURIES OF SPECIAL STRUCTURES. size. In all cases they require free removal, but providing this is properly doi.e there is no fear of recurrence. Enclwndromata are much more rare, and many of them become converted into bone. Occasionally, when they originate from the antrum, they attain an enormous size, though of very slow growth, and lead to great tlcformity. Like the former they may begin either in the substance of the bone or under the periosteum, and they require free removal. It seems probable that those which are stated to have recurred were either not thoroughly excised, or were in reality chondrifying sarcomata. Ivory and cancellous exostoses are occasionally met with. The former gener- ally grow either in the antrum or from the angle of the lower jaw. The latter may be formed from cartilage, but very often are covered in with an unusually thick layer of compact tissue. Sometimes they originate in the interior of the bones, and in many cases they are so ill defined that it is impossible to draw a distinct line between them and that i)eculiar form of hyperostosis or overgrowth of the jaw which is occasionally met with in young peo])le, and which in its turn is very difficult to distinguish from the milder forms of leontiasis. Exostoses must be carefully separated from bony outgrowths due to displaced or supernumerary teeth, which are by no means uncommon. Odontomata, or tumors formed in connection with the teeth, may be either mere outgrowths (exostoses of the fangs) composed chiefly of cement, or, much more rarely, gigantic misshapen masses of dentine, enamel, and cement, thrown together with more or less of order and arrangement. They have only been met with in the lower jaw and in young people ; and in all probability they spring from the germs of one or more of the molar teeth which have become displaced and have grown out into an irregular mass, sometimes as large as a turkey's egg. The symptoms to which they give rise are very indefinite. Unless the surface protrudes through the gum, there is merely a slow growing tumor, causing immense expansion of the lower jaw ; and it has happened on several occasions that large portions of the bone have been excised under the impression that there was a centrally placed malignant growth. One tooth is always absent from the series, and occasionally the growth of the neighboring ones is interfered with to such an extent that they remain buried in the substance of the jaw. If the nature of the ca.se is recognized there is no difficulty in removing j^art of the wall of the cyst, and detaching the mass from the fibro-cellular membrane surrounding it. Myeloid sarcoma may develo]) either in the interior of the lower jaw — forming a rounded, tense, and elastic swelling, often suspiciously like a cyst, only of more rapid growth — or under the periosteum. In this situation it is sometimes called myeloid epulis, and is distinguished from the ordinary fibrous form by its darker color, which shows distinctly through the mucous membrane. Of all the sarco- mata it is the least malignant, and may never recur if excised freely. In the upper jaw it usually grows from the antrum, and is softer and more vascular, containing frequently a very large i)roiJortion of round or spindle cells. Round-celled and spindle-celled sarcomata are intensely malignant. They may spring from the i)eriosteal surface of either jaw, but their favorite seat is the antrum, in which they grow with great rapidity, thrusting the walls out in all directions and extending into neighboring cavities. The nostril becomes blocked ; the floor of the orbit is raised and the eyeball protruded ; the hard palate is forced down ; the facial surface is thrust forward ; and the whole side of the face seems enlarged. Then in a short time the growth spreads into the pharynx, or extends down the sockets of the teeth, detaching them and forming a fungating mass on the alveolar margin ; or it grows out into the nose and simulates a polypus, or involves the skin of the face. Nothing else in so short a time can produce so great or so gen- eral an enlargement. Free removal of the whole bone is essential, but very often the disease is already too far advanced before the patient is aware of the affection. Rapid recurrence is the rule, the secondary growths being generally softer and more malignant than the primary. TUMORS OF THE JAW. 773 Sarcomata growini^^ from the jaws, like those of other bones, occasionally undergo partial chondrification or ossification, forming what used formerly to be described as osteoid cancer and malignant enchondroma. Cystic degeneration is not uncommon, esi)ecially in the myeloid form. Primary carcinoma does not occur in the jaws, but secondary growths, extend- ing in the case of the upper jaw from the nasal mucous membrane (tubular epithe- lioma), or from the palate surface (squamous), are not uncommon, and, without any great external show, lead to complete destruction of the bone ; a probe, for example, may pass through a small, comparatively insignificant, opening in the palate into a great ulcerated space. In the case of the lower jaw, ingrowths of epithelial cells in the form of columns are met with in connection with multilo- cular cysts. Cysts. — Both the upper and the lower jaws are frequently the seat of cystic disease, which may originate in connection with the mucous membrane, or the teeth, or be dependent upon the degeneration of new growths, sarcoma or epithe- lioma. Mucous cysts are chiefly found in the antrum, developing from the glands lying in it, and are very generally associated with the presence of polypi. The mucous and submucous tissues, as in the nose, sometimes undergo chronic hyper- trophy ; when the fibrous portion predominates, a polypus results ; when it is the glandular part, cysts are produced. These are usually multiple, rarely attain any very large size, and contain a clear mucous fluid. Sometimes they cause a certain amount of absorption of the bone upon which they rest. Dentigerous Cysts. — Cysts formed in connection with the teeth are either due to an error of development, or are the result of chronic irritation and inflam- mation. The former are known as dentigerous cysts. One of the permanent teeth, generally the canine, remains buried in the jaw ; the fluid which normally collects between the enamel organ and the surrounding tissues, as the tooth approaches the surface, gradually increases in quantity ; a certain degree of ten- sion is caused ; and by degrees a cyst is formed deep in the substance of the bone, lined with soft but thick membrane. The tooth at first is attached to the wall at one spot, but subsequently it becomes free. The diagnosis rarely presents any difificulty ; the swelling is always met with in young adult life ; one of the perma- nent teeth is missing from the series, and very often the temporary one has not been detached ; the outer side of the jaw especially is expanded ; the surface is perfectly uniform and painless; and sometimes, on deep pressure, a certain degree of crackling can be made out. Occasionally they are formed in connection with the other teeth, and a few instances are recorded in which the temporary teeth, and even supernumerary ones, were associated with them. Subperiosteal Cysts. — The other form of dental cyst is met with at any age, and appears to be the result of chronic irritation in connection with the fangs. From their situation under the lining membrane of the alveoli, they are sometimes known as subperiosteal. Fluid collects around the root of a carious tooth, the bone is absorbed, a lining membrane is formed, and at length a distinct cyst is produced, which may or may not be attached to the tooth. At first its contents are thick and semi-purulent; later, as the pus undergoes fatty degeneration, they become softer, cheesy, and at length serous. Cholesterin crystals are generally present in abundance. These cysts are rarely larger than a hazel-nut, but some- times, when they are situated in the anterior wall of the antrum, they encroach upon its space to such an extent that they may easily be taken for it, and it is not improbable that many of the cases of so-called hydrops antri are really to be accounted for either by the presence of one of these cysts in the wall, or by one having ruptured into the cavity. The symptoms, when the cyst is sufficiently large to give rise to any, are merely those of a chronic, painless enlargement of part of the jaw. As a rule, by the time it is large enough to form a projection, the wall over it is absorbed, and there is merely a thin crackling plate of bone which yields beneath the finger. 774 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The treatment consists in free incision of the cavity, exploration to make sure there is no persisting cause, such as a misplaced or supplementary tooth, and drainage. According to Heath, periosteal cysts occur in the lower jaw without any apparent immediate connection with the teeth, though very possibly some irrita- tion connected with those organs may have been the original cause of the mischief. Cysts that develop in connection with myeloid or other sarcomata rarely admit of diagnosis, and do not possess any practical importance. Multilocular cysts, on the other hand, the so-called cystic sarcomata, are of great interest. They are more common in the lower jaw than in the upper, and originate, in most instances, in some form of injury, or from the irritation of decayed teeth. Formerly they were regarded as simple cysts, but it has been shown that they are really of epithelial origin, due to the downgrowth of columns of cells from the surface into the interior of the bone. As a result, great cellular spaces are formed inside, and the internal and external plates are so far separated from each other that in extreme cases the alveolar portion of the horizontal ramus is reduced to the condition of a few scattered trabecule, and the teeth are com- pletely detached. The central cells in the larger columns undergo colloid degen- eration, and in this way cysts are formed, filled with a thin, glairy, or blood-tinged fluid, and surrounded by imperfect layers of columnar epithelium. Their growth is very slow, and, probably owing to the bony capsule and to the early degeneration of the epithelium, they have but little tendency to implicate surrounding structures or the lymphatic glands. In one or two instances, however, sarcomatous tissue has been found associated with them, and then the prognosis is not so good. Owing to the fact that the alveolar margin and the sockets of the teeth are much more involved than the lower, firmer portion of the horizontal ramus, it is possible, in many cases, to excise the whole of the growth from the mucous surface, scraping it away freely, without removal of the whole thickness of the bone. Whether this should be done or not depends chiefly upon the age of the patient and the amount of solid tissue present. In case of any recurrence, the whole affected portion should certainly be removed. OPERATIONS ON THE JAWS. Excision of the Upper Jaw. This may be complete or partial, not removing the floor of the orbit. Where possible the latter is to be preferred, as it causes less deformity and does not expose the eyeball to the risk of displacement or injury. In cases of sarcoma, for which this operation is most frequently performed, free removal of every part of the bone is essential. The patient is placed in a semi-recumbent i)osition with the head and shoul- ders well supported. The ancesthetic must be administered by means of Junker's apparatus, the tube being passed through the other nostril or the mouth, according to the convenience of the moment. A preliminary tracheotomy is not necessary, although it is a wise precaution when a hemorrhage is expected, but the adminis- trator must pay special attention to the breathing, and particularly to the danger of blood finding its way down the larynx. The incision (usually known as Fergusson's) runs down the centre of the upper lip, round the ala of the nose to the inner angle of the orliit, and along its lower margin as far as the malar prominence. The arteries of the lip are the only ones that bleed, unless the growth has infiltrated the skin. The flap is reflected far enough to expose the whole of the bone that requires to be removed. An incisor tooth is drawn, and an incision made with a stout scalpel along the floor of the nose, down the hard palate in the middle line, and transversely outward at its posterior margin toward the last molar. The object is to preserve OPERATIONS ON THE JAWS. 775 the soft palate when the bone is removed, the separation being completed with blunt-pointed scissors. The ala of the nose and the ijeriosteum of the orbit are to be detached in the same way. The bones may be partially divided with a saw or cut through at once with a pair of long-handled bone-forceps. The latter is the more speedy and does not really lead to more splintering. One blade is passed into the mouth, the other down the nostril, and the hard palate divided with a single cut ; the nasal process is treated in the same way, and then the outer angle of the orbit, the line of divi- sion running into the s])heno-maxillary fissure, l^y this the bone is ])ractically freed, and if gras])ed with a pair of lion-forceps, one set of teeth fixing themselves in the hartl palate, the other on the malar eminence, it can be easily detached by wrenching it from side to side, and separating the soft structures as they resist with a pair of blunt-pointed scissors. There is seldom any hemorrhage ; the arteries divided are all minute, and if torn across retract at once. Sometimes, however, when the growth is very rapid and the vessels much dilated, it is fairly free ; and if the substance of the tumor (in which the vessels are often little more than open channels) is torn, it may be of any extent. It must be stopped by pressing a sponge firmly against the bleeding part, or, if this fails, with the actual cautery. I. Gensoul. 2. Velpeau. 3. Syme. 4. Malgaigne. 5. Nelaton. 6. Fergusson. 7. Dieffenbach. 8. Weber. 9. v. Langenbeck. Fig. 336. — Incisions for Section of the Superior Maxilla. If the whole growth has been removed and the bleeding stayed, nothing further need be done ; the flap is simply replaced and fixed with two or three sutures, a hare-lip pin being used for the lip. If, however, the bone is crushed by the forceps, or if the surface of the growth presents a torn and ragged surface, the wound must be carefully examined, and the rest either removed with a sharp spoon or destroyed by packing the cavity with lint covered with a paste made of chloride of zinc and starch. Sometimes it is necessary to plug the space with strips of iodoform gauze in order to check the oozing ; but, whatever material is used, it must be withdrawn at the end of twenty- four hours, owing to the rapidity with which it becomes foul, and partly for this reason, partly from the pain it causes, it should be avoided whenever it is possible. The after-treatment is very simple and the deformity left strangely slight. The lower eyelid, however, may become oedematous, especially when the floor of the orbit is removed, and cause a very unsightly projection ; and, in cases in which it is necessary to remove the malar bone as well, the prominence of the cheek, of course, is lost, so that the depression becomes more conspicuous. Partial operations are much more common. The floor of the orbit may be left, the bone being sawn across below the infra-orbital foramen ; or the incision 776 DISEASES AND INJURIES OF SPECIAL STRUCTURES. may be confined to the side of the nose, and the anterior wall of the antrum exposed sulificiently to allow a tumor to be gouged out from the interior; or large portions of the alveolar margin with the teeth may be removed from the inside of the mouth in cases of epulis. Temporary resections, in which more or less of the Ijone is separatetl from the rest and reflected, without dividing the periosteum or soft tissues, have l)een described on i)age 7 58. Excision of the Lower Jaw. This may be either complete, the symphysis being divided and the condyle disarticulated, or partial ; and it may be performed altogether from the inside of the mouth, or through an external incision. The former operation, except in the case of such diseases as phosphorus necrosis, is exceedingly difficult and danger- ous from the risk of wounding the facial and maxillary vessels in a part that is almost inaccessible from the interior ; the latter involves a cicatrix of some m\% ' Fig. 337. Resection of Lower Half of Jaw. Fig. 338. Cutting the Skin and Sawing Through tlie Bone. Twisting from the Joint. extent (dei)ending upon the amount of bone that requires taking away), but if the red portion of the lip is not divided, and the incision is kept under the horizontal ramus it is scarcely noticeable. The facial artery must, of course, be divided, but the nerve does not suffer unless the incision is carried unnecessarily high up the posterior margin of the vertical ramus. If one-half of the bone is to be removed, a vertical incision is made through the lip, and a horizontal one at right angles to this, along the inferior margin as far as the angle, and up behind the vertical ramus to a level with the lobule of the ear. The soft tissues are dissected off the external surface of the bone and reflected upward ; the jaw divided near the symphysis, one of the teeth being drawn for the purpose, and the structures on the inner side separated in the same way. The bone should be sawn nearly through and the section completed with bone-forceps, and care should be taken when the division is near, and still more at the symphysis, that the tongue does not fall backward. The facial artery should, of course, be secured at once. OPERATIONS ON THE JAWS. ^n The anterior end of the detached half must now be grasped with forceps, and pulled down to complete the separation of the masseter and internal ijterygoid. For the latter the bone must be everted. Then, if it is intended to disarticulate, either the temporal muscle must be detached from the coronoid or this process cut off with bone-forceps and left for excision later. If it catches against the malar bone while it is being depressed this must be done. As soon as this is effected, the jaw can be depressed a great deal further, and by keeping the point of the knife well against the bone the long internal lateral ligament (with the inferior dental nerve and artery), the capsule and jiart of the external pterygoid can be divided. The jaw then comes away readily, the rest of the soft structures being divided, one by one, with blunt-pointed scissors. Cireat care is required not to divide the internal maxillary artery, which lies outside the internal lateral ligament, between it and the bone, or to tear it by everting the ramus too much and twisting it round the neck of the condyle. Partial excision, leaving the condyle and the coronoid process, is more easy. In many instances slighter operations still are possible : a segment of the hori- zontal famus only may be removed (when this is done the division of the jaw should be nearly completed in both lines of section before either is carried right through, or in making the second the support of the jaw is lost) ; or, as in epulis, and occasionally in epithelioma, the alveolar portion may be taken away and the lower border left. 50 773 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER XII. INJURIES AND DISEASES OF THE TONGUE, SALIVARY GLANDS AND TONSILS. CONGENITAL AFFECTIONS OF THE TONGUE. Tongue-tie is caused by the fra^num being of unusual shape or size ; it may be too broad or attached too far forward. In the vast majority of instances this affection is imaginary, but cases are met with in whicli it renders suckbng very difificult, or, later, interferes with articulation. The mucous membrane should be divided with a pair of blunt-pointed scissors, and sufficient sej^aration effected by tearing. The opposite condition, undue laxity of the frasnum, so that the tongue can sink backward, with its dorsum against the wall of the pharynx and its base over the glottis, is much more rare. Several cases, however, are recorded in which it is stated to have caused death. The same thing has been known to occur after very complete division of the frtenum. Fixation to the floor of the mouth by folds of mucous membrane, absence of the tongue altogether, bifid tongue, and other defects are very rare. Macroglossia. — One or two examples of true hypertrophy of the tongue, involving all the component structures, have been recorded, but by macroglossia is generally understood an enlargement of a different character. It affects only the connective tissue, lymph spaces and lymphatics, which are enormously dilated. The blood-vessels are occasionally larger than natural, and in some instances a certain amount of adenoid growth has been described ; but there does not appear to be any increase in the number or size of the muscular elements. Macroglossia is nearly always congenital and is occasionally associated with hydrocele of the neck ; but it is often not noticed for some time after birth. In the few instances in which it appears to have developed late in life it has followed injury, inflammation, or the acute specific fevers, its pathology in all probability being essentially the same. The enlargement that is met with in cretins, idiots, and others of weak intellect, is merely the result of inflammation consequent upon repeated protrusion and injury. The appearance is characteristic. The shape of the tongue is more or less natural, but it protrudes many inches beyond the mouth, and the surface is covered with enlarged papillae, often bulbous at the ends, and .separated from each other by deep smooth-walled fissures. The general color is paler than natural, and it has a delicate semi-translucent appearance on the surface. In the slighter cases it can still be withdrawn ; in those which have lasted some length of time this is no longer possible ; the mouth cannot be closed ; the saliva dribbles away ; the lower lip becomes everted, and the chin covered with eczema ; even the lower jaw is enlarged and the teeth forced down by constant pressure until they are practically horizontal. Then the protruded portion of the tongue begins to suffer. From constant exposure the surface becomes hard, dried up, cracked, and ulcerated ; repeated injuries from the teeth, which are always rubbing against its under surface and its sides, and other causes, lead to attacks of inflammation, each of which brings a fresh amount of oedema and leaves the condition worse than it was before ; and at length, partly from the discomfort, ])artly from the difficulty of introducing food (not so much the swallowing of it), the patient's condition becomes one of absolute misery. The only treatment that can give permanent relief is the excision of a V- shaped portion; and this should be practiced in all cases in which the contour of INFLAMMATION OF THE TONGUE. ■79 the lower jaw and the direction of the teeth are becoming affected. If the thick- ness is very great the natural shape of the tongue may be partially restored by excising a horizontal as well as a vertical wedge, the surfaces being brought together by catgut sutures running through the whole thickness. In cases of recent injury when the tongue is more than usually swollen, soft linen moistened with glycerine may be wrapped round it to reduce the oidema, although of course it has no effect upon the permanent hypertrophy. Inflammation of the Tongue. The mucous membrane of the tongue, like that of the mouth, is liable to all the varieties of superficial ulcera- tion that have already been de- scribed. Aphthie may form upon the tip and edges ; thrush may occur in infants and adults whose health has broken down ; herpes is occasionally seen : and ulcera- tive stomatitis sometimes extends on to it from the cheek or palate. In addition to these, however, and to the various kinds of specific disease, such as syphilis and tu- bercle, the tongue is especially subject to certain forms of chronic inflammation, some superficial and spreading over the greater portion, others local and ending in deep ulceration. These are due, there is no doubt, to the constant injury and irritation to which the surface is exposed ; but they are also very largely dependent either upon in- dividual predisposition or the general state of health. The same irritant — tobacco smoke, for example — which may be continued in one case for years without producing the least effect, in another causes serious irritation within a very short space of time ; and a ragged tooth, which may not hurt so long as the general health is good, cuts into the tongue and leads to ulceration as soon as it begins to fail. It is possible that in this case the condition of the tongue itself is sufficient explanation : it becomes enlarged and flabby ; the teeth cut into it ; and the epithelium covering it may be more delicate than natural ; but this is certainly not satisfactory in the case of the former, nor will it account for the obsti- nate persistence of some of these varieties of inflammation when they have once commenced. Acute Glossitis. Acute inflammation of the tongue may be caused by cold, mercury, poisoned wounds, the presence of foreign bodies, or the stings of insects. It has also been known to occur in the course of erysipelas and some of the eruptive fevers. The mucous membrane only may be affected, or the whole substance of the tongue ; and it may end in speedy resolution, in a circumscribed abscess, or in a most acute form of diffuse inflammation, which spreads to the floor of the mouth, involves the aperture of the larynx, and not unfrequently proves fatal from asphyxia or septic inflammation. There is no difficulty in the diagnosis. The surface is dark and livid, the dorsum covered with fur ; the size increases so that it is tightly pressed against the Fig. 339. — Macroglossia. 78o DISEASES AND INJURIES OF SPECIAL STRUCTURES. teeth, and movement is attended with severe pain. If the inflammation continues the swelling soon becomes enormous; the tongue fills the mouth, ])rotrudes be- tween the teeth, presses up against the palate and projects backward over the glottis. The tissues at the floor of the mouth become swollen and tense, so as to raise it further still ; the mouth cannot be shut ; the saliva pours away ; articulation and deglutition are impossible ; and there is imminent danger of asphyxia. 'I'he pain in acute cases is very great and there is dreadful distress, but the temperature is seldom high. As the inflammation subsides, superficial sloughs not uncommonly make their appearance where it has pressed against the teeth, leaving troublesome ulcers ; or this is followed by a condition of chronic induration and enlargement ; or, in very rare cases, by persistence of the sloughing, until, if the patient does not succumb from septic poisoning and broncho-pneumonia, the whole organ is practically destroyed. The treatment depends upon the severity of the attack. In the milder cases, in which the distress is not urgent and there is no immediate fear, the bowels should be opened freely with a saline purge, chlorate of potash given internally, and the mouth washed out constantly with an ice-cold solution of carbolic acid or permanganate of potash. Fragments of ice may be sucked meanwhile. In the more severe ones, when the mouth is nearly filled, leeches may be applied behind the angles of the jaws, and careful e.xamination made with the finger over the dorsum of the tongue as far as it will reach. If a special projection can be felt, or even if there is merely a difference in con.sistence, a puncture should be made with a scalpel, either on the dorsum in the middle line, or below, through the floor, according to its position, and a further exploration made with a steel director in the hope of finding a circumscribed abscess. In the most severe cases, however, nothing of the kind is possible, and all that can be done is to make a free incision down the dorsum of the tongue on each side of the middle line, about half an inch from it, and offer a chance of escape to the inflammatory effusion. The depth need not be great, but the submucous tissue should be opened up. Afterward the patient usually requires a prolonged course of tonics. Acute glcssitis rarely occurs except in those whose health is already broken down, and its course is so rapid and so severe that death may ensue simply from exhaustion. Tracheotomy may be required at any moment. Simple Ulceration. This is usually caused by friction against the edge of a tooth or plate ; but the liability to its occurrence and its severity depend very largely upon the state of health at the time. The sore is generally situated at the side or under the tip ; it may be single or multiple, according to the cause. When quite recent there is merely a super- ficial blister or excoriation, surrounded by a narrow zone of redness. In older cases and when the irritation is severe, it is more like a deep cut, extending into the substance of the tongue, with a sloughy surface and sharply-defined angry edges. The dorsum near it is covered with fur ; the mucous membrane around is swollen and (jedematous, so that the sore appears raised above the level of the rest ; the breath is offensive, and movement very painful. In very chronic ones the appearance is different again. The signs of acute irritation, the redness, swelling, and sloughing base are wanting ; and in their place there is an amount of indura- tion that suggests epithelioma at once. It is in these that Butlin's method of e.xamining a scraping from the surface (if cocaine is used a considerable thickness is easily obtained) is chiefly useful, and it should always be tried when there is the least suspicion. The diagnosis rests chiefly upon the position, the signs of inflammation, and the evidence of an exciting cause If this can be found and removed, either by filing down or extracting a tooth, or by covering over a sharp projection with a shield of vulcanite, the irritated surface soon loses its redness and begins to granu- late. Borax, chlorate of potash, and a lotion of chromic acid (gr. x. ad 3J) are INFLAMMATION OF THE TONGUE. 781 the most useful applications. If, however, the sore is indurated, in a person over forty years of age, and if improvement does not very soon take place, a further examination should be made, and unless it is perfectly satisfactory, there should be no hesitation in excising the whole affected area. Ulcers of this kind frequently leave fissured cicatrices extending some depth in the substance of the tongue. Chronic Superficial Glossitis, The surface of the tongue is liable to a peculiar variety of inflammation which is of great importance, owing to its obstinacy and to the tendency to pass on to epithelioma. It is known by many names, and assumes many forms, but there is no evidence to show that there is any essential difference between them. A single patch is sometimes spoken of as leuco?na ; the term chronic siipeificial glossitis is usually reserved for that condition in which the whole surface is smooth and red- I. The early stage, with slight enlargement. Fig. 340. — Chronic Superficial Glossitis. 2. The later stage, with dense coating of epithelium, cracked and fissured. dened, the papillae having disappeared ; when a large portion is covered with a thick milk-white mass of sodden epithelium, it is called leucoplakia ; a very rare condition, in which the filiform papillse, over more or less of the surface, are enormously hypertrophied, may, Avith some re.servation, be spoken of as ichthyosis (it is not a congenital affection like true ichthyosis, but merely an inflamed papil- lomatous growth) ; psoriasis, tylosis, keratosis, and other similar expressions are not needed. It is much more common in men than women, and rarely occurs under forty years of age. Tobacco smoking, raw spirits, hot and irritating articles of diet, and syphilis are usually regarded as the causes, and there is no question that in the majority a perfectly definite history of one or all of these can be obtained ; but it is equally true that it occurs sometimes in patients who have never suffered from syphilis and who have never smoked or drank to excess. In some the whole sur- face soon becomes involved, and these must be regarded as in some way specially predisposed to it ; in others it remains limited to small patches for a great length 782 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of time, but it always begins opposite some irritant, either a tooth or the spot at which the end of a pipe rests. It is exceedingly common among dock laborers at the l^ast Knd, and I believe is due chiefly to smoking, and very possibly to the kind of tobacco. 'I'he appearances differ immensely in different stages. In the earliest, one or more spots upon the surface are smooth, glossy, and redder than the parts around. The mucous membrane is hyi)eraimic and tedematous, the horny layer of the epithelium is detached, and the natural inequalities of the surface are leveled up. The swelling is not noticeable unless a considerable portion of the tongue is involved ; then the increase in size is shown by the deep dej^ressions for the teeth all round the edge (Fig. 340). By-and-by, as the epithelial layer continues to grow, l)luish-white, semi-translucent patches make their appearance here and there ; gradually these become thicker and more opacpie in the centre, and spread further and further round the margin, until at length, if the irritation continues, the whole surface is covered over with a sodden layer like the epidermis of the hand after it has been poulticed. Before this stage is reached other changes begin. The dense covering of epithelium, like sodden wash-leather to look at, impedes the movements of the tongue; its flexibility is lost; often it shrinks in size and becomes hard and dense ; deep cracks and fissures form, arranged longitudinally and transversely in a symmetrical pattern ; and, after a while, as these become more and more worn, ulceration follows. In severe cases the inflammation is seldom limited to the tongue itself; not unfrequently the white patches extend over the floor of the mouth, and on to the lips and i)alate as well. The ichthyotic variety is very rare in comparison. It originates as an inflam- matory overgrowth of the papillce at one or more i)oints. They grow out and form rugged thorn-like masses covered with sodden layers of epithelium, but do not apparently infiltrate the deeper layers to the same extent. It usually occurs upon the tongue, but I have seen a typical e.xample upon the inner surface of the upper lip caused by persistent smoking. The symptoms of which the jiatient complains are very slight. There is a certain amount of discomfort, but it comes on so slowly that it is scarcely noticed. The tongue is tender ; in the later stages it feels uncomfortable and stiff, and the sense of taste is impaired, but unless the surface becomes ulcerated opposite a tooth or deep down in one of the fissures, there is rarely any actual pain. The prognosis, except in the slighter cases, is very unfavorable. Partly, no doubt, this arises from the fact that the same causes are usually allowed to con- tinue at work, although, perhaps, with a less degree of intensity ; but, indepen- dently of this, treatment has singularly little influence, if once the epithelium has definitely become opaque. What proportion of these cases end in carcinoma is very uncertain ; according to Butlin, the number is probably under-estimated. Sometimes an ulcer or a fissure becomes the seat of malignant disease, the column of epithelium growing down into the subjacent layers, as in other parts of the body; but not unfrequently it develops simultaneously over a large extent of surface in ca.ses in which the leucomatous condition of the tongue has ever been sufficiently marked to attract attention. Treatment. — All sources of irritation should be removed at once ; diet must be carefully regulated, and smoking prohibited ; it is clearly impossible even to procure relief if the causes are allowed to continue. The rest is simply palliative. Mercury and iodide of potash very rarely effect any good. Local washes of bi- carbonate of potash or borax are sometimes beneficial ; in other cases chromic acid or dilute bicyanide of mercury painted over the surface once or twice a week answers better. Caustic should never be u.sed, but localized indurated patches or obstinately persisting ulcers may sometimes be excised, even though there is at the time no evidence of malignant disease. INFLAMMATION OF THE TONGUE. 783 Syphilitic Affections of the Tonsruc. Primary chancre is very rare, but it may occur, usually near the tip. 'I'he induration is always well marked, and this, together with the age of the patient, the rapid enlargement of the glands, and the influence of treatment, is the chief diagnostic feature. Mucous patches are very common, and present immense variety. On the dorsum they form flattened elevations of a grayish-white color, smooth or slightly papillated on the surface. There is no red areola surroundimg them and they are not sensitive. Under the tongue they grow out into low, cauliflower-like projec- tions. At the tip and margin where they are irritated by the teeth, they develop intoiJlcers. Sometimes these are superficial, but often, if there is a ragged edge, they extend deeply into the mucous and submucous tissue, leaving irregular fissures and cicatrices when they heal. In many cases it is very difficult, if not impossible, to distinguish these from simple traumatic ulcers, except by their persistence, and by the slight degree of inflammation around them. In the later stages syphilitic inflammation is almost as common. vSometimes it takes the form of a rounded gumma deep in the substance of the tongue, form- ing a soft, ill-defined swelling, usually projecting on the dorsum in the middle line. This may be absorbed and disappear under treatment, leaving a buried cica- trix which, without imi)lica'ting the surface, entirely destroys the shape; or it may break, like any other gumma, and form a sloughing cavity with overhanging ragged edges. In other cases the exudation is more diff'used, and numerous small tubercles are developed one after the other, leaving irregular sores and radiating scars. Sometimes, again, hard patches make their appearance in the mucous and submu- cous tissue, and grow larger and larger until they form definite elevated plaques, the surface of which loses the papillae, becomes dense and white and then breaks down into irregular ulcers and fissures ; and occasionally what is known as scleros- ing glossitis sets in ; the substance of the tongue is infiltrated more or less through- out ; the natural tissue elements are destroyed, and an uneven, fissured, hardened, and distorted mass is left. As these different forms rarely or never occur by them- selves, and as they are nearly always complicated by leucomatous patches and ulcers caused by the teeth, the ultimate result in a tongue affected by severe syphilis can hardly be described ; the shape is altogether altered ; {t\\ or none of the papillre are left; deep fissures traverse the surface in all directions; hardened elevations, covered with dense, white epithelium, project between, and ragged, irregular, and painful ulcers are scattered around the margins and at the bottom of the clefts. Diagnosis. — The induration in syphilis is rarely so dense or so well-defined as in epithelioma. Other signs are of little value in comparison. Both diseases are common at the same time of life, although, of course, syphilis may occur earlier. If the sore is on the dorsum, if there is little pain on pressure and little salivation, it is probably due to syphilis ; but it is impossible to say more, as one so often develops from the other. If there is the least doubt, a scraping from the surface should be examined under the microscope. Iodide of potash not unfre- quently causes a temporary improvement in typical malignant cases (possibly, because of the syphilitic foundation), and care must be taken not to be misled by this. Treatment. — The constitutional treatment of syphilitic glossitis is most important ; but at least as much care must be paid to local conditions. The mouth should be washed out frequently with a gargle of chlorate of potash and lotio nigra, or of very dilute bichloride of mercury. Obstinate patches should be painted over every day with chromic acid (gr. x ad 5J), or bicyanide of mer- cury (gr. XV ad 3J). Iodoform, if the patient can stand it, is especially valuable for deep ragged ulcers ; but caustic, which stops almost immediately the progress of fissures at the angles of the mouth, should never be used in the case of the 7S4 DISEASES AND INJURIES OF SPECIAL STRUCTURES. tongue. Smoking should be altogether left off; very great attention must be paid to diet ; all hot or highly seasoned articles of food, and spirits, avoided ; and the teeth carefully examined to make sure that no ragged corners project and irritate the surface. Tubercular Disease. Tul)ercular ulceration of the tongue may occur either as a jjrimary affection, or be secondary to similar disease in the lungs or larynx. 'I'he diagnosis in the early period is exceedingly difficult. The strongest family or personal history of one disorder does not exclude the possibility of another. It may occur at any age or in either sex, although it is more common, like most other affections of the tongue, in men. The tip or the dorsum is the part usually attacked first ; minute semi-translucent vesicles appear in the mucous membrane ; these grow larger and larger until they break, leaving shallow ulcers with slightly reddened edges. Then, by degrees, as the disease extends, fresh vesicles form around, and the ulcers grow deeper and deeper, until at length they develop into ragged exca- vations, with pale, flabby sides and bases. There is no induration, and this, with the age of the patient, the history, and the evidence of tubercle, either in the tissues around or in other organs, is the chief feature distinguishing it from epi- thelioma. The pain at first is not severe, but later, when the ulceration extends to the deeper parts, it often becomes extreme, and, by preventing the patient taking food, materially hastens the progress of the disease. The prognosis, especially when the affection is secondary to disea.se of the lungs or larynx, is exceedingly bad ; it nearly always indicates rapid extension. Primary tubercular ulceration is more susceptible of treatment. Excision is some- times possible, the wound healing readily ; if this cannot be effected, an attempt may be made to destroy the surface of the sore by free scraping and the actual cautery ; but if this is done it must be thorough ; half measures are worse than useless. Lactic acid has been strongly recommended, but the application is very painful. In more advanced cases iodoform with borax and a minute quantity of morphia may be dusted on by means of an insufflator. Constitutional treatment, cod-liver oil, iron, and nourishing diet, are, of course, absolutely essential ; and every care must be taken to protect the tongue from sharp or rough edges of teeth, and from irritation by hot or stimulating articles of diet. Finally, when the pain and salivation can no longer be controlled by other mcoisures, a certain amount of relief is obtained by division or resection of the lingual nerve. Lupus sometimes extends to the tongue, causing a form of ulceration which can hardly be distinguished from this, and occasionally other varieties of inflam- mation occur, due to persistent dyspepsia, gout, and (very seldom at the present day) mercury. Tumors of the Tongue. Ncevus forms a smooth, soft, lobulated swelling, usually of a purplish-red color, with a few brighter spots upon it. It can be recognized at once by the way in which it disappears on pressure and slowly fills again, but it rarely attracts much notice unless it gets in the way of the teeth ; then it may lead to serious hemor- rhage. Sometimes it degenerates, leaving a warty growth upon the surface. If it persists or continues to grow, it can be cured by a single application of the cautery. A similar dilatation of the lymphatics is sometimes seen. Dermoid h'J'/j- occasionally develop in the tongue ; probal)ly, as they are nearly always in the middle line, from the hyo-lingual canal. Mucous cysts, similar to those found on the lips and cheek, may occur, especially on the dorsum. Hydatid cysts, blood cysts, and other varieties are very rare. Chronic abscess, which in many respects closely recembles a cyst, is not so uncommon. Papillomata are frequent at all ages. They are distinguished from epithelioma TUMORS OF THE TONGUE. 785 / ji^ V Fig. 341. — Epithelioma of the Tongue. by the absence of induration, l)ut great care is re(niired in the case of people over forty years of age. If there is the least suspicion, very free removal of the base as well as of the growth, is advisable. Sometimes dendritic condylomata resem- ble them very closely. Lipomata and fibromata, probably of congenital origin, are occasionally met with, growing out in polypoid form, and one or two cases of sarcoma and adenoma are on record ; but all these are very exceptional. Squamous epithelioma, on the other hand, is exceedingly common, especially between the ages of forty and fifty-five. Before thirty it is very rare, and, in com- parison, it is seldom met with in women. The immediate cause is unknown, although there is no question that it is in some way the outcome of persistent irri- tation. Smoking and dram^drinking un- doubtedly assist in its production ; in a very large proportion of cases it begins in an old leucomatous patch, an irritated papilloma, or a chronic ulcer on the side of the tongue ; syphilis predisposes to it by the sores and scars it leaves behind ; it is not uncommon for it to develop at the seat of an old gumma, or even directly from a syphilitic ulcer ; but not one of these things, nor all of them together, offer a satisfactory explanation for its growth. It may spring from any ulcer, however caused, from any scar, or any part of the tongue that is irritated, whether by a tooth or by caustic, and even in some cases apparently from a healthy surface. Its first appearance is equally variable, depending upon the condition of the spot at which it grows. There may be merely a little induration at the ba.se of a papilloma or under the floor of an ulcer or fissure ; a leucomatous patch may insidiously become thick and dense, or a nodule may form quietly without being noticed in the substance of the mucous membrane. Naturallv, from the causes that predispose to its occurrence, it is more common on the edges and at the tip ; but no part is exempt. However it forms, when it is first seen it usually has already assumed the shape of an ulcer ; the epithelial surface has broken down, and an uneven, ragged sore with a sloughing base, is already developed. The only constant feature is the induration due to the accumulation of the epithelial growth. The edges are irregular, raised above the surrounding part, and intensely hard ; the base may be covered with warty granulations, may even not be ulcer- ated at all (when, for example, it originates from a papilloma or a superficial leu- coma), but it is always hard. Induration, in short, is the distinctive feature of the disease ; the only other affection that resembles it is a primary chancre, and that is very rare in comparison ; and it is so marked a characteristic that any sore or warty growth in a person over forty years of age, that presents it in the least degree, should be regarded as exceedingly suspicious. It may be scraped and examined, or it may be excised at once, but under no circumstances should it be allowed more than a fortnight's grace. Pain may be present from the first ; in the later stages it is never absent, radiating into the ear and over the whole side of the face Salivation is of frequent occurrence and very distressing, from the movement of the tongue it occasions. The glands become enlarged exceedingly soon, nearly always within the first three months, sometimes even earlier. Sooner or later, according to the position of the 7S6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. growth, the disease extends to the floor of the mouth or along the arches of the palate to the tonsil ; the tongue becomes fixed, and even the bone at length involved. When this stage is reached the suffering becomes intense ; sj^eech and swallowing are almost imjiossible ; the pain never ceases ; salivation is profuse ; the mouth is filled with a foul, sloughing ulcer, and the strength fails rapidly. Death usually takes place in a year or eighteen months. The constant pain, the want of food and sleep, the hemorrhage from the ulcers in the floor of the mouth, and the sujjpuration and sloughing speedily bring on the most profound exhaustion. Some- times this alone is sufficient ; in other cases the immediate cause is an attack of bleeding rather worse than usual, or what is more common still, septic pneumonia, due to the inhalation of particles from the foul and putrid surface. It is note- worthy that secondary deposits, other than those in the glands and floor of the mouth, are not so common in this variety of carcinoma as in many others. The diagnosis in the early stages is often very difficult. Papillomata, syphi- litic and tubercular ulcers, and those due to chronic irritation, all liearaclose' resemblance to carcinoma, and not unfrequently pass into it ; while it must be always remembered that the clearest evidence of syphilis does not preclude in the least the presence of carcinoma too ; some would even go so far as to say that it is actually in favor of it. If there is the slightest induration, a scraping should be examined, and unless the absence of epithelioma is proved the sore should be excised. Small operations of this kind are not in any way .serious, while the risk on the other side is fearful. As already mentioned, no reliance can be placed on temporary improvement under the influence of iodide of potash. Treatment. — l*Larly removal is at present the only hope of cure. It is true that the percentage of. cases that have lived for more than a year without recurrence is very small, but when it is recollected that hospital patients (and many private ones) often do not apply for treatment until months have passed, and that then they frequently will not submit to operation until some other remedy has been tried and failed, the blame should not be laid upon the operation. It is certain that in cases of early and thorough removal, not only is the immediate mortality very much less, but the period of immunity very much longer. When, owing to the position or extent of the growth, there is no chance of complete removal, or when the carcinoma has returned, much can still be done to relieve suffering. Excision of the growth is certainly justifiable if it offers a hope of relief from pain ; the stump of the tongue sometimes remains healthy, even when the operation is too late to intercept the glandular enlargement. In excep- tional cases parts of the surface may be destroyed with the actual cautery, if only the painful spot is limited in extent ; but discretion must be used, as ineffectual cauterization only makes the growth tenfold more rapi d. The lingual nerve may be divided ; this nearly always stops the pain and salivation at once, although, unless a portion is resected, the benefit is only for a time. In most cases, however, espe- cially toward the end, morjjhia is absolutely necessary, and if it is given it should be given freely. Butlin recommends dusting the surface with a powder comi)osed of iodoform, borax, and morphia. The fcetor, which is very distressing, must be checked with iodoform, or washes of permanganate of potash, dilute carbolic acid, or other antiseptics. A small quantity of cocaine may be added if the smarting is severe. Inhalations of euca- lyptus and creasote are also very useful. If there is any hemorrhage it must be checked by local pressure, ice, or the application of styptics. The feeding of ])atients suffering from epithelioma of the tongue in its advanced stages is always difficult. Mastication is impo.ssible ; the pain is so intense when anything touches the tongue that deglutition can hardly be carried out ; and later the larynx is often insufficiently protected. So long as swallowing is possible the food should be carefully prepared beforehand ; but in many cases the patients after a little while prefer to feed themselves by means of a funnel and soft rubber tube. Toward the end even this may be impossible, and it may be necessary to pass a tube through the nostril or make use of nutrient enemata. EXCISION OF THE TONGUE. 787 OPERATIONS UPON THE TONCiUE. Removal of the tongue may be accomplished through the mouth, with or with- out previous division of the cheek ; or through the floor after a varying amount of dissection. Division of the jaw itself adds very greatly to the gravity of the operation, witliout — unless the disease has involved the bone — any commensurate advantage. The choice of operation is naturally influenced chiefly by the seat of disease. If the growth is very recent, little more than a suspicious papilloma, and near the tip, a very small operation through the mouth may suffice. If it is more advanced, the whole tongue can be removed without external incision ; but if either of the glands is involved, or it is thought (and there can be little doubt about it) that the patient stands a better chance by removing not only the tongue itself but the lymphatic tissues on the floor of the mouth, a submaxillary incision is es.sential. Removal of the anterior half is not necessarily a serious operation : removal of the whole, whether through the mouth or by means of a submaxillary incision, undoubt- edly is, but there is no evidence that the latter of these two methods is worse than the former. An incision through the cheek is only required when the growth extends down the side of the tongue in that direction. The chief dangers attendant on removal are' : hetnorrhage from the lingual arteries, weakening the patient at the time and causing broncho- pneumonia later ; asphyxia, from blood trickling into the lungs, acute oedema of the larynx, or falling back of the stump when the muscles that attach the tongue to the symphysis are divided ; and especially broticho-pncumonia. This, which is by far the most fre- quent cause of death, is the result of blood, particles of food, or septic material from the foul and sloughing surface finding their way down the trachea. Sometimes there is gangrene of the lung ; more frequently minute scattered points of consoli- dation, which do not give rise to any physical signs, but which can be diagnosed with almost as great certainty from the aspect of the patient. There may be no rise of temperature, no pain, and scarcely any cough ; but the patient does not seem to rally ; the face is dusky and pinched ; the eyes surrounded by dark rings ; the pulse quick and very small ; and the respiration hurried and shallow. If it occurs it is practically fatal ; but a very great deal may be done in the way of prevention by selecting suitable methods of operation and by careful after-treat- ment. I. Removal without an External Incision. This may be accomplished either with scissors (Whitehead's method) or with an ecraseur (Morrant Baker's) ; the galvano-cautery is practically abandoned, owing to the extensive sloughing it causes. {a) The scissors used by Whitehead are flat and straight, sharp up to the tips, which are square and blunted. The patient is placed under an anaesthetic in the position that will secure the best light ; chloroform is usually preferred, given by means of a rubber ball syringe ; but even more than the usual amount of caution is necessary, and unless a preliminary laryngotomy is performed, the administrator must watch with the greatest care that no blood trickles down into the trachea. The hands may be fastened to the side, but nothing should pass round the chest ; and the body should not be fastened to the operating table, as it may be necessary at any moment to roll the patient over on to his side and syringe out the mouth in order to free it from blood. As soon as the patient is anaesthetized, Coleman's or Mason's gag is placed between the teeth on the side opposite to the operator, and entrusted to an assistant, who attends to this and to the sponging. The lips can be drawn out of the way with retractors fastened to an elastic band, if it is considered necessary. A double silk ligature is then passed well through the substance of the tongue and given to a second assistant. The operator begins by cutting the raucous membrane that extends from the 788 DISEASES AND INJURIES OF SPECIAL STRUCTURES. tongue to the alveolar process, keeping close to the bone. The anterior pillar of the fauces and the structures that attach the tongue to the jaw come next, the assistant meanwhile keeping the tongue well forward ; then the muscles that form the base are cut across by a series of successive snips until the entire structure is separated on the plane of the inferior border of the lower jaw, and as far back as the safety of the epiglottis permits. The arteries are tied or twisted as they are divided, and a ligature passed through the remains of the glosso-epiglottic fold to draw the stump forward, in case of secondary hemorrhage. Whitehead has never found any difficulty in securing the arteries. If there is any bleeding it can be controlled at once by passing the finger behind the root of the tongue, drawing it forward and pressing it toward the opposite side, as Heath recommends. Jacobson, with the view of avoiding it, merely cuts a deep groove through the mucous membrane on the side and dorsum, and then tears the soft muscular tissues with closed scissors until the artery and nerve are seen. Billroth ties the linguals first, but those who have followed out Whitehead's directions generally consider it unnecessary. [The hemorrhage is certainly and easily controlled by passing an eyed trans- fixion needle through the skin and upward through the base of the tongue in the centre. A heavy ligature is now passed into the eye to the middle of the ligature ; the needle is now withdrawn, bringing the ligature with it, which is cut to release the needle, which is then thrust through the same skin opening, and pushed into the mouth close by the side of the tongue opposite the ligature. One of the free ends is now threaded into the eye of the needle and withdrawn with it. The needle is now thrust through at the other side of the tongue and the remaining end threaded and withdrawn. The ends are now tied firmly, and both linguals are securely comj^ressed.] (/;) When the ecraseur is used the preliminary steps are the same, but two ligatures are passed through the tongue, one through each half, and the whole organ divided down the median septum. If the dorsum and tip are cut fairly deeply with a straight blunt-pointed bistoury, the two halves can be separated from each other with the forefinger without causing any material hemorrhage. The mucous mem- brane and the muscles passing from the jaw to the tongue are divided as before ; and then, as soon as the two halves are thoroughly freed as far back as is considered advisable, a loop of stout whip-cord attached to an ecra.seur is passed over each. The section should be from the middle line outward, and the loop may be tightened fairly quickly at first, but as soon as any resistance is felt not more than one turn should be made in the minute. Very frequently the vessels, with, perhaps, the nerve, are dragged out in a long loop, when they can be easily secured and tied. If the whole of the structures that attach the tongue to the jaw have been divided, it is advisable to fasten the stump to the mucous membrane at the side of the mouth by means of sutures, for fear of its falling back. It is very difficult to estimate the relative advantages of the.se methods, as they both require a considerable degree of skill, and operators are naturally inclined to that which they have practiced most. Morrant Baker's is the easier, and if the ecraseur is only used slowly, is practically exempt from bleeding. On the other hand, it tends to make the stum]) convex, although this is concealed by the mus- cular contraction, and it is probable that the amount of bruising is greater. Cer- tainly this was the case with the old chain ecraseur. Contrasted with this, the scissors are sometimes followed by serious hemorrhage, but the operator can see the whole time what he is doing. It is still an open question whether it is ever advisable to leave half the tongue. In most instances it bends round upon itself, owing to the contraction of the cicatrix, and only becomes an incumbrance ; but occasionally it moulds itself into shape and assists both in speaking and swallowing. Preliminary laryngotomy is advocated by many, and no doubt jjossesses great advantages, with slight, if any, additional risk. The fauces can be plugged so that no blood can possibly pass down ; the administration of the anoesthetic is EXCISION OF THE TONGUE. 789 easier ; the month can be sponged freely if there is any bleeding : and the operator can proceed ([uietly and deliberately. As Jacobson points out, when scissors are used the amount of swelling and inflammation after the operation is so slight that there is no need to retain the cannula after the patient has rallied from the anaesthetic. If any glands require removal, or if there is any infiltration in the floor of the mouth, a separate incision is advisable. The dissection in such cases must neces- sarily be very thorough if it is attempted. 2. Removal isv Sub-maxillary Incision. Of these, by far the best is that devised by Kocher, who performs it under the carbolic si)ray. A preliminary tracheotomy is performed and an ordinary cannula inserted. Entry of blood is prevented by plugging the pharynx with a sponge soaked in car- bolic acid. The incision runs along the anterior border of the sterno-mastoid from the ear nearly down to the middle of the muscle ; from this it turns forward to the hyoid bone and along the anterior border of the digastric to the symphysis. A flap, containing skin, platysma, and fascia is reflected upward ; the facial artery and vein tied ; the lingual secured on the hyoglossus ; and the sub-maxillary fossa completely cleared out, beginning from behind. All the cellular tissue is removed, together with the lymphatic glands, and the sub-maxillary and sub-lingual ones if they appear involved. The mylo-hyoid muscle is then separated, the mucous mem- brane divided, and the tongue drawn through the opening. If the whole thick- ness is removed the opposite lingual must be tied as well. Before commencing the operation the mouth and the nasal cavities are thor- oughly washed out with a solution of perchloride of mercury (i in 2000) ; and after it is finished and the wound adjusted with sutures the surface of the stump and the pharynx behind it are covered over completely with a sponge soaked with carbolic acid. The dressings are changed twice a day, advantage being taken of the opportunity to pass an oesophageal tube and feed the patient ; for the rest nutrient enemata are used. The operation is undoubtedly more extensive than the others, but it is believed that this is amply compensated for by the thorough- ness with w^hich the whole of the affected tissues is removed and the way in which the risk of septic inflammation and pulmonary complications is avoided. Kocher himself has been very successful as regards immediate mortality, but the operation does not seem to have been performed by other surgeons to any great extent. The after-treatment of these cases requires even more than ordinary care. Every endeavor must be used to prevent putrefaction, which, owing to the tem- perature, moisture, and alkaline reaction, is very prone to follow; the patient's strength must be husbanded and maintained in everyway; and precautions taken to prevent food or the discharge from the wound entering the lungs. With this in view, Kocher fills the entire cavity, from the edge of the wound back into the mouth and pharynx, w^th a sponge soaked in carbolic acid solution, shutting off the naso-pharyngeal cavity on the one hand and the larynx and pharynx on the other. The same object may, however, be achieved much more satisfactorily by means of a plan recommended by Barker. The whole wound is carefully cleansed, dried, and dusted with iodoform, and the two ends of the incision sutured. In the middle a piece of rubber tubing is adjusted, long enough to reach well down into the oesophagus ; and all the space around is carefully packed with antiseptic wool. This can be left untouched for days, the patient being easily fed by means of a funnel as often as it may be required. The ordinary practice, when the tongue is removed through the mouth, is either to wash the cavity out at frequent intervals with a dilute antiseptic, or to keep the surface of the w-ound as dry as possible by means of iodoform. Drainage is not very successful ; a large tube may be passed through the floor of the mouth and fixed at the proper level, but it is of little use except to secure a thorough flow 790 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the antiseptic across the surface of the woiiiul. If the first method is preferred it is a wise precaution to make the i)atient practice washing out the mouth before- hand, as there is sure to be a certain amount of awkwardness at first. Immediately after the ojjeration the surface of the wound is brushed over with chloride of zinc, or better with Whitehead's varnish (Friar's balsam, in which a saturated solution of iodoform in ether has been substituted for rectified spirit), and as soon as the effects of the anaesthetic have thoroughly passed off and the patient has rallied, the mouth is washed out at frequent intervals with a dilute solution of carbolic acid or per- manganate of potash, the head being held on one side so that none of the discharge is swallowed. In addition, the surface of the wound may be brushed over four or five times a day with a solution of iodoform, or the patient may inhale eucalyptus vapor or some other volatile antiseptic. In most cases, however, there is no difficulty in keejjing the surface of the wound dry. The simplest method is, at the time of the operation, to fill the cavity with iodoform (after sponging it out) and rub it well into the surface, or to use Whitehead's varnish. The more scientific plan is to prepare some gauze with iodoform (by means of glycerine and colophony dissolved in alcohol), cut it into strips, and pack the whole cavity with these, laying them flat one upon the other, with fresh iodoform between until the wound is filled. The deeper layers adhere to the raw surface, from which they cannot be separated until it has begun to granulate ; the superficial ones, sodden with saliva, may be removed and renewed from time to time. At the end of a {illar of the fauces, nothing but excision is of any avail ; and the same treatment should be recommended for those cases of follicular tonsillitis in which the patient is constantly suffering from recurrent attacks, occasioned by the reten- tion of the decomposing discharge on the surface of the gland. Moreover, it seems probable that tonsils affected in this way are more prone to be attacked by diphtheria than others, the membrane beginning in the crypts and growing out from them over the epithelial surface ; and this alone would be a most efficient reason. As an alternative the application of the galvano-cautery is sometimes made use of. The throat must be thoroughly penciled with cocaine, and the burner applied while cold to the surface of the gland ; the current is then turned on and a sufficient amount of tissue destroyed to make sure of a smooth, dense cicatrix when the wound heals. The pain is said to be slight, and to be relieved by suck- ing small fragments of ice for an hour or two afterward. Acute phlegmonous inflammation requires more vigorous measures. An attempt may be made to cut the attack short at its onset by giving aconite (n\^j every half-hour) until there is a distinct ; '^^ effect upon the pulse ; but it rarely suc- \ \ ceeds. The bowels should be opened \ \ freely, while the patient can still swallow \^ \ without much difficulty ; ice placed around the neck, small fragments kept in the ^■\ \ mouth ; the patient induced to take as '^.^^ \ much liquid food as he can ; and the surface of the swelling explored with the finger, Fic. 342. — Tonsillotcme. cocaine being used freely both to relieve the pain, so that the patient may be able to open his mouth, and to prevent the spasmodic contraction of the muscles of deglutition, produced by touching the surface. If any spot can be found that is softer or more yielding than the rest, a puncture should be made in it with a bis- toury, the blade of which is protected up to within an inch of the point by means of strapping wrapped around it. The tongue must be held down out of the way ; the edge of the blade must point upward and inward, and the puncture be made just through the margin of the anterior pillar (which is forced prominently into the mouth), perfectly straight from before backward. Excision of the tonsil may be performed with a bistoury, but it is much more satisfactory to employ a tonsillotome or guillotine. The simplest consists merely of a ring to slip over the projection, with, on its inner margin, a groove, carry- ing a blade. Both ring and blade are on the same handle, one gliding on the 51 794 DISEASES AND INJURIES OF SPECIAL STRUCTURES. other. A more complicated one carries a forked spear as well : this, by means of a spring, transfixes the growth and draws it slightly inward toward the middle line, making it secure, and ensuring sufficient being taken away. The assistant stands behind the patient, holding the head so that the light falls into the mouth, and pressing with his fingers just behind the angles of the jaws in order to steady the tonsils. An ancesthetic may be used, but even in children cocaine is sufficient. The operator stands in front, and it is of great advantage to him if he can use his two hands equally well. As much of the growth as projects beyond the pillar of the fauces should be removed, for although the cicatrix contracts to some slight degree, it really produces very little effect if the gland contains much soft adenoid tissue. When, owing to the frequency of follicular inflammation, it is denser and more fibrous, there is less probal)ility of the growth recommencing. Both tonsils should, if they require it, be removed at the same sitting ; the pain and incon- venience are not materially greater than when one is taken away, and the cure is effected in half the time. Hemorrhage that does not stop on the application of ice is very rare. If capillary oozing continues to any serious extent, perchloride of iron or some other styptic must be employed. It has, however, been necessary to tie the common carotid. In addition to these the tonsil is liable to be attacked by various forms of specific inflammation. Diphtheria, for example, not unfrequently begins upon the tonsil, starting from an apparently simple attack of follicular tonsillitis and spread- ing thence to the mucous membranes around. Scarlatinal ulceration may occur, and open up the internal carotid by the sloughing it causes. The same thing may happen in severe cases of blood-poisoning, such as result from the inhalation of sewer gas. Syphilis very often attacks them ; there are very few cases of primary chancre, it is true, but a peculiar circular and sometimes punched-out ulcer is nearly invariable in the early secondary stage, and very extensive ulceration may occur at a later period, destroying the soft palate and the pillars of the fauces, and dragging the base of the tongue backward by the cicatrization it entails. Tuber- cular disease is more rare, and in the earlier stages is difficult of diagnosis; later, when the ulceration becomes general, it is scarcely possible to tell in what part the disease began. Tonsillar calculi are not uncommon, caused in all probability by the gradual inspissation of the masses of muco-pus that are found buried in some of the follicles. In composition they resemble the tartar that collects upon the teeth, and they may reach the size of a pea or a small bean. The only tumors that occur with any frequency are epithelioma and lympho- sarcoma, and even they are not common. The former is nearly always secondary, originating in the structures near and gradually extending into it. The latter is primary, but very little can be done for either. Sarcomatous growths have been shelled out after ligature of the carotid, with success as far as the immediate result of the operation was concerned ; but very rapid recurrence took place in all. DISEASES OF THE SALIVARY GLANDS. Inflammation'. The parotid suffers the most often of the three ; the sublingual the least. Acute parotitis is well known from its occurrence in connection with mumps. It may, however, be caused in many other ways. In some epidemics of typhoid fever, for example, it is fairly common ; in others it is very rare. In pyoemia it is often met with ; not unfrequently, even when there is no suspicion of this, it follows operations on the abdominal viscera ; and occasionally it is due to ptyal- ism. the passage of foreign bodies up the duct, syphilis, tubercle, and other dis- orders. DISEASES OF THE SALIVARY GLANDS. 795 In mumps suppuration is rare. The gland on one side suddenly becomes tense antl swollen, assuming a characteristic shape, and causing very severe pain, especially when an attempt is made to open the mouth ; and then when it is beginning to subside, the opposite one usually behaves in the same way. Some- times the submaxillary gland is affected, together with or independently of the parotid. Metastatic inflammation of the testicle is not by any means uncommon, and is of some importance, as it may end in atrophy. The ovaries and the meninges of the brain are also stated to be occasionally attacked, but this is much more rare. In the other varieties of parotitis, supi)uration is of fre(pient occur- rence and is often attended with high fever, owing to the tension of the fascia that surrounds the gland. The i)us has been known to work its way into the ear and discharge through the external auditory meatus ; to descend under the deep fascia of the neck ; and even to track upward along the course of the nerves into the base of the skull and set up acute suppurative meningitis. In front of the ear over the parotid there is a small group of lymphatic glands which occasionally enlarge and become inflamed, and there are others in the in- terior as w^ell ; but the shape of the swelling is so different that there is very little risk of their being mistaken. The treatment presents nothing special. Suppuration is hard to detect until the collection has attained a considerable size, owang to the dense fascia over the gland ; but sometimes it is indicated by local cedema or by the presence of one especially tender spot. A grooved needle should be used for exploration, and if any pus is found the abscess should be opened after Hilton's method, as it is im- possible to say, under such conditions, in what direction the very important struc- tures that lie in the gland are displaced. Salivary Calculi. Calculi, composed of phosphate and carbonate of lime with magnesia and a proportion of animal matter, are sometimes met with in the duct of the submax- illary gland, and much more rarely in that of the parotid. The usual size is about that of a date-stone ; small ones are passed occasionally, and very large ones, the size of a pigeon's egg, have been recorded. In most cases they do not give rise to symptoms of any kind unless the duct is blocked : then the gland enlarges and becomes distended until it is able to overcome the resistance in front and relieve itself for the time. Occasionally, however, they cause considerable inflammation and lead to the formation of a mass of dense inflammatory deposit extending through the whole submaxillary region. The nature of the trouble 11 J i i J i 1 • i.- • jj\ n Fig. 343. — Salivary Calculus, IS usually detected at once by examination with one nnger weighing 48 grains. Natural in the mouth and another under the chin, or by passing a probe down the duct. A free incision should be made through the mucous membrane so as to release it without breaking it ; if this occurs the removal of all the fragments is sometimes very tedious. Tumors. The parotid gland is occasionally the seat of a peculiar variety of new growth, distinguished from all others as a parotid glatiduiar tumor. Sometimes a similar growth is met with in connection with the submaxillary. It consists of fibrous, mucous, cartilaginous, and glandular tissue combined in varying proportions, and forms a firm, elastic mass of an irregularly lobulated shape. Usually it is enveloped in a dense capsule and buried in the substance of the gland. Occasionally it is detached, lying on it, but in all probability developed in connection with it. It has been suggested that the presence of cartilage may be accounted for by the size. 796 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Fig. 344. — Submaxillary Tumor. persistence of some portion of the branchial arches, the first in the ca.se of the parotid, the second for the submaxillary. Parotid tumors of this description are usually met with in young adults, and increase so slowly that little attention is paid to them. As age advances, however, they are liable to change their characters suddenly and develop into rapidly growing adeno- sarcomata ; and sometimes they assume this character from the first, ma.sses of vascular gland ti.ssue devel- oping in some parts, and soft sarcomatous growth in others. When this occurs the tumor becomes painful and tender ; the skin grows thin ; the surface is reddened with dilated veins; and all the tissues near become involved. In a little while ulceration follows ; the covering breaks down ; gigantic fungating masses that bleed at the slightest touch protrude through the opening; hemorrhage sets in ; and partly from this, partly from septic absorption and exhaustion, the result not unfrequently proves fatal within a few months. Other tumors are seldom met with. Cysts may form either independently or in connection with other tumors, but they rarely attain any size. Mucous cysts are met with in the submaxillary, but probably not in the parotid. Lymphatic growths are occasionally found, and a itw instances of fibromata and sarcomata are on record. It is questionable whether the cases of cancer were not really adeno-sarcomata, as the sarcomatous tissue is very unevenly distributed. The only treatment is excision, but to be successful it must be done while the growth is small. The incision should lie over the posterior border of the gland ; if necessary a second may run forward from this at right angles to it. If the capsule is opened freely the tumor can sometimes be shelled out ; but if it has deep connections, running, for example, down to the styloid process or behind the ramus of the jaw, or if the facial nerve, instead of lying beneath it, runs through it, the operation becomes exceedingly difficult. It is advisable if possible to keep inside the capsule ; and if the facial nerve runs into the tumor an attempt must be made to dissect out the chief branches, but the result is rarely satisfactory. Facial paralysis invariably results if any traction is put upon the nerve in separa- ting the tumor from it ; but, fortunately, unless the fibres are too much bruised, or are cut away to such an extent that the ends cannot be brought together, the muscles usually regain sufficient power to prevent conspicuous deformity. In cases of accidental division the ends should of course be sutured at once. Excision of the parotid has been performed, but never with sufficient success to justify repetition. EXAMINATION OF THE EAR. if)i CHAPTER XIII. SURGICAL DISEASES OF THE EAR AND LARYNX. By T. Mark Hovell. SECTION 1.— DISEASES OF THE EAR. Examination of the Ear. To ensure this being carried out thoroughly, it is well to adopt a definite order for employing the various tests to the patient's hearing and for inspecting the ear and other parts. This is best done by grouping the methods of examina- tion which require light and those for which it is unnecessary. Any watch may be used as a test for hearing, provided the distance has been ascertained at which its tick can be heard by a normal ear. This distance is recorded as a denominator, and the patient's hearing power is the numerator. Thus, using a watch that can be heard at six feet to test a patient who hears at thirty-six inches with the right ear and twenty inches with the left, the result would be recorded : right, 4|- ; left, -ff. A vibrating tu?iiiig-fork, when placed on the vertex of the skull in the middle line, should be heard equally in both ears, and when one meatus is closed with a finger the sound should be louder on that side, on account of the vibrations being confined and consequently to some extent thrown back upon the labyrinth. If, therefore, a patient hears a tuning-fork, applied as above mentioned, louder in the ear in which the hearing is impaired, it maybe inferred that the conducting appa- ratus is at fault, and if it is not heard as well as in the other ear, that the labyrinth or auditory nerve is affected. Malingering may be detected sometimes by using the tuning-fork in this way, the impostor thinking that he ought not to hear so well with the ear closed. The extent to which the labyrinth or auditory nerve is impaired may be roughly gauged by placing the tuning-fork over the mastoid process of the affected side and noting the number of seconds that the vibrations can be heard by the surgeon when the fork is applied to his own head after the patient has ceased to hear them. The auscultation tube is a piece of rubber tubing about thirty inches long, having at each end a hollow piece of ivory or vulcanite to fit the meatus. To distinguish the end used for patients, one ear-piece may be made of ivory, the other of vulcanite. By placing one end in the patient's ear and the other in one's own the con- dition of the Eustachian tube can be ascertained whilst the tympanum is being inflated, by Valsalva's or Politzer's method or by means of a Eustachian catheter. Thus, if there is moist mucus in the tube or tympanum a bubbling sound is heard, or whistling if the calibre of the tube is narrowed. In cases in which the mem- brana tympani is perforated the injected air can be felt by the surgeon striking against his own membrane. Valsalva s jnethod of inflating the tympanum consists in expiring forcibly through the nose whilst the mouth is closed and the nostrils are compressed by a finger and thumb. In a healthy ear the entrance of air is accompanied by a feeling of fullness and slight cracking sound. Politzer's method cox\%\'i\% in holding a small quantity of water in the mohth, and then, whilst it is being swallowed, forcing air from an India rubber bag through one nostril while the other is compressed with a finger or thumb to prevent the air 798 DISEASES AND INJURIES OF SPECIAL STRUCTURES. escaping. The sensation produced in the ear is similar to that caused by Valsalva's inflation, but more marked. The late Dr. Peter Allen used to force air into both nostrils simultaneously by blocking their orifices with an India-rubber pad through which pa.s.sed two jiieces of tubing, one of which enters each nostril. Instead of swallowing water, the naso-pharynx may be shut off by the patient whistling or uttering a guttural sound, such as " buck." In children it is unneces- sary, as the Eustachian tube is more patent. A Eustachian catheter should not be more than four and one-half inches long, and it is most convenient to use one with a diameter of small size. Whilst introducing it the surgeon should stand at the patient's right side with the catheter held lightly between the thumb and index finger of his right hand, the beak or curved end pointing downward, and allow it to slip through the nostril until it touches the posterior wall of the naso-i)harnyx. It should then be withdrawn half an inch and the beak turned outward and sometimes slightly up- ward, when it will be found to be in the ori- fice of the Eustachian tube. As the dimensions of the nostrils vary very much, owing to deviations of the septum, cartilaginous and bony spurs, and other abnormal conditions, there is no fixed rule for the position of the catheter during its passage. It often passes best if the beak is directed horizontally outward beneath the inferior turbinated bone as soon as it is well within the nostril, turning it down again a little as it goes through the choana. A catheter should always be passed with the greatest gentleness, and, in many instances it is best to allow it to find its own way. Should it be impos- FlG. 345. — Allen's Air-pad. Fig. 346. — Alr-b.ig with Nozzle to fit a Catheter, suitable also for Politzer's Inflation, with a Teat slipped over it. sible to reach the tube through one nostril, the curve of the instrument must be increased, and an attempt made to do so through the other. If the catheter is drawn backward by muscular contraction, when the beak is turned outward in the naso-pharynx, it is an indication that it is l)ehind the posterior lip of the Eusta- chian orifice. A special catheter with a distinguishing mark should be kei)t for syphilitic cases. If a nostril is extremely sensitive, it may be sponged with a four per* cent, solution of cocaine. As soon as the catheter is in position, the little and ring fingers of the left hand should be placed one on each side of the patient's nose, the palm of the hand DISEASES OF THE EXTERNAL EAR. 799 being downward and forward, and the outer end of the instrument grasped between the thumb and intlex finger. J^y this means the catheter is firmly held, and the hand at the same time well supported against the patient's face. The nozzle of the air-bag should now be introduced, and the thumb and index finger of the left hantl slipped forward to hold it in place. Air is then forced into the tympanum by compressing the air-bag. Many aurists prefer a modification of Politzer's bag, having a piece of tubing between the air re.servoir and the nozzle, which prevents the movement of the bag being communicated to the catheter. For examining the membrana tympani, two kinds of speculum are used, one consisting simply of a funnel of metal or vulcanite, the other (Brunton's) of a metal funnel with a lens at the opposite end and an aperture at the side for the admission of light. For using the former daylight is sufficient, but for the latter artificial illumination is necessary. The focus for a Brunton's speculum should be three-quarters of an inch from the end when the centre of the cap containing the lens is level with the larger extremity of the speculum. Before the speculum is intro- duced, any abnormal condition of the outer part of the ear should be noted, and the auricle raised upward and backward in order to straighten the canal. A healthy membrane is of a bluish-gray color, and is placed obliquely across the canal, its upper and posterior part being more exter- nal than the lower and anterior. Passing downward and backward and a little inward, nearer the anterior than the posterior edge of the membrane, is a whitish ridge, the handle of the malleus, and passing forward and downward from its lower extremity, which is slightly enlarged, and situated just below the centre of the membrane, is a triangular glistening surface called the cone of light, having its base toward the periphery. At the upper part of the handle of the malleus is a white projection, the short process of the malleus, and stretching backward and forward from the short process to the edge of the membrane are two slight ridges, the anterior and the posterior folds, the latter being the more clearly defined. Above these folds the membrana propria is absent, the part being called Schrap- nell's membrane. Not infrequently a whitish line (showing the position of the long process of the incus) is seen behind, internal and parallel to the upper part of the handle of the malleus. Occasionally the outer part of the stapes can be distinguished. After the position, color, degree of transparency, and any abnormal condi- tion of the membrane that may exist, have been carefully noted, the nares, pharynx, and naso-pharynx should be examined. Fig. 347. — Brunton's Auiiscope. Diseases of the External Ear. Anomalous formations of the auricle are sometimes found ; they are generally associated with defects in the meatus or the deeper parts of the ear. Accumulation of wax is due either to increased activity of the glands, or to obstacles interfering with the escape of their secretion. The former condition is often associated with disorders of the external and middle ear, the latter may be produced by exostoses, or foreign bodies, or by the cerumen being pushed into the meatus during attempts to cleanse it. The symptoms vary according to the size and position of the plug. They are, generally, deafness, often coming on or increasing suddenly, tinnitus, giddi- 8oo DISEASES AND INJURIES OF SPECIAL STRUCTURES. ness, and cough ; usually there is no pain. The glistening surface of the wax has been mistaken for the niembrana tynipana. Treatment. — Syringing with w^arm water is generally sufficient to clear the meatus if the stream is directed against its floor, but should the plug be hard and near the orifice it may be gently moved with a spud. If the syringing causes pain, the wa.x may be softened with the following drops: — Grammes. Sodn? bicarb., 60 Cjlycerini, |20 Aq. dest., ad 32 If the ear is tender a few drops of liq. opii sedativus may be added. After the wax has been removed the meatus should be dried with absorbent cotton-wool and a piece kept in the meatus for some hours, Othccmatoma, or blood-tumor of the auricle {Jucinatoina ai/ris), may occur spontaneously or be due to injury ; the former is much more commonly found among insane patients, and more often in men than in woman. It appears as a swelling on the outer surface of the auricle, produced by the effusion of blood beneath the i)erichondrium. The size, outline, and tenseness of the tumor depend upon the amount ; its color, on the dei)th. Treatment. — If the tumor is small and not very tense, it may be left to subside, or the fluid may be evacuated and pressure applied. Traumatic cases are sometimes attended by great disfigurement. Fungi in the external auditory meatus are usually found where there has pre- viously been disease of the parts, producing an accumulation of epidermic scales. There is usually tinnitus, pain, and impairment of hearing. On examining the meatus, the fungus is seen on the walls of the canal and often also on the tympanic membrane. Treatment. — The ear should be syringed several times a day w^ith a warm solution of perchloride of mercury (i in 1000), or hyposulphite of soda (5 grains to .^i). And then a few drops of warm alcohol should be put into the ear. This should be continued for several days. Circumscribed or furuncular inflammation of the external meatus is usually found in the cartilaginous portion, and is often associated with deranged health ; it may be due, however, to local irritation. Symptoms. — If the deeper part is affected fever and even delirium may occur, especially in children. The pain often radiates over the side of the head, and is increased by movement of the jaw and by making pressure over the tragus ; it generally increases toward night, and continues with but slight diminution until the abscess bursts or is opened. Deafness, when present, is mainly due to the obstruction. Tinnitus may be present. There is often no congestion of the meatus, but one or more extremely tender swellings inside. Recurrence is com- mon, especially in weakly subjects. Treatment. — Leeches may l)e applied to the tragus ; plugs of gelatine con- taining i'6 grain (.01) of extract of ojiium inserted into the meatus ; and an inci- sion made into the swollen tissue. After the incision the parts should be painted with carbolized glycerine or solution of boric acid. Hot i)oultices should not be applied to the auricle. Opium should be given internally to relieve pain, and attention paid to the general health. Exostoses are generally multiple and sessile, and they vary in size from slight elevations to large rounded projections. They are often associated with chronic catarrh of the middle ear, and are also said to be caused by gout, syphilis, and sea bathing. They grow slowly and .should not be interfered with unless they close the meatus. They can be removed with a dental drill. Pedunculated growths are sometimes found in cases of chronic suppuration ; they grow quickly, and are, as a rule, easily removed with a pair of forceps. Foreign Bodies in the External Auditory Meatus. — When a yjatient is said to have a foreign body in the ear, the first stej) is to ascertain that the statement is DISEASES OF THE MIDDLE EAR. 80 1 correct. In the case of a child, no detailed examination shoukl he attempted until an anaesthetic has been administered. A foreign body may remain for weeks and even months in the meatus without doing much if any harm, while l)ermancnt injury may be caused by improper attempts at removal. If the meatus is swollen, and the for- eign body is a substance not acted on by moisture, such as a button or bead, it is best to make no im- mediate attempt but to apply some soothing lotion, and wait until the inflammation has subsided. In many cases this course may be adopted, even if it is a pea or bean or other substance -known to swell when moist. A foreign body can generally be removed by careful syringing, if the stream of water is directed between it and the wall of the meatus, and it is only in excep- tional cases that forceps, hooks, etc., should be used. When permanent impair- ment of hearing follows, it is more often due to the attempts which have been made to remove it than to the effects of the foreign body itself. Fig. 348.— Ear Forceps. Diseases of the Middle Ear. Acute inflammation of the middle ear is most frequently produced by a draught of cold air striking the ear or the extension of inflammation from the naso-pharynx, but it may follow the use of a nasal douche or sea bathing. Symptoms. — A feeling of fullness in the ear is first complained of, followed by pain of a throbbing or stabbing character, often radiating over the side of the head and increased by swallowing. There is deafness and sometimes tinnitus, with fever, especially in children. Tenderness over the mastoid process, and symptoms of naso-pharyngeal catarrh are often present. In the early stage the membrane looks a little dull and the vessels running along the posterior border of the handle of the malleus are congested. As the attack becomes more severe the congestion of the membrane increases and vesicles may form on its surface. The superficial epithelial layers become swollen and are thrown off in thick plates. If mucus or pus collects in the tympanum, the membrane becomes bulged out- ward, and unless a puncture is then made in it, rupture will take place, the escape of the fluid giving almost immediate relief to the symptoms. In some cases the symptoms subside without this stage being reached. Treatment. — The patient should be confined to the house, and in an acute case to bed. An aperient should be given, and if much pain is present three to six leeches should be applied over the tragus and below the meatus, internal to the lobule. Hot fomentations and sedative drops may be applied to the meatus. The membrane should be punctured in the posterior inferior segments as soon as it begins to bulge. When the acute symptoms have passed off, air should be gently injected into the tympanum through a Eustachian catheter or by means of a Politzer's- bag, at first once daily, the interval being lengthened until the hear- ing is restored. If there is any discharge from the meatus, finely powdered boric acid should be insufflated after the ear has been carefully dried with absorbent cotton-wool, or a solution of boric acid dropped in. Chronic suppurative inflammation of the middle ear is the result of the acute form of the disease ; it often continues for years if not efficiently treated, and may produce very serious complications. On examination, after the ear has been syringed, the membrane is dull and the handle of the malleus invisible on account 8o2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the swollen condition of the epithelial layer ; but if this is removed the color is more or less red. If the perforation is large, the inner wall of the tympanum may be distinctly seen, and in some cases portions of the ossicula, the appearance depending upon the amount of congestion and the size of the perforation. The hearing is more or less impaired, and patients sometimes complain of giddiness, but tinnitus is not often i)resent. Treatment consists in keeping the parts scrupulously clean. The discharge should be washed away several times a day with a disinfecting lotion, and the meatus dried with absorbent cotton-wool wrapped round a probe, finely powdered boric acid being insufflated afterward. As the discharge lessens, the application may be made at longer intervals. In old-standing cases the following drops, warmed, may be used several times a day: Sulphate of zinc 2 to 8 grains, tinct. opii 3ijj water to %. Granulations that spring from the meatus or membrane should be scraped away with a sharp spoon or destroyed with a saturated solution of chromic acid, according to their position, care being taken not to injure sur- rounding structures. Polypi attached to the tympanic cavity should be removed with a snare, unless very small. The wire should be pas.sed as near asjjossible to their root and the loop then tightened until the polypus is grasped, when it may be dragged out ; if the wire is tightened too much, the growth is cut and a por- tion of it left behind. The polypus may also be seized with forceps and twisted out. Before removal a 10 per cent, or 15 percent, solution of cocaine should be dropped into the meatus, and afterward the root destroyed with a saturated solu- tion of chromic acid, warmed alcohol being dropped into the meatus afterward. Inflammation of t/ie mastoid cells may be produced by the extension of the disease from the tympanum. The symptoms are deep-seated pain and tenderness over the mastoid process, accompanied with more or less fever. When the peri- osteum is affected, the tissues behind the ear are swollen and the auricle stands out from the head. If pus has formed, fluctuation may be detected. Treatment. — In the early stages, three to six leeches and hot fomentations should be applied over the seat of pain, and sedative drops to the meatus. If these measures fail to give relief, an incision should be made down the mastoid process and the periosteum divided. If the symj^toms continue after this treat- ment, the mastoid cells must be opened. For this purpose a drill about an eighth of an inch in diameter is large enough ; it should be provided with a guard to regulate its penetration. The opening should be made at the junction of a ver- tical line drawn a quarter of an inch behind the meatus with another line drawn horizontally on a level with its upper border. The direction is inward, forward, and a little upward. Relief may follow the operation, although no pus is found in the mastoid antrum. The thickness of the outer table of the skull varies, but it is generally about a fifth of an inch in this position. If, on making an incision on to the mastoid process, pus is found to be escaping through an opening in the bone, it is best to enlarge it instead of making a fresh one. As soon as the mas- toid cells have been reached, they should be washed out with a warm disinfecting lotion. Caries and necrosis may attack the meatus, mastoid process, and tympanum. When this occurs the granulations constantly return, even after jjersistent attempts have been made to destroy them, and the discharge frequently remains offensive. Facial paralysis may be present. In children an anaesthetic should be adminis- tered, and if any caries is found the diseased surface should be scraped, and any sequestra that are present removed. Phlebitis, when it occurs, generally affects the lateral sinus and the jugular vein, and may }iroduce pynemia. Meningitis and cerebral abscess may occur during acute or chronic suppura- tive inflammation of the middle ear, but are more often found in the course of the latter. If the i)osition of the abscess can be localized, the skull may be at once trephined and the pus evacuated. An exploratory operation may be made in a severe case, although the precise seat of the abscess cannot be determined. EXAMINATION OF THE LARYNX. 803 Syphilitic Affections of the Ear. Condylomata and ulcers are sometimes found in the external auditory meatus. Acute catarrh of the middle ear, probably due to the periostitis, may occur, and when chronic catarrh is already present, it runs a much more rapid course than in ordinary cases, frequently leaving the patient extremely deaf, in consecpience of the internal ear having become imj)licated. At puberty, subjects of inherited syphilis are liable to lose their hearing, in consecjuence, it is believed, of the disease affecting the terminal portion of the auditory nerve. SECTION II.— DISEASES OF THE LARYNX. Examination of the Larynx. The instruments used for examining the larynx are so well known that it is unnecessary to describe them. Before purchasing a frontal mirror, it is well to try whether a spectacle frame or an elastic band round the head is the more comfort- able, because for constant use a strong preference is sometimes felt for one or the other. The aperture in the mirror should be elliptical in shape and not more than y^ of an inch in the longest diameter ; it should be made in the glass as well as in its metal back. A special set of faucial mirrors should be kept for syphilitic cases, and distinguished from those in general use by their handles being of a different color. The mirrors which have been introduced with an electric lamp attached are mere toys and useless for continuous work. To examine the larynx the faucial mirror should be warmed until the dimness which appears as soon as heat is applied has almost passed off. If held over the lamp until it has quite disappeared, the mirror is generally too hot. The tongue should then be protruded and firmly but gently held with a napkin between the thumb and forefinger of the left hand. Care should be taken to keep the under surface of the tongue from touching the incisor teeth : this will not occur if the forefinger is held horizontally and the left hand kept well raised. While the tongue is held, the rays of light reflected from the frontal mirror must be focused on the base of the uvula and the faucial mirror placed firmly but lightly against the same place, gently raising it so as to lift the soft palate. If the tip of the uvula is reflected in the mirror, this must be lowered a little. Patients should be directed not to hold their breath whilst their throat is being examined. When much irritability of the pharynx exists, a 4 per cent, to 10 per cent, solution of cocaine should be sprayed or painted over the soft palate and posterior wall. Occasionally the larynx may be examined without the tongue being protruded ; this method is sometimes useful when the pharynx is very irritable and a solution of cocaine is not at hand. Inhalation. — Apparatus for the inhalation of medicated steam should be con- structed so that the air may enter near the bottom of the vessel and bubble slowly through the whole depth of the fluid. Patients should be directed to breathe slowly, six or seven times a minute only, not to expire into the inhaler, and to re- main indoors for twenty minutes or half an hour afterward, to avoid catching cold. Steam inhalation should be used at a temperature between 140° F. and 150° F. Sedative inhalations may be composed of: tse. benzoini co., 3J ; acid, benzo- ici, gr. iij ; kaolin, gr. xij, and tse. tolu, n^^xviii ; lupulin, gr. xxx ; or sodae bicarb., gr. xx, and succus conii, gij ; a pint of water at 140° F. being used in each case : stimulating ones of two or three minims of oil of Scotch pine, oil of juniper or of creasote, with a few grains of light carbonate of magnesia, used in the same way. 8o4 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Insufflation. — The patient should be directed to hold his tongue well forward with a handkerchief, using his right hand to enable the operator to direct the application by the aid of a mirror held in his left. If a powder is used the end of the insufflator is bent at a right angle to the stem, and the descending arm is not more than half an inch in length. Blowing down the tube with the mouth ensures a more accurate application than using a ball syringe. It is convenient to have the rubber tube which connects the mouth-piece with the instrument not less than fifteen inches long. The best spray producers are worked by compressed air, the high tension en- suring the even distribution and fine division of the fluid. There is not then the same tendency to cause coughing. Hand sprays should be fitted with two balls, the anterior being used as a reservoir. By compressing the tubing between this and the bottle until the moment the spray is used, the tension is increased and the fluid more finely atomized. Brushes are necessary where a particular portion of the larynx has to be touched with the solution ; they should be made so that they readily come to a point directly they are wetted. If too large, difficulty will be experienced in introducing them into the larynx. On the Continent and in America solutions are applied by means of a piece of cotton-wool twisted round a piece of bent wire, instead of a brush. Inflammation of the Larynx. Acute laryngitis (catarrhal laryngitis') is most frequently met with in persons whose vital powers have become depressed by anxiety, excessive mental work or prolonged physical exertion, sedentary occupation or living in ill-ventilated rooms. The commonest exciting cause is sudden or prolonged exposure to a damp cold atmosphere or to a draught of cold air impinging upon the neck or an ear, especi- ally when the skin is perspiring freely, but an attack maybe caused by the inhala- tion of dust, fumes from chemical compounds, or a vitiated atmosphere heavily charged with tobacco smoke. It is sometimes due to the straining of long- continued shouting, to paroxy.sms of coughing or speaking for a length of time in an improperly pitched tone of voice, or to the entrance of a foreign body into the larynx. In many cases the inflammation extends from the nares or pharynx, and occasionally from the trachea. Errors in diet, and particularly the free con- sumption of hot alcoholic drinks, may originate and keep up catarrhal laryngitis, especially in its subacute form. The symptoms vary according to the stage and degree of the attack. At first there is diminution in the amount of secretion, and this gives rise to a sensa- tion of tickling or dryness which frequently produces cough ; later on the secretion of mucus increases, but it rarely becomes excessive. On making a laryngoscopic examination, the whole of the larynx is seen to be extremely congested, and in many cases an elliptical aperture between the cords is visible during phonation, produced by imperfect approximation. Erosions on the upper surface or inner border of one or both vocal cords are frequently met with, the places denuded of epithelium generally being oval in outline and lighter in color than the sur- rounding tissues. True ulceration is never met with in laryngitis unconnected with constitutional disease. Occasionally after a violent fit of coughing blood is seen on the surface of the mucous membrane or extravasated into the submucous tissue. This condition has been termed laryngitis haemorrhagica, but it hardly deserves a separate name, as it is only a chance occurrence. The voice may be merely hoarse or almost absent, its alteration in tone being dependent more upon the paretic condition of the vocal cords or mechanical interference with their movements, than the congestion or swollen condition of the mucous membrane of the larynx itself. Adults, as a rule, recover from an attack of acute laryngitis in a few days if treated from the commencement, but, if neglected, the affection may remain in the subacute form for some time and eventually pass into the chronic stage. In children acute laryngitis is a much more serious matter, on CHRONIC LARYNGITIS. 805 account of the interference with respiration, due partly to the smaller size of the glottis. Treatment. — The patient should be kept in a warm room on light diet, without any stimulants. Sedative inhalations should be given every three or four hours if the case is acute, or at longer intervals when less severe. A saline febrifuge should be administered, to which may be added a small quantity of opium to relieve the cough ; the form which I prefer is a mixture of citrate of potash with the compound tincture of camphor. One or two drachms of the ammoniated tincture of ([uinine, taken in water every three or four hours, is sometimes useful. An aperient, especially a small dose of calomel, is often beneficial at the com- mencement. In children the air should be warmed and moistened by making a tent over the bed and allowing the steam from a bronchitis kettle or Lee's steam draught inhaler to enter it. Chronic Laryngitis. This often follows an acute or subacute attack, especially if it has been neglected ; but any of the conditions that excite acute inflammation may induce it or maintain it when it has once commenced. A congested condition of the mucous membrane is very common in boys at puberty, owing to the hyperaemia that accom- panies the sudden development of this organ (causing what is popularly known as " cracked voice ") ; and asimilar affection is present in most cases of old-standing disease and in chronic bronchitis. Men suffer more frequently than women, owing in all probability to more frequent exposure ; children of both sexes are comparatively exempt. The subjective symptoms in many cases are not marked, especially when there is no necessity to make frequent use of the voice. Slight irritation and dryness of the throat, with a tickling cough, are all that a patient usually experiences ; but these speedily become greatly increased, if the voice is used for any length of time, and a pricking or burning sensation in the throat may ensue, accompanied by a feeling of obstruction, which the patient endeavors to relieve by constantly " clearing the throat." The objective symptoms are hoarseness, increased secretion, and certain defi- nite changes in the tissues of the parts. A marked feature of this disease is that in recent cases the hoarseness is most noticeable when the patient begins to use the voice after having been silent for some time, the natural tone, however, being assumed in a few minutes. This phenomenon is probably due to the increase in the blood supply and nerve force to the part consequent upon the vocal effort. If the patient continues to use his voice a feeling of fatigue is soon experienced and hoarseness quickly supervenes. When the affection is less recent, the voice may be continually hoarse or even lost. Sometimes it is natural unless attempts are made to exert it, such as by preaching, singing, etc. In chronic laryngitis there is usually increased secretion of mucus, which may be seen adhering to the interior of the larynx and especially to the vocal cords, gluing the latter together. As a rule it is thick, grayish in color, and at times, when expectorated, streaked with blood. If chronic bronchitis exists the secretion is more profuse and less tena- cious in character. The larynx is generally more or less congested, but at times the hyperaemia is limited to a particular part of the cavity, a vocal cord or a portion of one being not infrequently the only seat of marked increased vascularity. At times enlarged blood-vessels may be seen running parallel with the length of the cord along its centre or attached border, giving the part a streaky appearance. The mucous membrane is generally swollen, and in old-standing cases the sub- mucous tissue also is considerably involved. This thickening produces to some extent the hoarseness which accompanies the affection, but this symptom is at times greatly aggravated by the swollen interarytenoid fold interfering with the complete approximation of the vocal cords. As a result of chronic laryngitis, nodular excrescences are not infrequently met with, and the non-malignant forms of laryngeal growth owe their origin to long-standing hyperaemia. 8o6 DISEASES AND INJURIES OE SPECIAL STRUCTURES. Chronic inflammation of the larynx is often attended with changes in the tissues themselves, the subepithelial portion of the mucosa being converted into lymphoid tissue. In aggravated cases of chronic laryngitis one or both cords may be found f)ersistently congested and the surface granular in apjjearance, or a por- tion of a cord (generally the anterior) may be seen to be markedly increased in size, in consequence of the hypertrophied condition of the connective tissue of the part. Another feature noticeable at times in this affection is a paretic condi- tion of some of the intrinsic laryngeal muscles, producing loss of power, even if not actual loss of movement, in one or both cords, usually, however, only in one. If but one cord is affected, on phonation the opposite one crosses the mesial line to approximate with it, provided the raucous membrane is not too swollen to allow of such movement. Erosions of shallow ulcerations, which extend no deeper than the epithelial layer, are not infrequently seen in this disease, a frequent seat being the posterior wall of the larynx and the cartilaginous portion of the vocal cords. In some cases of chronic laryngitis, especially those occurring in strumous jjersons, the subglottic region becomes especially involved, giving rise to hoarseness, which is often quickly followed by comj^lete loss of voice. Thickening of the tissues, especially at the outer surface of the vocal cords, is the condition which specially attracts attention when a laryngoscopic examination is made, the tumefaction often presenting the appearance of a second vocal cord immediately below the true one. The surface of the swelling is generally smooth and whitish-gray in color, but occasionally it is ulcerated and touched with red. In some cases the disease appears to originate in the cartilage or perichon- drium, the structures below the anterior commissure of the vocal cords, or those on the inner surface of the sides of the cricoid cartilage, being most frequently affected — both situations in which the mucous membrane is in direct contact with the perichondrium. In consequence of the swelling which exists in these cases, dyspnoea may occur to an extent which necessitates tracheotomy. In all cases of long-standing chronic laryngitis the individual and family history of the patient should be carefully inquired into and the lungs examined from time to time. With efficient local treatment a favorable prognosis may be given, provided that (i) the disease is of comparatively recent date ; (2) is not accompanied by any marked tissue changes ; (3) the exciting cause has been removed. Treatment. — Unless remedies are persistently employed, the aff"ection will remain stationary, even if it does not progress; or the symptoms may disapp)ear for a time and then recur with the slightest irritation. Chronic laryngitis affect- ing the subglottic region is much more intractable than the ordinary variety, on account of the difficulty of applying remedies. In cases of chronic laryngitis, which are not of long standing and which pre- sent no marked tissue changes, stimulating steam inhalations — pine oil or creasote, for example — are of very great service, but it is necessary to expire the vapor through the nostrils as well as draw it into the larynx, because the pharynx and naso-pharynx are usually also involved. The inhalation of fumes of chloride of ammonium is useful in checking excessive secretion. It is essential that it should be neutral, as an excess of either hydrochloric acid or ammonia causes irritation. In more advanced cases astringents may be applied to the larynx with a brush, or, better still, in the form of spray. A solution of chloride of zinc (15 to 30 grains to an ounce of water), or perchloride of iron (30 to 120 grains to an ounce of water), may be used with a brush. Should spasm of the glottis result from the application, the patient should be made to speak and repeat a word until the spasm subsides! Solutions for application in the form of a spray should be weaker : — Chloride of zinc, 2 to 10 gr. lo ^ j Sulphate of zinc, 2 10 10 gr. to Perchloride of iron, J4 to 2 gr. to Alum, 1 to 10 gr. to ,^ j i LARYNGITJS. 807 Where there is much inspissated mucus adhering to the interior of the larynx, it is well to spray the cavity with a weak alkaline solution to soften the tenacious film and allow it to be got rid of before any other application is made. Should much thickening exist the stronger astringents must be used, and if these fail to reduce the hypertrophied tissue, it may be necessary to destroy it by means of a galvano- cautery. Where there is long-standing hyper^emia with diminished secretion, car- bolic acid and glycerine (^ss-^j of pure carbolic acid to 5J of glycerine) may be applied. Turpentine is sometimes useful if the secretion is excessive. If paresis of the laryngeal muscles has supervened, electricity must be employed to the interior of the larynx, a constant or combined current being the most efficacious. As long as inflammation exists in the larynx it is obvious that the voice should be used as little as possible. When congestion or relaxation of the pharynx or nares is present it must be treated, and any local source of irritation removed^ Atten- tion should be paid to the general health, and tonics prescribed, or change of air recommended, as may be required. Perichondritis of the larynx usually occurs as a sequel to some other disease, such as phthisis, cancer, syphilis, typhoid fever, or to an injury, but it may be primary. It is generally found in adults, and is more common amongst males than females. A dull aching pain in the larynx is often experienced, and there is generally more or less congestion, with swelling of the tissues over the affected part. Ulceration may occur, and if an abscess has formed and burst internally, pus may be visible. Immobility of one or both vocal cords may result from the swollen condition of the tissues around the arytenoid cartilages, or from implication of the recurrent laryngeal nerve. OEdema is generally present in secondary perichondritis. The cricoid and arytenoid cartilages are most frequently affected, the inflammation usually beginning in the perichondrium. Beyond soothing inhalations and scari- fication (if there is much oedema) little can be done locally to arrest the disease. Leeches are occasionally useful in the early stages, and sometimes an abscess may be detected and opened with a laryngeal lancet before it has burst. Trache- otomy is often required. Dilatation with hollow bougies has been recommended to counteract the stenosis which often follows this affection, but the results of this method of treatment are unsatisfactory. Lai-yngeal phthisis is usually associated with pulmonary disease, but it may be well marked in the larynx without any evidence of it in the chest, and it is said to have proved fatal without any tubercle having been found in the lungs. The predisposing causes are the same as those of pulmonary phthisis. Males are more frequently aff'ected than females, and most cases occur between the ages of twenty and thirty. Excessive use of the voice undoubtedly hastens the development of the disease. Symptoms. — In the early stages there is nothing characteristic in the appearance of the larynx beyond that of chronic laryngitis, but as the disease advances, the mucous membrane becomes thickened and infiltrated by the tuber- cular deposit, commencing over the arytenoid cartilages or in the interarytenoid fold, and spreading as a pyriform swelling toward the epiglottis. It may begin, however, in the epiglottis or other parts. By degrees the other parts of the larynx become affected, until most if not all of the laryngeal tissues are involved. It is unusual to find extensive infiltration confined to one side. In the majority of cases pallor of the mucous membrane is a distinguishing feature of this disease, but as phthisical subjects are prone to catarrhal affections, congestion and erosions of the mucous membrane are often present at the same time. Tubercular ulcers have a marked tendency to coalesce, thereby giving the surface attached a worm-eaten appearance. Individual ones are shallow and of small size, their floor having a granular appearance. Not infrequently the epi- glottis and the neighboring structures are extensively destroyed. Paresis of one or both vocal cords may be present, due either to tubercular infiltration of the laryngeal muscles, or to the interference with their movements that arises from So8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the swelling of the laryngeal tissues. The general debility, however, the loss of tone in all the muscles, and the extreme bodily weakness induced by this disease are not without influence. The right vocal cord is more frequently affected than the left, in con.sequence of the recurrent laryngeal nerve on that side being pressed upon by pleuritic e.xudation, or as a result of consolidation of the apex of the lung. Pressure from enlarged bronchial glands sometimes acts in the same way. Necrosis and caries of the cartilages may occur ; wart-like excrescences are some- times seen projecting into the interior, and in cases not far advanced thickening of the interarytenoid fold with irregular tooth-like projections may be seen similar in appearance to those found in chronic laryngitis. Hoarseness is often present in the early stages of the disease, but this largely depends upon the condition of the larynx. At times the voice is almost lost in consequence of the imperfect action of the vocal cords, or the want of sufficient expiratory power in the lungs. Cough rarely fails, but it is not accompanied with much expectoration when the laryngeal changes are slight, unless the lungs are decidedly involved or catarrh is present. In the earlier stages a certain degree of pain on swallowing may be experienced ; later, as the swelling extends, there may be as well a feeling of obstruction to the passage of food. Still later, especially when the epiglottis and ventricular bands are involved, the greatest discomfort is produced by liquids passing into the larynx. Unless i)erichondritis is present there is no pain in the larynx except during deglutition. In giving a prognosis the most important points are the condition of the epiglottis and arytenoid cartilages and the extent to which ulceration has advanced. Treatment. — In addition to the usual constitutional measures, local treat- ment is of service in modifying the progress of the disease and adding to the com- fort of the patient. Lozenges containing a small quantity of opium or morphia are useful for relieving cough. Daring attacks of catarrh, sedative inhalations give relief, and stimulating inhalations may be used when the tissues are anaemic and not much infiltrated. Lactic acid appears to arrest the spread of the affec- tion ; it may be apj^lied with a brush, or injected directly into the tissues; a 20 per cent, solution being used at the commencement, and the strength increased to 40 or 60 per cent. Astringents applied either with a brush or by means of a spray rarely do good, and frequently cause irritation. Considerable relief, however, may be obtained by the application of a 20 per cent, solution of menthol in olive oil. It occasion- ally happens that the infiltration of the tissues of the larynx becomes so great as to require tracheotomy, but the operation ought never to be done merely with the object of giving rest to the larynx. The pain in swallowing may be somewhat relieved by the application of cocaine and by thickening the liquid nourishment and directing the patient to swallow it in gulps. Patients have been recommended to lie in the prone position across a bed and to suck up the nourishment through a tube. Lupus is usually associated with evidence of the disease on the skin or the soft palate, but occasionally it is confined to the throat. It is more often found in females than in males, and amongst the lower classes of society. Its charac- teristic features are hypertrophic changes followed by slowly spreading ulceration, the surface of which has a worm-eaten appearance; sometimes the hypertrophied tissues are nodulated. The mucous membrane is congested less than in syphilis, but more than in phthisis, and its sen.sibility is usually diminished. The epiglottis is frequently attacked, and may be completely destroyed. Syphilitic laryngitis is not an invariable accompaniment of the manifestations of the disease elsewhere, and often does not come on until some time after the pharyngeal symptoms have disappeared. Its most constant feature is congestion, which is usually difficult to remove. Mucous patches and condylomata are pres- ent at times, and have usually an oval or sometimes roundish outline ; they are less persistent than in the pharynx and not always symmetrical, sometimes occur- TUMORS OF THE LARYNX. 809 ring on the ventricular bands and arytenoid cartilages or edges of the epiglottis. Erosions of the mucous membrane and superficial ulceration are not uncommon, and their tendency to recur is a marked feature of the affection. The degree of hoarseness is dependent upon the extent and position of the laryngeal changes, and although in most cases a natural tone of voice for conversation is eventuallv regained, the singing voice frequently remains impaired. Tertiary syphilis of the larynx is asually marked by deep ulceration, but cases occur in which persistent congestion, accompanied by more or less thickening, with or without superficial ulceration, is the prominent feature. The.se changes sometimes make their appearance many years after the initial lesion, impairment of health generally being the determining cause. The epiglottis is frequently the seat of ulceration, its lateral or upper border being usually first attacked. In the later stages of syphilitic disease cedema is often present. When false excrescences occur, they are generally situated on the interarytenoid fold or anterior surface of the posterior wall of the larynx. Cium- mata are occasionally found. The cicatrix produced by the ulceration may form a web between the vocal cords, and frequently causes stenosis, rendering tracheo- tomy necessary. The thickening around the cricoarytenoid joint not unfrequently leads to permanent stiffening of the articulation. In many cases only general treatment is required. When there is much con- gestion, a sedative inhalation, such as benzoin, is beneficial, and, later, a stimu- lating inhalation, such as vap. pini sylvestris, will assist recovery. Long-standing congestion should be treated by astringents, applied either by means of a spray- producer or a brush. In cases of obstinate ulceration great benefit is sometimes obtained by heating calomel in the bulb of a glass tube and blowing it, whilst in a state of vapor, on the affected part. Leprosy. — The chief feature of laryngeal leprosy is extreme thickening of the mucous membrane : sometimes papillary growths or tuberous masses are present. The larynx is never affected unless the disease is present in other parts of the body. Tumors of the Larynx. Carcinoma is more often found in males than in females. Epithelioma is the most frequent variety, but encephaloid and scirrhus are said to occur. The sub- jective symptoms vary according to the stage of the disease and the part affected. Usually there is pain, confined at first to the larynx, but radiating to the ears and adjacent parts after ulceration has commenced. Dyspnoea and dysphagia follow sooner or later. Hoarseness is generally the most prominent objective symptom ; it frequently precedes all others by a considerable period, but the voice is rarely entirely lost. When ulceration has commenced the breath may become exces- sively foetid, and hemorrhage may occur from a vessel being laid open. The glands are seldom affected, and then only when the disease is at an advanced stage. This is due to the lymphatics being less freely connected with the glandu- lar system than those from most other organs, and for the same reason general cachexia and secondary growths in other parts of the body are rare. The disease first appears as a swelling, situated most frequently on one of the ventricular bands, although any other part of the larynx may be affected ; as it increases in size the outline becomes irregular, the color becomes red from congestion of the mucous membrane (though sometimes it is a dirty gray), and ulceration quickly supervenes. tEdema is generally present in the later stage. Treatment. — All growths of a doubtful nature should be removed by an intra-laryngeal operation for microscopical examination. If found to be cancer- ous, two courses are open : (i) to leave the disease to run its course ; (2) to attempt to eradicate it by surgical interference. With a view to the latter, thyrotomy, partial extirpation, and complete extir- pation of the larynx have been performed, but at present the results of these operations are not encouraging. Many patients die from the immediate effects 52 8io DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the operation, and the disease is very liable to return, even after what appears to be com])lete removal. Thyrotomy cannot be recommended, in conse(inence of the difficulty of removing all the growth. The result of total extirpation of the larynx has been hitherto far from satisfactory. The percentage of mortality due to immediate effects of the operation is very high, and the jiitiable condition of the patients who survive, even for a short time, detracts greatly from any advantage which may have been gained. The operation ought not to be per- formed unless the patient's sanction is obtained, after all the disadvantages as well as the advantages have been fully detailed to him. More may be said for a partial operation, especially if performed while the disease is still recent and apparently localized. When the disease is allowed to run a natural course the average duration of life is eighteen months. If symptoms of stenosis arise, tracheotomy should be performed before the general health becomes lowered by insufficient aeration. Pain must be relieved by morphia, either injected hypodermically or insufflated into the larynx, and dysphagia met by the use of a feeding-tube or nutrient enemata. Non-malignant growths most frequently occur in the larynx when congestion has lasted for some time, as in catarrhal or exanthematous laryngitis. Males are more frequently affected than females. Symptoms vary according to the nature, size, and situation of the growth. When it is attached to one of the vocal cords, the voice is generally altered in tone, and if it is of any size dyspncjca is usually present. Papillomata are the most common. They are u.sually of a pink color, but may be white or bright red, and are generally sessile, and often multiple. When removed they have a tendency to recur or to spring from a part of the larynx pre- viously healthy. Fibromata are of a brighter red, and round or oval in outline, though some- times they grow out like cauliflower excrescences. They are always single and usually pedunculated ; and the surface is generally smooth, though it may be rough, irregular, or w-avy. There are two varieties, () the soft. The former come next to pajtillomata in the order of frequency, and consist of bundles of white fibrous tissue covered with several layers of epithelium ; the soft are comparatively rare, and consist of fibro-cellular tissue with serous fluid diffused through their substance. Cystic tumors are not often met with ; they are generally situated on the epi- glottis or spring from the ventricle of Morgagni, and usually cause some local irritation. Myxomata, or true mucous growths, angciomata, or vascular growths, and lipomata, or fatty growths, are occasionally met with. Treatment. — Most laryngeal growths can be removed through the mouth by means of forceps or a snare. If the patient is an adult, before the operation is attempted, the larynx and pharynx should be sponged with a 5 or 10 per cent, solution of cocaine; for a child 4 per cent, is sufficiently strong. When the i)arts are thoroughly ana2Sthetized, the patient should be directed to hold the tip of his tongue with a napkin in his right hand. The forceps and faucial mirror having been warmed, the mirror, held in the left hand, should be placed in position, and, as soon as a view of the grow-th is obtained, the forceps introduced, the blades being kept closed until the growth is reached. Unless the operator is skilled in intra-laryngeal manipulation, he ought not to attempt to cut or drag anything away unless he has seen that only the growth is between the blades. Growths which are too tough to be extracted with forceps should be snared and slowly divided with the wire. Cysts may be crushed with forceps or laid open with a guarded lancet attached to a curved handle. After removal a solu- tion of perchloride of iron, 60 to 120 grains to the ounce, should be applied every two or three days for a week or so, to prevent recurrence. AFFECTIONS OF THE MUSCLES OF THE LARYNX. 8ii It may be necessary to anaesthetize a child before attempting to remove the growth. When this is done the child should be seated in an upright position on a nurse's lap, the mouth kept open with a gag, and the tongue held out by an as- sistant. The collection of saliva often prevents a good view of the interior of the larynx being obtained. In very e.xceptional cases it may be desirable to destroy the remains of a growth with the electric cautery. When this is the case, a suitable electrode hav- ing been selected, all the i)latinum with the exception of the point should be insulated by tying a thin piece of ivory on each side of it (vaccine points do very well), and coating them over with a thick layer of gum-arabic. The larynx must be thoroughly anaesthetized, and the electric current not allowed to pass until the point is resting on the surface which has to be destroyed. An cxtra-laryngeal method of re inovitig growths ought not to be resorted to unless the growth is causing danger to life, and an experienced intra-laryngeal operator is of opinion that no other procedure will be successful. This mode of removal is sometimes required when a growth is very large, has an extensive attachment, and is of very tough texture, or is situated where it cannot be reached through the mouth. It must, however, be remembered that the mere size, tough- ness, or extensive attachment does not justify an extra-laryngeal operation being performed. Disorders of Sensation. Sensory affections of the larynx are occasionally met with associated with some other disease. Amesthesia occurs as a sequel to diphtheria and in bulbar paralysis. When present in a marked degree there is danger of pneumonia being set up by particles of food passing into the air passages. Hypercesthesia very often accompanies inflammatory conditions. Parcesthesia is usually met with after a foreign body has lodged in the larynx, even when only for a short time, the sensation of its presence continuing for hours and even days after its removal. Sometimes this is associated with ill-health. Neuralgia rarely occurs, and when present is merely a local manifestation of a general condition. Electricity is of use in some cases of anaesthesia and in paresthesia, if it per- sists ; but when the latter has been caused by a foreign body, sedative inhalations or a {&\N applications of an astringent to the affected parts are usually sufficient to effect a cure. Muscular Paralysis. This may be due either {a) to disease or injury of the medulla oblongata or the nerves supplying the muscles, or {p) to affections of the muscles themselves. Among the diseases which produce these results may be mentioned syphilis, can- cer, lead poisoning, rheumatism, and exposure to cold. Pressure on a recurrent laryngeal nerve affects the abductor before the adduc- tor filaments. This injury is liable to be produced by goitre, aneurysm, enlarged lymphatic glands, or thickening of the pleura at the apex of the right lung. When both groups of muscles are paralyzed, the vocal cord on the corresponding side remains fixed in the cadaveric position. /. e., midway between extreme abduction and adduction, and on phonation the healthy cord is drawn to, or even over, the middle line, compensating for the immobility of the paralyzed cord. Paralysis of the abductor or adductor muscles may be unilateral or bilateral. When only one abductor is affected the voice is usually unaltered, but there is more or less dyspncea and stridulous breathing. When both abductors are para- lyzed, the vocal cords lie almost parallel, but generally separated rather more behind than in front. The voice is usually but little altered : expiration is free ; but inspiration difficult on the least exertion and attended with stridor, which is 8i2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. also generally i)resent during sleep. It usually occurs in adults, and is more common in males than females, resulting from either neuropathic or myopathic changes. When only one abductor is paralyzed, the voice is hoarse or may be almost lost, and laughing, coughing, and sneezing are always altered in character. Bilateral pa7-alysis of the adductors (^functional aphonia) is more frequently met with in women than men, and among young women than old ones. The subjects of this affection are often antemic and in a feeble state of health ; occa- sionally they are found to be suffering from some disorder of the sexual system. It may, however, result from catarrh, rheumatism, lead poisoning, and other causes, and is often met with in the second and third stages of phthisis. Although the aphonia is usually constant, sometimes a few words are uttered in a natural tone of voice, especially those at the beginning of a sentence. A notable feature is that coughing and sneezing are little altered in character. On attempted pho- nation, although the vocal cords are adducted slightly, a considerable interval is left between them ; sometimes one is more affected than its fellow. The mucous membrane of the larynx is usually pale. The cetitral adductor {arytenoideus propi'ius) is often affected in conjunction with the lateral adductors, but may alone be paralyzed. When in this condition there is loss of voice, and although the vocal cords approximate in the anterior three-fourths of their length, they remain separated by a triangular opening in their posterior fourth. The external tensors {crico-thyroidei) are occasionally paralyzed in conse- quence of exposure to a draught of cold air on the neck, but violent or long-con- tinued use of the voice, especially in the open air, may produce the same result. The symptoms are : loss of voice, sometimes only gruffness, and when a finger is placed on one of the muscles during phonation no movement is detected. When the affection is bilateral the central portion of the vocal cords is depressed during inspiration and raised in expiration. The glottis also has the appearance of a wavy line. The inter7ial tensors {thyro-arytenoidei interni) are not infrequently affected as a result of over-fatigue of the voice, or strain from an excessive vocal effort. When this has occurred, the vocal cords appear slightly bowed outward, leaving an elliptical aperture between them. Treatment. — This must depend upon the cause and duration of the affec- tion. If congestion is present, sedative steam inhalations, such as benzoin, should be emi)loyed, and when it has subsided the application of electricity to the muscles affected may be of service. This is done by attaching one jiole of a bat- tery to a metal disc fastened over the affected muscle by a piece of elastic tied round the patient's neck, and the other to a laryngeal electrode, contact being made by depressing the lever as soon as the end of the electrode touches the affected part of the larynx. In cases of bilateral paralysis of the abductors, unless the aperture between the cords is seen to enlarge within a short time after treat- ment has been commenced, tracheotomy ought to be performed without delay. In many cases of functional aphonia the application of a strong astringent (chloride of zinc 30 grs. to 5J, or perchloride of iron 120 grs. to 5J) to the in- terior of the larynx is sufficient to restore the voice ; but, if this fails, faradism applied to the vocal cords will produce the desired result. Should the voice be lost soon after it has been regained, it is better to wait until the general health is improved, because the shock produced by the constant application of electricity, especially if a strong current is used, frequently tends to retard the ultimate re- covery of the i)atient. In the treatment of laryngeal paralysis constitutional remedies are often required, and in some cases are more important than local measures. AFFECTIONS OF THE MUSCLES OF THE LARYNX. 813 Muscular Spasm. Spasm of the adductors of the vocal cords {Millar' s asthma) is most fre- quently met with in children between six months and two years old, after which age the tendency decidedly diminishes. Males are much more subject to it than females, and those who are rickety are especially liable to be attacked. Most cases are met with during the first itw months of the year, in conse- quence of the more excitable condition of the child's nervous system at that time, dependent upon confinement to the house during the winter months. Difficult dentition and intestinal irritation, produced by indigestible food or worms, are the chief exciting causes. Sometimes the attacks occur during sleep, but they may be brought on by the child crying, sucking, or being dandled. Symptoms. — .\ severe attack begins with several short stridulous inspira- tions, followed by a longer and more noisy one, after which respiration ceases, the head is thrown backward, and the spine bent in the same direction. The eyes are fixed or turn from side to side ; the fingers are clenched over the thumbs and the wrists flexed ; the feet are flexed and rotated slightly outward, and the great toes adducted. The child's face becomes dusky, and the superficial veins distended. Suddenly the spasm relaxes and the child recommences to breathe. Usually the attacks recur from time to time, sometimes at frequent intervals, but any one of them may prove fatal. Pyrexia is generally absent. Treatment. — During the attack the child should be slapped on the back, cold water thrown on the face, and smelling-salts held to the nose. When the spasm has passed off an enema should be given and a mercurial purge administered. With a view to diminish the tendency of spasms, musk (gr. 1-3) or bromide of ammonia or potassium should be administered every three or four hours. The greatest attention must be paid to diet. Ii4 DISEASES AND INJURIES OF SPECIAI STRUCTURES. CHAPTER XIV. DISEASES AND INJURIES OF THE NECK AND THROAT. MALFORMATIONS. Bran'Chial Fistula. The Eustachian tube is the modified first branchial cleft of fijetal life. The others usually leave no representative, but occasionally a fistulous opening is found at birth corresponding to one of them. The second and fourth appear to persist more frequently than the third ; the former opens in the neighborhood of the lesser cornu of the hyoid bone, and may or may not communicate with the pharynx ; the latter lies just at the' inner margin of the sterno-mastoid immediately above the sternum. Occasionally it opens into the trachea or pharynx. They give rise to no symptoms and usually require no treatment. Pedunculated fibro-cartilaginous masses are sometimes found in the neighborhood of their external orifice. Spina bifida, which occasionally occurs in the cervical region, najvi, hydro- cele of the neck, dermoid cysts, and those developed in connection with the thyreoid body and the thyroglottic canal, congenital lipomata and malformations of the pharnyx, are described elsewhere. INJURIES OF THE NECK. Wounds. Transverse incised wounds are frequently met with in the front of the neck. For the most part they are self-inflicted ; many lie in the suprahyoid space, some in the thyrohyoid, and others over the larynx or trachea. Generally in right- handed people they begin on the left, high up, and run obliquely toward the right, becoming less and less deep ; and not unfrequently they are jagged, the skin rolling up into folds before the pressure of the knife, so that it appears as if several cuts had been inflicted. Sometimes they extend from one side to the other, dividing the trachea and oesophagus or both the carotid arteries, and even notching the vertebral column ; much more they are superficial, not penetrating, perhaps, into the deep fascia. There are various reasons for this : the edge of the knife in many instances is directed against the lower jaw, or the force is spent against the cartilages ; when the head is thrown back the larynx is thrust forward and the vessels recede; resolution often fails at the last moment, and if the air-passages are opened the sudden collapse of the thorax, previously expanded to its utmost, is sufficient to interrupt the tension of the muscles and break the force of the arm. In this way the vessels escape unhurt in by far the larger number of cases. Besides these, gunshot injuries and punctured wounds, stabs, for example, from behind, penetrating the apex of the lung, or involving the great vessels at the root of the neck, and even penetrating between the arches of the vertebrae into the spinal canal, are occasionally met with. Union by the first intention is the exception. It is almost impossible to keep the wound at rest, and partly owing to the elasticity of the skin, partly to the action of the platysma, the edges always curl inward, so that perfect adaptation cannot be obtained. Death may occur almost instantaneously from lo.ss of blood, arterial or venous, from air being drawn into a wounded vein, from suffocation, owing to a detached portion of the tongue or one of the cartilages falling into the larynx or trachea, or from blood pouring into the lungs, or it may follow later from inflammation or other compli- WOUNDS OF THE NECK. 815 cations. Emi^hysema is not uncommon, but is rarely of much importance ; spasm and oedema of the glottis may set in at any moment ; food, dust, cold air, blood, or pus may find its way down to the lungs, and set up bronchitis or broncho- pneumonia ; abscesses may form around the air passages, and spread into the tissues of the neck, and down behind the cervical fascia to the pleura and pericar- dium ; and if these complications do not prove fatal, perichondritis and necrosis of the cartilages may set in ; granulations may spring up and close the larynx or trachea ; a fistulous orifice may be left, or aphonia, dyspnoea, or dysphagia may persist for the rest of life, caused by the cicatrization that takes place in the interior. When the wound lies above the hyoid the facial and lingual arteries may be' cut, the cavity of the mouth opened, and the tongue and the epiglottis hacked in such a way that they fall back over the larynx and cause instant death. The hemorrhage is usually free and the blood may pour down into the trachea as well as escape externally. Food and saliva pass out through the opening ; the move- ments of the tongue are impaired (sometimes the hypoglossal nerve is divided) ; the elevators of the hyoid are cut across ; and swallowing and vocalization cannot be properly carried out. If the thyrohyoid membrane is divided, the epiglottis and even the arytenoid cartilages may be detached and hang down ; or the aryepi- glottic folds may be cut, and the superior thyroid artery and superior laryngeal nerve divided. When the brunt of the force falls upon the cartilages the great vessels usually escape ; they lie far back in the angle, and unless the incision begins under the ear, or traverses the cricothyroid space they are generally well out of the way. The immediate risk, therefore, is not so great ; but whenever the larynx is wounded, the danger of inflammation, of spasm and oedema of the glottis, and of food passing down into the air passages, owing to the imperfect way in which they are protected, is very serious. Dyspnoea and a sense of impending suffocation are always present; the least attempt at swallowing or speaking brings on fits of spasmodic coughing : and, if the patient survives, permanent impairment of the voice is not uncommon. Hemorrhage is more frequent in wounds of the lower part of the neck ; it may come from the carotid or thyroid arteries ; from the anterior, external or internal jugular veins, or even from the thyroid gland, which, sometimes, when cut into, bleeds profusely ; and, if the trachea is cut across, the blood may pour down into the lungs so as to cause instant death. Wounds of the trachea of them- selves are not very serious ; but when it is divided the two ends retract so that a wide space appears between them, the lower sinking down into the thorax and moving to such an extent with each inspiration that it is almost impossible to fix it. The oesophagus and the recurrent laryngeal nerve are often wounded at the same time. Punctured wounds at the root of the neck, if they involve the upper aperture of the thorax, are often fatal at once from injury to the great vessels ; but instances are recorded in which recovery has taken place, even when the apex of the lung has been injured and the brachial plexus divided. Treatment. — Hemorrhage must be stopped at once by pressure. If the vessel is a large one, the finger must be inserted into the wound and kept upon the bleeding point ; division of one of the carotids is generally fatal immediately, but instances are on record in which the hemorrhage has been stayed temporarily in this way, until better means could be adopted. If the wound is too large, or there are many bleeding points, a handkerchief, or a sponge, may be used ; but care must be taken not to compress the trachea or to drive the blood down into it. Then, as soon as possible, the arteries should be secured, either by torsion or ligature at both ends, and the veins tied. Complete division of the internal jugular is not necessarily fatal ; a small lateral wound should be treated as if a branch had been torn off from the side. In deep punctured wounds, behind the angle of the jaw, when the bleeding is plainly arterial, and when it is impossible to secure the vessel without a long and dangerous dissection, an attempt should be made to ascertain by pressure upon the external carotid whether it proceeds from 8i6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. one of its branches — and, if so, this should be tied ; under other circumstances a ligature should be placed round the common trunk. Wounds further l)ack in the neck are still more serious. The vertel)ral artery, or some of the main branches of the occipital and superior intercostal, may be divided ; or even the spinal cord may be injured. If an artery is severed an attempt must be made to tie it ; if this fails the wound must be jjlugged from the bottom with some antiseptic. This has succeeded even in the case of the vertebral. In other cases asphyxia is a more prominent symptom. When it arises from the entry of air into veins, or from blood pouring down into the trachea, help, as a rule, is too late ; but if a portion of the tongue or of the larynx has been detached, and is hanging over the aperture, it is sometimes possible to lift it out of the way in time. The subsecpient treatment depends uj^on the extent of the injury. A deep ligature, for example, may be passed through the base of the tongue to keep it forward ; the epiglottis, if extensively cut into, is better removed, and this does not seem to interfere with deglutition ; otherwise it may be .secured with sutures \ and the same may be done with the other cartilages. Divided nerves, if the ends can be found, should always be drawn together again. Wounds of the oesophagus must be closed with catgut, but, especially if they are transverse, there is little chance of primary union. When the trachea is cut across an attempt must always be made to approximate the ends with sutures ; but, owing to the extent of the retraction and the movement of the parts, this is by no means easy. Finally, if blood has poured into the trachea, as much as possible must be removed by means of suction or by feathers, so as to limit the area of decomposition and inflammation ; with an extensive wound in the air passages the patient cannot cough it up. If the incision is of great length, sutures may be inserted at the ends to draw the edges together, but even then they rarely unite by the first intention : the central portion, if the air passages have been wounded and cannot be .secured by sutures, should be left open, so as to afford free exit for the discharge, which might otherwi.se find its w^ay into the lungs. Gaping is prevented, as soon as the patient is placed in bed, by raising the shoulders and fixing the head with bandages in a l)osition of moderate flexion, taking care, of course, not to force it down so far as to interfere with respiration. If the larynx is badly injured it is better to jjerform tracheotomy at once and insert a rubber tube ; it is almost sure to be required later on for oedema or spasm of the glottis, to prevent the entry of foul air or discharges into the lungs, or from narrowing of the glottis owing to the cicatrization and growth of granulations. A thin flat sponge wrung out of hot water should be laid over the wound to prevent dust entering in ; and the air of the room must be kept warm and moist by means of a steam kettle. Bronchitis is nearly sure to occur if the air passages are opened, and is very likely to run on to ])neumonia. The patient is often broken down in health already, and is in a state of extreme depression ; he is weakened still further by hemorrhage ; coughing is impossible owing to the position of the wound ; and even if blood does not enter the lungs, and decomi)ose there, inflammation is very likely to extend down from the seat of injury, or be caused by particles of food, or by the air that has been fouled in passing over a septic surface. The diet must be nutritious, with a moderate amount of stimulants ; and the patient must be fed either with enemata or by means of a tube passed down into the stomach. The danger is greatest if the cesophagus or])harynx is opened ; but if the muscles of the floor of the mouth are divided, or if there is any extensive injury to the upper part of the glottis, the same precautions must be taken. The larynx loses its power of protecting itself; coughing is impo.ssible owing to the escape of air; and often the sensibility of the mucous membrane is imjiaired. A soft india-rubber tube is generally sufiicient ; it may be passed either through the mouth or nose (never through the wound), and care must be taken to make certain that it has not accidentally entered the larynx. Liquid food may be poured down this by means of a funnel every four hours without much incon- FRACTURE OF THE IIYOTD BONE. Sry venience to the patient and without any risk. In all suicidal cases the patient must be carefully watched, for fear of doing himself further injury ; sometimes it is necessary to restrain the hands, but when possible this should be avoided. Little can be done for the despondency that is so often present ; if there is sleep- lessness or much excitement chloral may be given ; bromide is too depressing and opium is inadvisable in bronchitis. The prognosis in such cases is much worse than might be expected from the extent of the wound. If (lysi)n(ea arises the wound must be examined at once, and if necessary, tracheotomy jjerformed. Occasionally this is recpiired at a later period, owing to irregular contraction or cicatrization in the interior, or to the presence of exuber- ant granulations, which cannot be got rid of by scraping or cauterization. Qui- nine, carbonate of ammonia, ether and other stimulants must be given freely if pneumonia sets in ; and the side of the chest may be enveloped in a poultice ; but the signs are often> too obscure until it is well advanced. There is no rise of temperature in many cases, and expectoration is ab.sent ; the face is pale and dusky, the forehead covered with beads of pers])iration, the respiration short and jerky and the pulse small and cjuick. Generally the patient rapidly falls into a kind of stupor. Deep-.seated abscesses and cellulitis of the neck are usually accompanied by rigors and high fever ; and the local signs are well marked. Sometimes the inflammation extends along the outside of the trachea into the mediastinum, and causes pleurisy and even pericarditis. If a fistulous opening is left it may be cured by a plastic operation, paring the edges and bringing them together with numerous points of suture ; or even by gliding a piece of skin over it from one side or the other, provided that it is certain that the patient can breathe sufficiently well when it is covered up. Fracture of the Hyoid Bone. Owing to its protected situation this is rarely broken except by direct violence, such as a blow or a squeeze, as in hanging. The greater cornu is the part that usually gives way. One or two instances, however, are recorded in which it was produced by muscular action alone. The diagnosis is seldom difficult : unless there is much swelling or ecchymo- sis, the fragments can generally be felt from the outside, and always by introduc- ing the finger into the mouth. There is intense pain on pressure, or on attempting to speak or swallow. Very often the fracture is compound, one of the ends having perforated the mucous membrane, and there is a profuse secretion of saliva mixed with blood. Sometimes the swelling extends to the larynx, so that the dyspnoea becomes serious. Treatment. — The fragments must be brought into position by manipulation, and the head and neck fixed, as far as possible, by a splint moulded over the shoulders and up the back of the head. Swallowing is so intensely painful, and sometimes sets up such an amount of coughing and irritation, that the patient may have to be fed by enemata for a i^vi days, until the fragments are consolidated, or an (^esophageal tube can be used. If the dyspnoea is severe, particularly if the fracture is compound, and if, as often happens, the wound becomes septic from the entry of food and other substances from the mouth, so that there is risk of acute laryngitis setting in, tracheotomy may be required at a moment's notice. Union generally takes place in three or four weeks, but suppuration, necrosis, oedema of the larynx, and septic pneumonia are not uncommon. Dislocation of the hyoid bone, or displacement consequent upon relaxation of the ligaments connecting it to the thyroid cartilage, has also been described. Fracture of the Cartilages of the Larynx. This may be caused in the same way ; even the trachea has been torn across by a violent blow from the point of an elbow. The thyroid, owing to its size, Si 8 DISEASES AND INJURIES OE SPECIAL STRUCTURES. position, and rigidity, is the one that usually suffers : sometimes the cricoid is broken as well. This accident may ])rove instantaneously fatal from obstruction or spasm of the glottis. Even when there is not much deformity the swelling, ecchymosis, and emphysema seriously narrow the rima glottidis and cause very alarming dyspniea. In general there is the most intense tlistress, with a sensation of impending suffocation, or this may be absent at first and then come on suddenly. The treatment is the same as for fracture of the hyoid, but unless the portion of cartilage broken off is very small and altogether external, so as not to involve the mucous membrane, tracheotomy or laryngotomy may be required at a moment's notice. The latter is preferable, as the opening can be used to restore the dis- placed cartilage to its position or to fix it by sutures. Contusion is much more common, and when severe — as, for examijle, in gar- roting — so that there is hemorrhage under the mucous membrane, may give rise to the same symptoms. It is said that sudden death has been caused by this or by spasm, without any fracture. Care must be taken not to mistake the crackling sensation that is often felt when the larynx is moved from side to side upon the vertebral column for cartilage-crepitus. Foreign Bodies in the Air Passages. Irritating vapors rarely penetrate beyond the larynx : usually they are driven out at once by coughing, and cause merely a transient hyperemia, though this may run on to inflammation. The same with licpiids, unless the larynx has lost its sensitiveness or the muscles are paralyzed. After diphtheria, for example, or when a patient is under an anaesthetic, or after wounds involving the floor of the mouth or the upper part of the larnyx, when the mucous membrane is dry and insensitive, it is not uncommon for blood or liquid food or material vomited up from the stomach to find its way down through the larynx into the trachea and lungs, and, decomposing there, set up broncho-pneumonia. Solid substances cause symptoms of much greater intensity. As a rule they enter by the mouth ; occasionally they ulcerate through from the oesophagus, especially in malignant disease. In the vast majority of cases this accident is the result of the careless habit of holding things in the mouth or between the teeth, especially with children. Something or other — a laugh, or a blow ui)on the back — causes a sudden insi)iration, and a foreign body is sucked down into the widely-open glottis and lodged in the air- passages before it is known that the hold on it is lost. Blow-tubes and pea-shooters are responsible for many, the child in filling its chest with air drawing the projectile into the larynx. In operations about the mouth, when the patient is under an anaesthetic, it has hap- pened many times : sets of false teeth, or wedges used to hold the mouth open, or teeth dropped from the forceps after extraction, in the haste to grasp another, are all recorded as having fallen into the larynx. The same thing may occur in the vomiting that follows anaesthesia. A case of sudden death after the adminis- tration of ether was found to be due to the skin of a ripe plum rolled up ; it had been vomited, drawn into the larynx, and was firmly wedged in the right bronchus, so that its end fell over and covered the orifice of the left. Round worms from the digestive tract, vomited during sleep, have been known to lead to the same result. Symptoms. — These vary according to the i)Osition, whether it is in the larynx itself, in the trachea, or in the smaller bronchi. They may be immediate, due to obstruction or irritation, or secondary, caused by the inflammation that invariably follows sooner or later. I. In the Larynx. — If it is large and round, so as to fit upon the rima glot- tidis, or sharp and angular, so as to cause spasm, suffocation may be immediate. The symptoms are of the most urgent description : the patient starts up wildly, gasping for breath, and clutching at his collar ; the face is livid, rapidly becom- FOREIGN BODIES IN THE AIR PASSAGES. 819 ing cyanpsed ; the veins on the forehead and neck stand out like cords ; he may be (luite unable to speak, or if the larynx is not (juite closed, utters the most dis- tressing sounds, attempting at the same time to push his finger down his throat ; expiration and coughing become more and more violent, until the body becomes convulsed, a cold sweat breaks out, and within a minute he falls down unconscious. In most cases, however, the immediate effect is not so intense : if the foreign substance is smooth, so that it does not set up much irritation, or if it is lodged in some place out of the way, like one of the ventricles, the symptoms may be com- l)aratively slight, although the patient is never free from danger. The cough is characteristic : it comes on in spasmodic fits of uncontrollable violence and often continues until the patient is utterly prostrate from exhaustion. The lea.st change of posture is sufficient to induce it. At first it is dry without expectoration, but afterwards, when inflammation sets in, this may be copious, thick, and stained with blood. Sometimes, especially in children, the symptoms bear some resemblance to croup ; but as a rule when they are due to a foreign body, expiration is more difficult than inspiration. Pain, a sensation of tickling often referred to the ear, and a sense of anxiety or of impending suffocation, are nearly always j^resent. The voice may be quite lost from the first, or, if not, it always becomes hoarse in a few hours, from the swelling and uidema that follow. Later on, if the foreign body is sharp and angular, so as to cause inflammation and ulceration of the mu- cous membrane, death may ensue from spasm and oedema of the glottis ; necrosis of the cartilages may occur'; the inflammation may spread to the lungs and cause pneumonia ; even blood-vessels may be ruptured, or the patient may die at length, worn out and exhausted. A coin, on the other hand, has been known to lie, coated over with mucus, in one of the ventricles for many months without causing urgent symptoms. 2. In the Trachea. — If the foreign body is fixed, like a puff dart, which lies with its point uppermost and with each expiration is driven further and further into the substance of the trachea, the immediate symptoms are not so striking. There is dyspnoea, but the cough is more continuous and is not of the same spas- modic, uncontrollable character. Aphonia is not present until the mucous mem- brane of the larynx becomes swollen from the constant effort at expulsion. Pain is always felt over the actual spot, and there is constant soreness behind the sternum. Inflammation, however, with ulceration and copious expectoration, very soon makes its appearance and extends rapidly to the lungs. If, on the other hand, the foreign body is free, the symptoms depend chiefly upon its shape and weight. At one moment it lies over the bronchi, generally the right, owing to the position of its orifice ; the next, it is coughed up against the larynx, and starts a violent paroxysm. Sometimes the patient is so fortunate as to cough it out, with instant relief; sometimes, on the other hand, it becomes impacted in the rima glottidis, or is caught and held by the muscular spasm, and immediate death ensues. Often the patient is conscious that it shifts its position. Some- times it can be heard and even felt from the outside. 3. In the Lungs. — When a foreign body is lodged in one of the bronchi there is rarely the same urgency. Dyspnoea, cough, copious expectoration, pain, and anxiety are all present, but the distress is not so extreme, and there is not the same sense of impending suffocation. If it lies in one of the large bronchi, valuable evidence may be gained from an examination of the chest. If the ob- struction is only partial, the movement on that side is diminished, the respiratory murmur is fainter, and, generally, an unusual whistling sound is heard as the air rushes past the obstruction, unless this is drowned by the coarse rales caused by the large amount of secretion that is poured out. On the other hand, should the whole of one lung or one lobe be shut off, vocal fremitus and the normal vesicular murmur are wanting, and, after a time, the percussion note becomes dull, while the respiration in the rest of the lung is puerile. Inflammation, when a foreign body is in the lung, may be long delayed 820 DISEASES AND INJURIES OF SPECIAL STRUCTURES. (especially if it is of an unirritating character), but it always breaks out at last. Suppuration sets in, abscesses form and lead to the destruction of the lung ; gan- grene, hemorrhage, or empyema may occur ; tuberculosis may break out, and the end nearly always comes within a few weeks, though sometimes not for years. Only exceptionally ha.s the foreign body found its way out at length through the wall of the thorax in the pus of an em])yema. Diagnosis. — In the ai)sence of history this is often impossible; no single symptom is i)eculiar to this accident. Many cases have occurred in which the presence of a foreign body has never been suspected (especially in the lungs) ; and nearly as many in which the suspicion has been wrong. In children the difficulty is peculiar great. Asphyxia may be caused by a foreign body driven into the ])harynx ; but as a rule, there is no time for exact diagnosis ; if it is not dislodged at once by the patient's own efforts or by the introduction of the finger into the throat, instant laryngotomy affords the only hope. Inflammatory affections, croup, esjiecially in children, and laryngitis, are more clifticult. The most important feature is the rapidity of the onset, and the extreme urgency of the symptoms, without, at first, any rise of temperature or sign of fever. In spasmodic croup, inspiration is more difficult than expiration. Hysteria, reflex irritation arising from disorders of the digestive tract, e.specially in children, spasm and oedema of the glottis, even aneurysm of the aorta, and whooping-cough, occasionally give rise to difficulty, especially if there is a history of a foreign body having disappeared from the mouth at the time of the onset. It is more common for a foreign body to be overlooked. If the symptoms are very acute, partictdarly if there is violent suffocative cough recurring in spasms, it is probable the foreign body is in the larynx, or else that it is loose in the trachea, and is coughed up against it. When they are severe at first, and subside without expulsion, it has probably either become lodged in one of the ventricles or has passed down in the bronchi. Treatment. — In some cases the symptoms are so urgent that laryngotomy (as being the most speedy) must be done at once with anything that is at hand. Even when the pulse can no longer be felt at the wrist, this may succeed with the help of artificial respiration. When not so urgent, and when, as usually happens, the patient is seen for the first time after the immediate paroxysm has subsided, the first thing is to ascertain the position. If it is in the larynx it may be extracted by means of the laryngoscope and laryngeal forceps. A 5 per cent, solution of cocaine brushed once or twice over the mucous membrane renders it white and perfectly insensitive, so that thorough examination can easily be carried out without fear of spasm. Or the same effect may be produced, though not nearly so well, by the prolonged application of ice, by the inhalation of chloroform vapor, or by injecting a small quantity of morphia just over the superior laryngeal nerve, at the greater cornu of the hyoid bone. If this fails, the choice lies between subhyoid jjharyngotomy, laryngotomy (or laryngo-tracheotomy, if more space is recpiired) and vertical division of the thyroid cartilage, according to the nature and position of the foreign body. Then it must either be extracted through the wound or pushed up from below. In no case should a patient be left without assistance if there is a foreign body in the larynx or floating in the trachea, especially if there has been already a severe attack of spasmodic dyspnoea. When it has passed beyond the larynx, and is fixed either in the trachea or in the lungs, there is not the same degree of urgency or of immediate risk to life. Tracheotomy, however, is usually advisable. It is true that it has been shown by statistics that in a very large proportion of cases expulsion takes i)lace without ; and, still further, that the percentage of deaths in those cases in which trache- otomy has been performed is higher than those in which it has not ; but I think it will be granted that, given any individual ca.se, the chance of safe expulsion is SCALD OF THE GLOTTIS. 821 B'iG. 349. — Golding-liird's Dilator. much greater after the trachea has been oiiened, and that the risk to life is not appreciably increased by the operation. No cannula should be inserted ; retractors, easily made with a piece of bent wire, should be fixed in the tracheal opening and fastened around the neck with an elastic band, so as to keep up a certain degree of tension upon the orifice, or Golding-Bird's dilator may be used. Sometimes expulsion is immediate, or the foreign body is coughed up so that it projects in the tracheal wound, or it is dislodged by inversion com- bined with compression of the thorax, especially if it is round in shape and of some weight ; emetics and sternutatories have been successful, but no reli- ance can be placed upon them ; or it may not happen for some days. There are many instances in which a cannula has been inserted and worn for some time, and then, quite unexpectedly, perhaps from changes it undergoes itself, or from ulceration around it, the foreign body has suddenly become detached and been expelled. If this does not take j)lace within the first four or five days, the air-passages must be explored with probes, hooked at the end, tracheal forceps (either Gross's, w^iich are made of German silver, so that they can be bent to any shape, or Mac- kenzie's or Durham's which are so contrived as to open only at the extremities), and even with the finger. All these attempts cause violent expiration, and some- times in this way, sometimes by being actually hooked up, foreign bodies have been extracted even from the right bronchus. Care must be taken, however, not to mistake the rigid angle between the bronchi for one. Much depends upon a knowledge of the shape ; tubular bodies may be laid hold of at the margin, or drawn up by passing both blades of a pair of forceps inside, and then separating them ; the worst of all are puff-darts, which become firmly wedged in. Afterward the same precautions must be taken as after tracheotomy ; the pa- tient must be confined to his room, the air kept warm and moist, the wound covered wath moistened gauze, and, so long as there is any fear of spasm or oedema of the larynx, the cannula should be retained and the patient fed by an oesopha- geal tube. A certain amount of thickening and irritation of the mucous mem- brane, wdth profuse expectoration, and, possibly, the growth of granulations, is very likely to persist for some time. In older cases, when some length of time has elapsed since the entry of the foreign body, the question of surgical interference must be guidied mainly by the condition of the lungs. Scald of the Glottis. In gas explosions and fires the pharynx is occasionally burnt, from the heated air or flame being drawn into the mouth ; scalding is more common, especially in young children, from trying to drink out of the spout of a kettle. In either case the chief danger arises from the injury to the upper part of the larynx, which may be badly hurt from the flame or steam being sucked down into it by the inspira- tion which precedes a scream. The ojsophagus usually escapes, unless there is a determined attempt to drink the fluid, and it is thrown at once to the back of the mouth. Unless the accident is seen, or there is other external evidence, the diagnosis must usually be made from the sudden onset of extreme dyspnoea. The lips and mouth may be blistered, but they often escape, as the fluid passes right to the back and is ejected through the nose. There is constant screaming, until, partly from exhaustion, partly from swelling and oedema, the voice is completely lost, and nothing can be heard but a hoarse, croupy inspiration. Dyspnoea may be 82 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Fig -Qidema of the Glottis, behind. present from the first ; often it sets in with much greater severity after a few hours, especially toward evening; the pain is very se- vere ; swallowing is almost impossible ; and even in children there is the most terril)le apprehen- sion. If the finger is introduced into the mouth the epiglottis can be felt hard and shriv- eled, and, pa.ssing back from each side of it, __^ 7T^'«M ^^^^ smooth rountled bodies, which project up- if ; JSSMx^^^a^l fli'l' ward on either side of the aperture of the larynx \. ^ >mlKK^^^m(\- M '■\i and almost clo.se it. These are the aryepiglot- tic folds, which become cedematous and swell up to such an extent that when the tongue is depres.sed they may be seen as shining, rounded, semi-translucent mas.ses, reaching nearly to the middle line. In severe cases the mucous mem- brane at the base of the epiglottis, the false vocal cords, and even the larynx below the rima glottidis, are more or less in the same con- dition. Death may occur from asphyxia within a few minutes of the accident ; more often the n from tlyspncca becouics worse and worse ; the voice is comi)letely lost ; inspiration is hoarse and croupy, the lower ribs sinking inward at each attempt ; and the child sits propped up, perfectly quiet, with its chest thrown forward and its chin upward, so as to secure the greatest muscular aid. The face is pale and cyano.sed, the lips dusky, the forehead covered with beads of perspiration — in short, there are all the signs of imminent suffocation. Later, if spasm of the glottis does not set in and prove immediately fatal, death may occur from exhaustion, from broncho-pneumonia due to extension of the inflammation, or from collap.se of the lungs. P>en in the slightest case the prognosis is very un- favorable. Treatment. — The first object is to prevent the inflammation spreading, and to protect the mucous membrane. When this is inflamed, and the cavity of the glottis already narrowed, the slightest irritant, one that under ordinary conditions would merely cau.se a transient cough, may bring on an attack of fatal spasm. The air must be kept warm and moist, without, however placing the child in a steam bath ; ice must be placed round the neck by means of a collar ; leeches may be applied outside ; and the child must be kept perfectly quiet, sitting up. In adults, the hyperemia and .sensitiveness of the mucous membrane may be kept in check by constantly sucking ice. Small doses of calomel (gr. j to gr. ij) every hour until there are free bilious evacuations, or very small ones of antimony or aconite, may be given in vigorous children if the fever is setting in with severity ; and if there is much secretion, an emetic — alum for example, which does not cause de])ression afterward. If, however, the dyspnoea continues to increase, jmrticu- larly if there are recurrent attacks of si)asm, and if the chest-wall is beginning to fall in, there is no choice but free scarification of the aryepiglottic folds, intuba- tion, or tracheotomy. The first of these is easily carried out with an ordinary bistoury, the edge of which is guarded up to within a third of an inch of the point with a spiral piece of strapping ; the forefinger of the left hand acts as a guide, and free incisions may be made without danger. I have known this followed by considerable relief, but as a rule it is only temporary. Intubation is more difficult to carry out, and requires sjjccial appliances, such as MacEwen's or O'Dwyer's tubes ; but this or tracheotomy must be resorted to. unless scarification affords distinct and lasting relief. It is true that, especially in children, opening the trachea is a serious operation, and adds an additional cause for the broncho-pneumonia which so commonly sets in ; but, it enables the child DIFFUSE INFLAMMATION OF CELLULAR TISSUE. Zit, to breathe freely, for a time at least ; it prevents exhaustion and the continued battling for air ; it stops the collapse of the lung and the danger of hepatization ; and it is the only effectual protection against spasm. If it is reserved to the last, and only performed in cases that are already desperate, the ill-success that attends it should not be laid entirely to the credit of the operation. INFL.AMMATORY AFFECTIONS. Owing to their exposed position, all the tissues of the neck are very liable to be attacked by inflammation ; the spine, for example may become the seat of tu- bercle, syphilis, or osteo-arthritis ; the muscles may be attacked by rheumatism ; gummata may develop in them (especially in the sterno-mastoid) ; or the sheaths of the nerves may become involved ; but, with the exception of the cellular tissue and the lymphatic glands, separate description is not required. Diffuse Inflammation of the Cellular Tissue. This is especially serious from the arrangement of the cervical fascia. It may be caused by poisoned wounds (either of the skin or the mucous surfaces) ; by in- fection through the blood-stream, as in pyaemia, or by extension from some neigh- boring focus of disease, alveolar abscess for example, suppuration in the floor of the mouth following operation, tonsillar abscess, and especially the periglandular inflammation that occurs in scarlatina and diphtheria. The intense depression characteristic of these disorders, lowering the vitality and the power of resistance of the tissues, is probably the cause why it spreads with such rapidity and so widely The symptoms are very grave from the first ; often there is a rigor ; the tem- perature rises rapidly ; the pulse is quick and feeble and delirium soon sets in. The pain is intense ; the head is fixed ; the tongue, if the sub-maxillary region is involved, forced up into the mouth ; the jaws hardly able to move ; and swallow- ing almost impossible. The skin is swollen and puffy ; the superficial veins are distended, and all the tissues of the neck hard and tense. If left to itself, the fascia may yield and allow the exudation to make its way toward the surface and point by the side of the neck ; but the inflammation is more likely to spread, in- volving one layer after another, until either the patient dies from acute blood- poisoning, or the mediastina are implicated, and pleurisy, pericarditis, or retro- sternal suppuration is added to the rest. Early and free incision is the only course. The patient should be placed under an anaesthetic ; an incision, an inch and a half or two inches in length, made over the most prominent part of the swelling, the deep fascia divided to the same extent upon a director, and if this does not give sufficient relief, the point of the director thrust into the middle of the swelling, and followed up after Hilton's method, with dressing forceps. Afterward a large drainage tube should be inserted, and the discharge encouraged as much as possible. The direction of the incision must be parallel to that of the main vessels, and it must be very carefully made, as it is not always possible to ascertain how far they are displaced. Even when the inflammation is not so severe as this, extensive destruction is by no means uncommon ; and sometimes, especially after scarlatina, profuse hemorrhage occurs about the time that the sloughs are separating. If it comes from the carotid or the jugular, an attempt must be made to find the bleeding point and isolate it for ligature, tracing it for some little distance up or down, as the case may be, so as to get clear of the sloughing part ; but if, as usually is the case, this is impossible, all that can be done is to apply styptics and pressure. The cavity must be cleansed and dried as thoroughly as possible, well covered with iodoform, and then plugged with iodoform gauze ; but the prognosis is very grave. 824 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Inflammation of the Lymphatic Glands. The cervical glands are especially liable to attacks of inflammation. Eczema capitis in infancy, and the eruption of the teeth and affections of the throat in childhood and youth, maintain in many cases a certain degree of chronic hyper- ajmia. Usually this subsides when the cause is removed ; but sometimes, before this can be done, other irritants make their appearance on the scene, and find'in the impoverished and weakened gland tissue the soil that suits them best. The pyogenic micrococci, for example, may gain access to them through abrasions of the mucous surface. If they are in sufficient number, or the tissue resistance is sufficiently enfeebled, suppuration follows, without much energy or constitutional disturbance, if the general nutrition is good ; but with the utmost virulence, leading to sloughing phagedsena, or diffuse cellulitis, if the vitality is depressed by any form of blood poisoning, scarlatinal, diphtheritic, or septicaemic. In other cases the tubercle bacilli are the irritant, entering in the same way. The glands slowly enlarge, caseate in the centre, and then break down. The capsule gives way, the caseous fluid penetrates into the circumjacent cellular tissue, infecting it wherever it spreads, and at length, after traveling long distances in all directions under the deep fascia, it makes its way out through this at some point and discharges on the surface, leaving behind it typical scrofulous sinuses. Syphilitic inflammation is characterized by the sudden enlargement of all the cervical glands at the same time, the onset of the secondary period. Suppuration is very rare, but complete resolution is often long delayed, and the least cause — mere exposure to a draught — is enough to bring back the swelling and make them tender and painful. Slight enlargement of this character is one of the most com- mon causes of stiff neck. Other forms of specific inflammation, occurring in connection with leprosy, plague, glanders, or actinomycosis are too rare to deserve special mention. Diagnosis. — Acute inflammation rarely presents any difficulty ; the pain, heat, and tenderness on pressure are sufficient to indicate what is taking place, although it is impossible to say whether the mischief is commencing in the gland itself, or, what is more frequent, in the cellular tissue round it. The distinction is not material, as in either case the treatment is the same ; if, after the cause has been removed, the inflammation does not subside with rest and cold, if the swell- ing continues to increase, and particularly if the skin becomes cedematous, an incision must be made through the superficial structures and a director used to explore, after Hilton's plan. Chronic inflammation is distinguished by the lobulated, chain -like character of the swelling, and seldom gives rise to any difficulty, except in the case of some of the varieties of lymphoma and lymphadenoma. Tubercular infiltration is marked by the slow, painless enlargement, involving one gland after another, and by the gradual softening and breaking down ; syphilitic disease by the firm, hard outline, the retention of the natural shape, and the very slight tendency to infil- trate or adhere to the tissues around. The treatment, as detailed already, is entirely dependent upon the cause. Torticollis. Wry-neck is due to irregular contraction of the muscles twisting the head. The sterno-mastoid is the one usually in fault, sometimes the only one, but the others and the cervical fascia often aggravate the evil. It may be primary, caused by disease of the muscle itself (this is usually distinguished as the congenital variety) ; or secondary, arising from inflammation of some of the structures near (the joints, vertebras, lymphatic glands, etc), or from a disordered condition of the nervous system. {a) Congenital torticollis is rarely noticed until some time after birth. This arises partly from the shortness of an infant's neck, partly from the fact that the TORTICOLLIS. 825 deformity itself is not nearly so well marked at this time of life as it is later. How- it originates is uncertain. Probably it is due to partial rupture of the muscle at the time of parturition ; at least a tender, ovoid mass is not unfrequently found, shortly after birth, in the sternal head of the sterno-mastoid, just where the tendi- nous and muscular fibres meet, and in several cases wry-neck is known to have been present later in life. The back of the head is drawn down ; the chin is directed toward the oppo- site side, so that the face looks somewhat upward, and the muscle itself stands out like a tense cord, with a hollow in front and behind. The sternal portion is usually the chief offender, and in bad cases the mastoid process may be dragged down so far as to lie immediately over and scarcely an inch from the sterno- clavicular articulation. As a result, the cervical vertebrae become twisted and deformed ; secondary curves make their appearance in the back ; the under side of the face does not grow in proportion to the rest, the line of the eyes becomes oblique, and, if the condition is not remedied before puberty, even the breast fails in its development. If the deformity is detected in time, an attempt may be made to prevent it by massage and passive motion, but nearly always tenotomy is required sooner or later. The only rule is to divide everything that prevents the full range of move- ment, both heads of the sterno-mastoid nearly always, and very often the cervical fascia as well, taking care, however, to avoid injuring the great vessels of the neck, which are frequently displaced. An anaesthetic is always advisable. The assistant, as in other cases of tenotomy, should hold the head so that the bands are relaxed while the tenotome is being passed behind them, and tightened up when the blade is in position. Separate punctures should be made wherever necessary ; the divi- sion of both heads of the muscles through one opening is only to be preferred when it is less dangerous than doing it through two, and a blunt-pointed tenotomy knife should always be used after the preliminary puncture has been made. The usual situation is about half an inch above the clavicle, but that spot should be selected at which the fibres stand out most distinctly, and the division should always be from behind forward. The little wounds should be sealed with iodoform or collodion, and the head brought as far as possible into a straight line at once. The extent to which this is possible depends partly upon the completeness of the division, partly upon the alteration in the cervical spine. If the patient is sufficiently old to appreciate the importance of the result, mechanical contrivances can usually be dispensed with ; friction, shampooing, passive motion, carrying a weight in the hand, and, above all, the use of a looking-glass, generally suffice not only to secure the desired effect, but to prevent relapse. In the case of children, however, and where, owing to the altered shape of the vertebrae, there is fear of recurrence, it may be necessary either to make use of a spinal support with a jury-mast, so as to secure oblique traction, or, what is nearly as efficient when properly looked after. Little's arrange- ment of strapping. One broad band is fastened horizontally round the head, a second round the waist, and a strong webbing strap with a rubber accumulator attached behind the ear on the sound side and below in the opposite nipple line. In old cases a second operation is often required to divide the bands of cervical fascia. (Ji) Acquired torticollis may be due to rheumatism or exposure to cold, or it may be symptomatic of inflammation of the lymphatic glands, the vertebra, or other structures in the neck, the muscles (for in this case the splenius and others are in a state of tonic spasm as well) contracting to save the affected part. In many of these cases the diagnosis of the exciting cause is exceedingly difficult, and very great care is required, as cervical caries is by no means uncommon. Tonic torticollis of this character can always be distinguished from the congenital variety by its relaxing completely under an anaesthetic, and by the absence of any short- ening of the cervical fascia. The other variety of acquired torticollis — that which occurs in connection S3 826 DISEASES AND INJURIES OF SPECIAL STRUCTURES. with disease of the central nervous system — is seldom met with until late in life, and is distinguished by the clonic character of the convulsions. The head can only be kept at rest by means of some external support ; as soon as it is left the muscles are seized with clonic spasms, which grow worse and worse as the patient attempts to control them. Sometimes one side only is affected ; more fre(iuently both, and in many instances other muscles as well. Massage, galvanism, counter- irritation, faradization of the opposing groups, and many other remedies have been tried without much benefit. Occasionally relief is obtained by bromide of potash, but it seldom lasts long. Neurectomy of the spinal accessory holds out a better prospect when only the sterno-mastoid is involved, especially if a large por- tion of the nerve and its connections with the cervical plexus are removed ; but in most instances the other muscles are affected as well. Tumors of the Neck. A very large number of the tumors of the neck are of congenital origin, although they may not begin to enlarge or become prominent until late in life. Nccvoid growths are fairly common. In most cases they consist of nothing but dilated veins and capillaries (the so-called blood-cysts of the supra-clavicular region) ; but not unfrequently they are associated with a variable amount of fibrous and fatty tissue, or w'ith hydrocele of the neck — in all probability a similar affection of the lymphatics. They can usually be recognized by the effect of gentle pressure ; but, if there is much solid tissue, or many phleboliths, and if the history is vague, the diagnosis is simply a matter of conjecture. The only satis- factory treatment is excision ; but as they may extend long distances under the muscles (in one case of a mixed nasvoid and lipomatous grow^th under my care, the supra-clavicular and subscapular regions w^ere completely dissected), and, not unfrequently, communicate with the jugular veins, the operation should not be lightly undertaken. Hydrocele of the neck, co/ige/iitai cystic hygroma, or lymphaJigeioma cxsticiim, has already been described. It may jje present at birth, or may not cause any conspicuous enlargement until adult life. Sometimes it occurs under the jaw, more frequently in the supra-clavicular region, extending into the axilla. It may be unilocular (the term hydrocele of the neck is sometimes re.served for this) or composed of numbers of cysts of all sizes, mixed with fibrous or fatty tissue. Generally the fluid they contain is clear and serous, but it may be red, chocolate- brown, or green, according to the amount of blood mixed with it and the changes it has undergone. Naturally, therefore, the degree of translucency is very vari- able. These growths not unfrecjuently extend very deeply into the neck ; they may pass the middle line, reach down into the thorax, surround the great vessels, and even extend ujiward into the occipital region. Oenerally i)art of them is superficial and the diagnosis easy, but sometimes they are altogether buried behind the trachea, or in the mediastinum, so that it is impossible to ascertain what their nature is. In some instances a fatal result has been caused by pressure upon im- portant organs ; in others, it has followed from deep-seated suppuration ; dis- api)earance, without operation, is very unusual. The treatment must be very cautious. Simple cysts may be tapped and drained, and the same thing may be done in the case of individual ones of larger growth ; but, though this gives temporary relief, they often refill. Injections of iodine and setons have succeeded, but in many cases they have caused diffuse attacks of inflammation, and even death has occurred. Excision is only possible when the growth is small and superficial. Repeated incision and drainage, care- fully avoiding suppuration, offer the best prospect. Hyo-lhigiial Cysts. — Another variety originates in connection with the hyo- lingual canal. This extends in the foetus from the foramen caecum to the hollow of the hyoid, and thence onward to the pyramidal process of the thyroid body. Part is developed from the stomatodreum (the lingual portion probably only), part TUMORS OF THE NECK. 827 from the liypo-pharyngeal diverticulum, around which tlie thyroid originates. In the infant the former often persists; the rest usually disap])ears or remains, as the levator glanduh\2 thyroidea:, the pyramidal lobe itself, the ligament extending from it, or the cysts that are so frecpiently developed near its a}jex. Some of the cysts that are formed from this are dermoid, containing sebaceous matter and hair (the lingual canal itself is epiblastic) ; others are simple and unilocular, filled with serum ; in others again, papillomatous and villous growths make their appearance (these are usually regarded as accessory thyroids, and may occur in the larynx and trachea), and sometimes again, they undergo malignant degeneration, and pass into a form of cystic epithelioma. Brancliial Cysts. — Congenital cysts, growing down to and involving the sheath of the great vessels, may develop from the lining of the branchial clefts at the side of the neck. Sometimes they are associated with branchial fistula. Their contents (they may be sebaceous or mucous) vary according to the character of the epithelium from which they spring. In addition to these growths of congenital origin, tumors of all kinds origi- nate in connection with the various tissues and structures in the neck. Sarcoma, lipoma, fibroma, and even enchondroma, may develop in the cellular or fibrous tissue (the last-named possibly from rudiments of the branchial cartilages) ; exos- toses, enchondromata, and myeloid sarcomata from the bones ; fusiform and sac- culated aneurysms, arterio-venous aneurysm and aneurysmal varix from the vessels, and molluscum, sebaceous cysts, papilloma, and epithelioma from the skin. The lymphatic glands present still greater variety. In addition to lymphoma, lymphadenoma, and sarcoma (growths originating in them), and to the various forms of specific inflammation (tubercle, syphilis, glanders, leprosy, etc.), which affect them and cause them to enlarge to such an extent that they are often desig- nated tumors (in spite of their inflammatory origin), they are liable to be the seat of secondary malignant growths of all kinds. Epithelioma of the lip and tongue affect the submaxillary ones ; sarcoma of the tonsil, those along the carotid sheath ; scirrhus of the breast, the supraclavicular chain ; and epithelioma of the oesophagus, the deeper ones that run down to the mediastinum. Carcinoma of the larynx, on the other hand, does not extend to them until late in the course of the disease. Epitheliomatous glands in the neck, especially behind the angle of the jaw% are peculiar in often becoming cystic, the central mass undergoing caseation and liquefaction. When this occurs, they increase rapidly in size, the skin over them becomes red and thin, and, not unfrequently, they burst and give way, discharging a mixture of caseous debris, blood and serum. Sometimes the hemorrhage is very serious. Tumors in connectioJi with the thyroid body (which are described separately) are distinguished by their rising and falling with the trachea in deglutition. Bur- sal cysts, which may occur over the thyroid cartilage, or the thyro-hyoid membrane, are known by their chronic character, by the age at which they occur, and by the thinness of their walls and the character of their contents. Hernia of the pharynx i^pharyngocele) or oesophagus (a protrusion of the mucous membrane through a defective portion of the wall, causing a great sac to develop behind the carotid vessels) may be diagnosed by its position, the variation in its size from time to time, and the pa.ssage of a sound. It may be congenital or acquired ; but if it gives rise to inconvenience, the only course is to excise it. Tracheocele (a similar protrusion between the cartilages of the larynx or trachea) is distinguished by its containing air, and by the variation in its size on forced expiration ; usually it projects in front. Gummata may occur in the muscles, especially the sterno-mastoid, or masses of bone may develop in them as a result of osteo-arthritis, or after strains. The sterno-mastoid induration of infants is probably traumatic, due to partial rupture and coagulation of the blood inside the sheath. 828 DISEASES AND INJURIES OE SPECIAL STRUCTURES. Operations on the Air Passages. Larxngotomx is performed in the crico-thyroid space. It is not suitable for children, and only for adults in cases of emergency or when a tube has to be used for a short time, during an operation, for example. The space is much too small (unless the cicro-thyroid and lateral crico-arytenoid muscles are incised) to admit of the removal of a foreign body or a i)apilloma. The question of an anaesthetic depends upon tlic urgency of the operation. The patient's head is thrown back as far as possible, while the neck rests upon a firm support, and the crico-thyroid space identified. A longitudinal incision is made exactly in the middle line over this, and the larynx opened by dividing the membrane transversely immediately above the cricoid cartilage. The crico-thyroid arteries are seldom injured, but if there is any hemorrhage the bleeding points can be secured at once with Wells' forceps. A laryngeal cannula, which is shorter than an ordinary tracheal one and flattened from above downward, can then be fitted in at once. Tracheotomy x'i required much more frequently. It may be performed for the relief of obstruction, whether it is temi)orary (as in croup, diphtheria, oedema of the glottis, or muscular spasm) or permanent (as in syphilitic stenosis) ; for the removal of foreign bodies ; to give rest to the larynx in cases of painful ulceration ; or as a precaution in operations in order to prevent the entry of blood. The trachea may be opened either above or below the isthmus of the thyroid ; but, unless there is some special indication to the contrary, the former should always be selected. The anterior jugular and inferior thyroid veins are in close relation with the lower part. The innominate artery bifurcates almost on it, and sometimes reaches far up into the neck. The thyroidea ima may cross it. It lies very much fiuiher from the surface and is much more easily displaced to one side. In infants, too, the thymus may cause a certain amount of difficulty. Except in cases of great emergency, an anaesthetic should always be given. Chloroform is better than ether, as it is less irritating : very little is required, especially in the case of children, as it is not necessary to induce absolute anaes- thesia. The recumbent position is the most convenient, the head, if the breathing will allow it, being thrown back, and the neck supported by a small but firm pillow or sand-bag. As there is sometimes a little difficulty in identifying the cricoid cartilage, a careful examination must always be made first. The incision must be two inches in length, beginning on the margin of the cricoid cartilage (unless it is wished to include this, as in laryngo-tracheotomy), dividing the skin and exposing the anterior layer of the deep fascia. If the assistant holds the head perfectly straight and the surgeon's hand is a light one, there is no need to fix the trachea yet. The skin can be made sufficiently tense by drawing it down upon the sternum. The next step is to identify the white line that marks the interval between the muscles. At this level they are not in contact, and the only structure in front of the trachea (with the exception of veins) is the cervical fascia that passes across from one to the other. To see this clearly the edges of the incision must be gently separated with the forefinger and thumb of the left hand, steadying the trachea without compressing it. Retractors held by an assistant nearly always displace it. The next proceeding varies according to the operator. Carefiil dissection with a scalpel until the rings of the trachea are thoroughly exposed used to be the invariable rule, but now there are many modifications. Whitehead advocates splitting the fascia from above downward with a raspatory (even a steel director may tear the veins) until the isthmus is reached. This is pushed down, and the trachea laid bare at once. Parker only makes two incisions, one to expose the white line, the other from below upward, through it into the trachea. Bose recommends a transverse incision through the fascia on the cricoid cartilage ; a blunt hook is then introduced into the slit and passed down behind the thyroid, and everything that lies in front pulled toward the sternum until the first three TRA CHE O TO MY. 829 rings are exposed. This has been called the bloodless method, and may be prac- ticed when there is a large plexus of distended veins, so placed that it would be difficult to avoid injuring them in any other way. Parker's method undoul)tedly shortens the o])eration, avoids shock, and lessens the size of the wound and the absorbing surface (a matter of great moment), but it can hardly be recommended unless the operator is thoroughly experienced. In actual practice each case must be judged upon its own merits : in some, it may be advisable to open the trachea at once ; occasionally it must be done, as respi- ration may cease with the shock caused by the first incision ; but in all alike it is necessary to expose and recognize the interval between the muscles, to keep exactly P'iG. 351. — Trachea Dilator. in the middle line, to avoid wounding the veins, and to make the deep incision from below upward. Undoubtedly it is safer not to open the trachea until it is thoroughly exposed ; and this should be the rule ; but, on the other hand, tedious dissection is equally to be avoided. The isthmus of the thyroid gives very little trouble : it can be pressed up or down by the finger without difficulty. [Some operators prefer to divide the isthmus between a double ligature.] Great care must be taken to open the trachea exactly in the middle line. The upper three rings should be divided, but not the cricoid. As soon as this is done the edges of the tracheal wound should be held Fig. 352. — Parker's Suction Apparatus. The cylinder is filled with antiseptic cotton-wool. open with dilating forceps until the immediate disturbance consequent on the change of breathing has subsided. Sometimes respiration ceases altogether, the abundant supply of oxygen causing apnoea. Sometimes rapid expiratory efforts are made : coughing, of course, is impossible. In cases of croup or diphtheria advantage may be taken of this to clear out any false membrane that can be seen. Parker recommends sweeping round the interior of the windpipe with a feather dijjped in a solution of soda or borax in order to detach and bring away as much as possible ; and, if this does not succeed, suction either by means of a ball- aspirator or a properly guarded mouth-tube (Fig. 352). The immediate applica- tion of the mouth to the wound must be absolutely condemned. 830 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The size c^ the trachea differs even at the same age, and this, of course, determines the diameter of the cannula; its shape must depend upon the part of the windpipe opened. Durham's and Parker's (Figs. 353 and 354) are the most satisfactory, the latter, however, owing to the absence of a guide, is occasionally a little difficult to introduce. Quarter-circle and bivalve tubes should never be used. Morrant Baker'srubber ones answer exceedingly well when the wound has assumed a definite shape, the amount of discharge often beginning to diminish at once. In most cases a double tube is necessary for purposes of cleansing (Parker dispenses with it when there is a well-trained nurse), and the inner one should project slightly beyond the outer, so that the latter may not l)ecome clogged. In addition, the collar of the tube should be movable, that it may accommodate itself to the action of the trachea in swallowing. There need not be any hurry about the introduction of the tube ; the wound can be held open with dilating forceps for a minute or two, the trachea thoroughly cleared, search made for a foreign body (in this case it is sometimes advisable to fix the edge of the trachea temporarily to the skin), or a suture passed through the lower part of the wound ready to fasten. Then the cannula may be quietly intro- duced on a pilot, if its construction admits of it, and, the guide being withdrawn, secured by means of a tape round the neck. In this way there is no fear either of Fig. 353. — Durham's Cannula with Pilot. Fig. 354. — Parker's Cannula. passing the tube between the trachea and the fascia or of leaving it in its proper position, but blocked with false membrane. No operation in surgery is so frequently bungled as tracheotomy ; easy as it appears on the dead subject, on a child with a short, fat neck, suffering from extreme dyspnoea, it is entirely different. Waste of time should, of course, never be permitted, but hurry is a great deal worse. The cricoid cartilage has been mistaken, the trachea pushed to one side and missed altogether (it is very easy in a child), the opening hacked or made on one side, the posterior wall cut into, important veins wounded, and the carotid, the innominate, and even the sac of an aneurysm laid open. This cannot hai)pen if the head is held straight, the incision made of sufficient length and exactly in the middle line, and if the operator feels from time to time what he is doing. If, after the first incision, he presses the skin on either side backward with his thumb and forefinger, the trachea is fixed in the middle between them without being compressed, and is kept well up in the wound. Hemorrhage occasionally is unavoidable. If an artery is cut its end should be clamped at once, and a large vein may be treated in the same way. Generally, however, the source cannot be detected ; it comes from the small vessels of the plexus betw^een the layers of the fascia, all of which are distended, owing to the dyspnoea. In these circumstances it is often advisable not to wait, but to open the trachea at once ; as air enters and the right side of the heart becomes relieved, the veins empty themselves and the hemorrhage ceases. Holding the TRA CHE O TOM Y. 831 trachea slightly forward with the dilating forceps helps to compress them and prevents the blood entering the lungs. When tracheotomy is i)erforme(l as a precautionary measure to prevent the entry of blood into the lungs during the course of an operation, the incision and various steps are the same, but a tami)on is inserted instead of a simple trache- otomy tube. The two best known are Trendelenberg's and Hahn's. Each consists of a tracheal tube, but in the former a dilatable rub- ber collar is used to block the space around it, between it and the mucous membrane, in the latter compressed sponge. Of the two this appears to be the better ; it is not so likely to slip or give way, but in all operations, except those on the larynx itself, a simple tracheotomy tube with a sponge (attached to a string), to block the upi)er aperture of the larynx, answers equally well, and is not nearly so likely to get out of order. p,^. 355— Hahn's After-treatment. — This varies naturally with the cause : it Tampon cannula , , 111 1 ' 1 1 • covered with com- must always be remembered that tracheotomy only reheves a symp- pressed sponge im- tom or prevents one ; the original trouble still remains. form"^'"^ *"'' '°'^°' {a) In the simplest case — chronic laryngeal stenosis, for instance, in \vhich there is no pulmonary complication — all that is needed, pro- vided the tube fits, is something to warm and moisten the air before it enters the lungs, and a dry absorbent dressing around the orifice to diminish the amount of discharge and lessen the risk of broncho-pneumonia and cellulitis. The patient should be kept as quiet as possible in a semi-recumbent position, and well pro- tected from draughts. A bronchitis kettle may be used, but it is better, for a time, at least, to protect the orifice with a thin, flat sponge, wrung out of hot water, so as to filter the air thoroughly. The wound should be powdered with iodoform, and the flanges of the cannula prevented from pressing upon it by little pads of absorbent wool. The frequency with which the tube requires changing depends upon the amount of irritation it causes ; a rubber one can often be introduced on a proper dilator by the second day. In cases such as these, there is very little of that tenacious mucus which is so troublesome in croup or diphtheria. For the first itw days the patient should be fed through the rectum ; the movements of the trachea in swallowing are very painful (cocaine sprayed over the wound prevents this to some extent), and there is great risk of fluid trickling down the larynx and pa.ssing by the side of the tube into the lungs. This may happen even after the cannula has been removed, if the larynx has not thoroughly recovered, but usually there is no danger after the wound has healed, and the patient has grown accustomed to the change of respiration and learned how to cough. If the rectum becomes irritable or thirst is distressing, an oesophageal tube should be used instead. Tracheotomy tubes, if worn permanently, should be frequently changed and carefully inspected from time to time. Their duration of life varies very much, and instances have been known of their breaking and of the end falling down into the bronchi. It is always as well to protect the orifice with a suitable respi- rator. (A) In diphtheria the after-treatment requires even greater care. The air must be warmed and moistened, and the cot surrounded by screens, but the top should be left open. The tube must be kept clean by means of feathers dipped in a solution of bicarbonate of soda or potash (soda bicarb., gr. xx ; glycerini, jss ; aq. ad 5J), and if there is any membrane heard or seen floating in the trachea or larynx it must be cleared away in the same manner. Parker recommends that the solution should be sprayed from time to time over the wound to prevent the viscid mucus collecting and drying around the orifice. The frequency with which the inner cannula requires changing depends upon the success with which this is carried out. At first it may need it almost every hour, but it must be remembered that the process is an exhausting one, and, for a time, very alarming to a child, so that every endeavor must be made to keep the passage free without. Each cannula 832 DISEASES AND INJURIES OE SPECIAL STRUCTURES. sliould have a double set of inner tul)es, so that when one is removed and a feather has been passed down the outer to make sure it is clear, the second can be intro- duced without delay. The outer need only be removed once a day. To clear them they should be ])laced in a hot solution of soda and well scrubbed. How long the tube should be continued depends u])on the course of the dis- ease ; but, in any case, the metal cannula should be replaced as soon as possible by a rubber one (it can usually be done by the third or fourth day) and this should not be worn longer than is absolutely necessary. Before leaving it off an attempt must be made to educate the larynx again, and to reduce the amount of air jjassing through the tube, by using one that is perforated on the convexity or very much shortened. The child, of course, must be watched night and day by some one who can use dilating forceps and replace the cannula at once if there is any real danger. Instances of very great difficulty are met with every now and then ; dyspntea comes on as soon as the tube is removed, and the child seems absolutely imal)le to breathe through its larnyx. In a few cases this is due to a mechanical impediment, cicatricial stenosis, or the growth of granulations from the mucous membrane, caused by the irritation of the cannula ; but in the majority no reason of this kind can be found, nor can more than a small proportion be accounted for on the hypothesis of diphtheritic paralysis. Probably it arises not so much from any structural alteration as from the inability of the child to direct its efforts with sufficient energy, and from actual fright. Most cases recover as the child grows stronger by patiently trying again and again ; sometimes galvanism is of service, but in a few nothing succeeds, and, then, if no organic obstruction can be found, the only course left is intubation — passing a tube into the larynx, through the mouth or through the wound, and retaining it there. Either O'Dwyer's or Mc- Ewen's can be used ; the essential point is that the lower end should be just Ijelow the level of the tracheal opening. A tube of this kind can be left without being removed for twenty-four hours or longer ; but if it becomes blocked, so that it cannot be cleared by coughing, or if symptoms of exhaustion come on owing to the distress it causes, it must be removed at once, and under no circumstances may the child be left alone for a moment. Prognosis. — Care must be taken to distinguish between the consequences of the operation and those of the disease for which it is performed. Much depends upon the age of the patient ; in an infant it is always serious, the structures involved are so small and delicate, and there is such great risk of pulmonary complications, independently of croup or diphtheria. If the lungs are already collapsed and par- tially consolidated, if the patient is exhausted by prolonged battling against immi- nent asphyxia, or if he is dying from the diphtheritic poison, the operation can do no good ; it must not be blamed for the result, but it may hasten the end. If it is to be of any real service, or if the wound is to be used not merely to relieve a symptom but to attack the disease by removing false membrane and giving the patient pure air, not that which has been befouled by i^assing over a poisoned sur- face, it must be performed while there is still a reasonable hope. Inflammation of the cellular tissue of the neck is the most common complica- tion. There is always a little at the first, causing a certain amount of swelling and cedema around the wound, but it is seldom serious unless the parts have been much disturbed in the oi)eration or the vitality of the tissues is greatly impaired. Usually it subsides in the course of a few days ; sometimes, however, it forms an abscess around the trachea (especially if the tube has missed the opening when it was being introduced), and occasionally it leads to diffuse suppuration, which may even spread down to the mediastina and involve the pleura or pericardium. Care must be taken that the tape fastening the cannula is not too tight. Irritation of the mucous membrane of the trachea may be caused by the end of the cannula. Usually this is due to the fact that it does not fit. Ulceration of the anterior wall, leading to perforation, w^as a common result when quarter-circle tubes were used, and though this is much more rare at the present time, masses of INTUBATION OF THE LARYNX. 833 granulations due to the constant friction of the end are not unfrc(juent. Slight cases, if the growth is easily accessible, may he relieved l)y means of an alum sjjray, or by painting it with an astringent solution ; more severe ones may require an enlargement of the wound and the ap])lication of the cautery or a curette. In a few very rare instances the trachea remains irritable, even when a rubber tube is worn, without any perceptible cause. Diphtheria very seldom attacks the wound. It may l)ecome foul and sloughy from the constant irritation, l)ut it is rare to find a definite adherent membrane. If it forms it must be destroyed at once. I'hiiphysema is sometimes met with, especially when the cervical fascia is opened up irregularly, and it is said that the air may spread in the tissues until it reaches and fills the pleura. In addition to these there is always the risk of bronchitis and broncho-pneu- monia, caused by the entry of cold or dry air, foreign bodies, dust, food, blood, or the secretion of the wound ; and, of course, all the ordinary complications of irritated wounds, such as sloughing, erysipelas, etc., may occur as well. Larytigo-trachcotomy. — In this operation the cricoid is divided as well as the upper rings of the trachea. It may be required in the ca.se of children with very short necks, or be advisable w^hen there is a growth or a foreign body in the larynx. Under other circumstances it should not be performed, as it is liable to lead to serious impairment of the voice. Subhyoid pharyngotomy (opening the pharynx through the thyro-hyoid mem- brane) has been performed for the removal of growths and foreign bodies in the larynx. It should only be resorted to in cases in which extraction by the aid of the laryngoscope has failed or is unsuitable. Thyrofomy. — Median longitudinal division of the thyroid cartilage may be required under similar circumstances. Laryngo-tracheotomy is performed first and a tracheal tube inserted ; in the case of papillomata, which are often very vascular, a tampon is advisable to prevent any blood trickling down the trachea. In some cases this, or the division of the crico-thyroid membrane, is sufficient ; if not, the incision is carried upward and the two halves of the thyroid cartilage separated. The greatest care must be taken to keep exactly in the middle line, and if possible avoid wounding the anterior commissure of the cords. In children and young adults the incision may be made with a scalpel, and it may not be necessary to divide the whole length ; the elasticity of the parts is so great that sufficient room can be obtained without. In old people this is not possible, and in many instances a fine saw must be used. After the growths have been removed and the base from which they spring seared with chromic acid, the margins of the cartilage must be accurately adjusted and secured with wire sutures passed through the perichondrium. The tracheal tube should be left for some days, until all danger of inflammation is past and the parts are fairly well united. The patient must in the meanwhile be kept perfectly quiet ; talking, and especially coughing, prevented as far as possible ; and all sources of irritation avoided. The voice is very likely to be impaired : not, perhaps, so much from inaccurate adjustment as from the subsecjuent cicatrization and contraction. Intubation of the Larynx. This method of treating temporary occlusion of the glottis has recently been revived by MacEwen (for adults) and O'Dwyer. The former employs long cylin- drical tubes after the pattern of gum-elastic catheters, introducing them through the mouth and changing them every twelve hours ; the latter much shorter ones, which (if not coughed up) may be left in situ for a fortnight, resting upon the ventricular bands without i)assing through. The shortest are an inch and a half in length ; the longest three. At the upper end is a diamond-shaped head flat- tened in front and provided with a small eye to carry a thread. Below is a neck which expands into a fusiform enlargement. Each tube is provided with a jointed 834 DISEASES AND INJURIES OE SPECIAL STRUCTURES. guide, which can be screwed on to an introducer. This consists of a stem set on a handle and carrying a sliding tube, so arranged that when the cannula is in position it can be pushed off the guide and left as the latter is withdrawn. Finally, there is an extractor for the purpose of getting the cannula out again. The can- nula and guides are made in five sizes, the smallest being suital)le for a child under two years of age. The child must be well wrapped up in a blanket and held by the nurse in a sitting position on her lap, so that the occiput rests against her left shoulder. The assistant stands behind and steadies the child's head. A suitable tube is selected, threaded with a long loop of silk, and fitted on a guide. This is then screwed on to the introducer and a gag placed in the mouth on the left side. The operator Fig. 356. — O'Dwyer's Tubes, i. Moulh Gag. 2. Introducer. 3. Scale. 4. E.\tracter. now hooks the loop attached to the tube round the little finger of his left hand, and passes the index finger over the tongue on to the epiglottis, following it up closely with the end of the tube in his right. Then he either simply hooks the epiglottis forward, and slips the tube over it, when, if suddenly turned down and kept in the middle line, it must pass into the larynx ; or he passes over it on to the arytenoid cartilages and guides the cannula in. In either case it must follow the palmar surface and glide in under the tip. The moment it is in position, the sliding tube should be shot forward, the guide drawn back, and the cannula pushed on with the finger. The object of the loop of silk is to withdraw it, should it have missed the proper opening or passed into the pharynx. The immediate effect is a violent fit of coughing, during which a large amount EXCISION OF THE LARYNX. 835 of ropy mucus is expectorated. As soon as this ceases the loop may be cut, the silk drawn out (taking care not to displace anything), and the tube left. Extraction is more difficult and may require an anaesthetic. The forceps are introduced closed, and the jaws separated from each other by touching a lever. The serrations are on the outer surface, so that there is no difficulty in holding the tube if it is once gras])ed. In America intubation has apparently met with great success ; those who advocate it affirm that there is no shock of hemorrhage, and that the relief is complete. In England, so far, very few cases are on record, and its merits in different diseases are not accurately known. In acute oedematous laryngitis, whether arising from scald of the glottis or other causes, it is probably preferable to tracheotomy ; and after tracheotomy, when the tube cannot be dispensed with, a laryngeal cannula has on several occasions been used with advantage ; but whether it can take the place of tracheotomy in diphtheria is very doubtful. The operation is certainly not so easy; in practiced hands the introduction or removal of a laryngeal cannula may not be of much moment, even under cir- cumstances such as these ; but it would lie almost impossible to those who have not had receipt experience in manipulation. The larynx itself seems to tolerate the tube very well ; they have been w^orn a fortnight without any ill consequence ; nor is there any tendency for them to slip down, though they are often coughed up. It is a distinct draNvback that they cannot be replaced by a nurse. It is said that the discharge from the trachea is freely coughed up through them, in spite of their narrow calibre. On the other hand, feeding a child is very difficult. An oesophageal tube may be tried, or the patient may be laid upon his back with the head hanging well down (so that everything falls of its own weight over the upper aperture of the larynx) ; but neither of these proceedings is easy, and in a large proportion of cases fluids find their way down by the side of the cannula into the lungs and set up broncho-pneumonia. Moreover, there is great risk that the cannula may force down some membrane in front of it, and block the trachea at once ; and this is so important that even those who recommend intubation advise that the tracheotomy instruments should be immediately at hand. If intu- bation is to be employed in cases in which parents refuse their consent to trache- otomy, this is a matter of serious moment. Finally, it does not allow the trachea or larynx to be cleared in any way except by the natural efforts at expulsion through the narrowed opening. Excision of the Larynx. Excision of the larynx may be complete or partial. The former implies the removal of the whole of the cartilages, with sometimes part of the trachea, pharynx, hyoid bone, and circumjacent structures, and with rare exceptions is the only measure that can be adopted in the case of malignant growths of extrinsic origin. The latter aims merely at removing the seat of disease, and is only applicable to intrinsic tumors, that is to say, those springing from the vocal cords, true or false, and the parts immediately around them. Excision has been performed for obstinately recurring and extensive papillo- mata, for lupus, perichondritis, and even for stenosis ; but with very i^\s excep- tions, too few to take into consideration, it is never called for except in the case of malignant disease. In sarcoma it has proved fairly successful ; in epithelioma, on the other hand, total extirpation is exceedingly fatal, in great measure from the direct effect of the operation. Partial excision, however, shows a much better result, and it seems probable, as the importance of the early diagnosis and early removal of carcinoma is more widely recognized, it will become better still. In other words, in extrinsic malignant disease, with very few exceptions, only pallia- tive measures are advisable ; and the same must be said of those cases of intrinsic disease in which the growth has advanced so far as to render complete extirpation 836 DISEASES AND INJURIES OF SPECIAL STRUCTURES. necessary ; with tracheotomy, cocaine, and morphia, the remainder of the patient's life must be made as tolerable as possible ; the chance of his surviving such an extensive operation is too small to justify its jjerformance ; and even if it were successful, recurrence in such advanced disease is almost certain. Limited in- trinsic growths, on the other hand, should be removed freely and without delay. With regard to the diagnosis of the character of an intra-laryngeal growth, it has been pointed out by Semon that, if in the case of a person who has passed the age of thirty-five, a small warty growth makes its appearance upon one of the vocal cords, causing hoarseness or aphonia ; if the cord to which it is attached becomes congested at an early period, and still more of its mobility is imi)aired ; if there are signs of irritation around ; or if the growth reappears very soon after partial or total destruction — it becomes at once the object of grave suspicion. It is the peculiarly limited character of intra-laryngeal carcinoma in its earlier stages that renders the diagnosis of malignant disease so difficult and at the same time so important. Moreover, it must always be remembered that if the result of the microscopic examination of a fragment is negative it proves nothing, so far as the presence of malignant disease is concerned. {a) Complete Excision. Preliminary tracheotomy, to prevent the entry of blood, is advisable, though it has not always been performed. By keeping close to the cartilages and by operating with the patient's head hanging down, this complication can be avoided until the trachea has been divided and a full-sized tube inserted. In any case the external portion of the cannula should be bent down by the side of the neck, and should be long enough to admit of an anaesthetic being given without inconveni- ence to the operator. If the disease is far advanced and the patient exhausted from dyspnoea, the tracheotomy should be performed a week at least before ; if, on the other hand, the disease is limited, it should be done at the same time and the same incision made use of. The patient may either be placed in the ordinary position, the incision being made from above downward ; or the dorsal spine may be so raised that the head is dependent and the separation from the trachea effected first. The latter is cer- tainly preferable if a tampon is not used. The incision runs vertically down the middle line from the hyoid to the second ring of the trachea. A transverse one is usually required as well. The soft parts over the cartilages are detached on either side, lifting up the perichon- drium from them by means of a raspatory or a pair of blunt-pointed scissors, and the separation carried back, first on one side and then on the other, until the con- strictors are reached, the superior laryngeal artery being secured by a double ligature and divided between. The trachea is then separated from the cricoid cartilage and carefully stitched to the skin, the tampon being removed and a large tube of vulcanite or lead inserted in its place. The larynx is drawn forward from below, and the separation from the oesophagus and pharynx behind carried gradu- ally upward, leaving, if possible, the mucous membrane that lines them untouched. The thyro-hyoid membrane is then divided, the condition of the epiglottis exam- ined, and the separation completed. The operation naturally requires numerous modifications. Enlarged glands may have to be dissected out, necessitating removal of the soft structures outside the larynx too ; portions of the lateral and anterior ])arts of the jjharynx may be involved ; the whole of the epiglottis and part of the hyoid bone may have to be taken away ; or, on the other hand, it may be possible on one side or both to leave the cornua of the thyroid cartilage ; it is recommended to do this at the time of the operation, and if neces.sary dissect them out afterward, as it lessens the risk of hemorrhage. Opinions as to the propriety of leaving the cricoid are divided ; according to Hahn it is better removed, as it interferes with deglutition. EXCISION OF THE LARYNX. 837 All bleeding points are then secured ; the cut edges of the pharynx sutured to the skin, and the cavity thoroughly packed with an absorbent dressing covered with iodoform. When the wound is sound an artificial larynx (either Gussenbauer's or Irvine's modification) may be in- troduced. Deglutition, if the pharynx has not been opened, is very satisfactory ; if, however, it has been necessary to remove much of the anterior wall, so that the wound cannot close, an oesopha- geal tube will be rei^uired for the rest of life. (J)) Partial Excision. This operation naturally varies in its details even more than the former. There are, however, two well-characterized methods — the unilateral and the subchondral. (i) Unilateral excision is performed in the same way and with the same precautions as the complete, but the transverse incision (which runs along the lower border of the hyoid) is, of course, only on one side. Half the hyoid and the epiglottis may be removed, but if possible the superior cornu of the thyroid should be left. The condition of the patient after a partial operation such as this is much more satis- factory ; deglutition is not interfered with, and very fair power over the voice is regained. (2) Subchondral excision has been proposed by Butlin, on the ground that malignant growths only involve cartilage very slowly, and that it would be possi- ble in early cases to open the larynx and remove the whole of the diseased part with sufficient freedom without destroying or even seriously interfering with the framework. Fig. 357-- rynx Gussenbauer's Artificial L3- (" Phonetic Cannule"). 838 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER X\\ DISEASES OF THE THYROID. The thyroid gland consists of a number of separate sacs lined with a single layer of nucleated cubical cells, and surrounded by exceedingly vascular adenoid tissue. Colloid degeneration, affecting the contents of the sacs and attended with atrophy of the cellular lining, is of such common occurrence as almost to be con- sidered normal. Nothing is known with regard to its function, beyond the gen- eral fact that the activity of growth and nutrition of all jjarts of the body (inclu- ding the brain) is intimately connected with its integrity. In women it frequently enlarges and becomes tender — at puberty, during the menstrual period, and dur- ing pregnancy. Cretinism is, in all probability, due to its imperfect development ; removal during childhood causes a similar condition, and, in a large proportion of cases, removal of the whole gland is followed by myxoedema, if performed on adults. The temperature falls ; the oxygenating capacity of the blood dimin- ishes ; leucocytosis sets in ; the coagulability is lessened ; the skin and subcuta- neous tissue undergo a peculiar transformation ; nervous symptoms (tremors, paresis, paresthesia, etc.) make their appearance, and, at length, a cretinoid con- dition, with imbecility and coma, follows. When this does not take place, it is probably owing to the fact that the whole gland has not been removed, or that accessory thyroids (which are of very common occurrence) have undergone com- pensative hypertrophy. Sometimes it follows with great rapidity shortly after the operation ; sometimes, on the other hand, slowly and gradually. In a few instances the immediate onset, after a period of apparently perfect health, has been brought on by exposure to cold. Inflammation of the Thvroid. Inflammation may be acute or chronic, and in resolution or in suppuration and sloughing, according to the cause and the addition or not of pyogenic irritants. The symptoms, when the attack is acute, are very alarming, often beginning with a rigor and high fever. Owing to the way in which the gland is bound down by the cervical fascia, the pain is very severe ; the tissues of the neck are hard and rigid, the superficial veins distended, the trachea and o-'sophagus compressed against the spine, and even cerebral symptoms caused by the obstruction to the cranial circulation. In most cases resolution sets in after forty-eight hours, and the acute symptoms begin to subside, but often the improvement is only partial; the diffuse enlargement disappears, but one or more local swellings remain ; the skin becomes red and cedematous, and at length fluctuation is apparent. Death may occur from pressure upon the trachea, from pus finding its way down into the lungs, or from pyaemia or .septicajmia. In one or two instances the gland has sloughed. The treatment must be energetic. At the first onset aconite or antimony may be given internally in small, frequently re])eated doses, until a distinct effect is produced upon the arterial tension. Ice-cold compresses should be placed upon the neck, the superficial veins pricked to relieve the circulation, and leeches ap- plied to the sui)ra-clavicular region. Venesection (either from the arm or the external jugular) may be advisable, if the patient is young and the inflammation sthenic. If signs of suppuration make their appearance, the superficial structures must be carefully divided, layer by layer, and a director used for exploration after Hilton's method. A drainage tube must be inserted to prevent the opening becoming valvular. GOITRE. 839 Simple Enlargement, or Goitre. All forms of enlargement of the thyroid that are not the result of inflamma- tion 'or malignant disease are groii])ed together d& goitre. The blood-vessels only may be affected, and the change limited to the gland {pulsathtg bronchocele) ; or this may be associated with other symptoms referable to the vascular system {ex- ophthalmic goitre, or Graves' disease). The vesicles or the interstitial connective tissue, or both together, may be hypertrophied without any change in structure and without any considerable alteration in proportion [parenchymatous (jx follicu- lar enlargement). This may be complicated by various forms of degeneration. The follicles may enlarge into colloid cysts, while the interstitial tissue atrophies and wastes until neighboring cavities fuse together and form huge, irregular spaces {cystic goitre). Sometimes the contents remain clear and gelatinous ; sometimes they become blood-stained and mixed with debris from the walls and vessels, until scarcely a trace of the original character is left. In many cases proliferating vil- lous growths, consisting almost entirely of blood-vessels with a thin layer of epi- thelium over them, make their appearance, springing from the inner wall of the vesicles, and filling them with a soft, almost erectile mass. In others the fibrous tissue is the part chiefly affected ; diffuse or localized bands are developed in all directions among the vesicles, and grow larger and harder until the whole struc- ture becomes solid {fibrous goitre). Finally, in most, the degeneration is not limited to any one tissue, but involves them all in varying proportion, so that masses of soft, va.scular, interstitial substance, vesicles, cysts with all kinds of contents, and dense fibrous tissue are mixed up together, and rendered still more complex by calcareous degeneration of the walls and capsule. An attempt has been made to distinguish simple hypertrophy from adenoma, reserving the latter for those cases in which there are either distinct separate tumors or isolated portions growing out in an atypical form ; but it is very doubt- ful if this can be maintained. A few cases are recorded in Avhich secondary growths, pulsating and resembling the normal thyroid in structure, have occurred in the bones of the skull and other parts of the body. In some of these an apparently simple goitre was present ; but, in others, there was scarcely any increase in size. Symptoms. — These depend upon the nature and rapidity of the enlarge- ment. Certain features are, however, common to all alike. The swelling may involve the whole gland and accurately follow its shape, or it may be confined to one side, or to the isthmus ; but, whatever part it involves, it always moves up and down with the larynx in swallowing. This is due to the arrangement of the cervical fascia, and is the distinctive feature of thyroid tu- mors. They may be smooth and uniform in outline, or covered with irregular bosses, or pedunculated and hanging by a stalk over the sternum. Sometimes the enlargement consists almost entirely of vessels or of cysts filled with masses of vascular outgrowths, so that the swelling is soft and elastic, and pulsates almost like an aneurysm, with, in many cases, a thrill. Sometimes, on the other hand, only the fibrous tissue is concerned, and the tumor is nodular, dense, and firm. Other symptoms are due to pressure. Large, slowly-growing tumors, that project in front and become pedunculated, do not offend in this way. Small ones, on the other hand, that lie in the isthmus or extend around the trachea between it and the oesophagus, and dense nodules that are sometimes scarcely apparent on the surface, are often much more serious, especially if their growth is rapid. The trachea may be flattened, bent, or displaced to one side of the neck. The cartil- ages may be absorbed, the recurrent laryngeal nerve paralyzed, the movement of the oesophagus interfered with, and the great vessels and ner\'es stretched or flat- tened. Sometimes goitrous thyroids suddenly enlarge ; they are exceedingly vascular, and excitement or violent exertion may lead to such intense congestion as to cause instant death. Acute goitre is very rare in England, although it is described as occurring in an epidemic form among troops in France. There is a certain amount of evidence 840 DISEASES AND INJURIES OF SPECIAL STRUCTURES. connecting it with the rheumatic diathesis, but the cause is as obscure as that of the common variety. The swelling is rapid and painful, the neck cannot be bent, the skin is tense and white ; usually there is considerable dyspnijea with hoarseness, and sometimes a rather high degree of fever. It has been suggested, on» the analogy of mumjjs, that it is really a form of sjjecific intlammation, but it has not been shown to be contagious. The hypera;mia that occurs during the menstrual period and at pregnancy is usually transient, and merely causes a feeling of fullness and tenderness in the neck. In a few cases, however, the swelling never subsides completely, and it may be followed by fibro-cystic degeneration. Pulsating bronchocele may occur as part of Graves' disease or independently. In the former case the whole gland is uniformly enlarged, all the blood-vessels are Fig. 358. — Pareiiciiymatous Enlargement of the Tliyroiil. dilated, the pulsation is equally marked over the whole surface, and the solid tissues do not hypertrophy until the disease has lasted some time. In addition, the enlargement of the gland is associated with other symptoms which have been assigned (although on very inadequate evidence) to a lesion of the sympathetic. In the latter case the primary affection appears to be the development ot exceed- ingly vascular intra-cystic growths, although, of course, the blood supply of the whole gland is increased as well. The surface is covered with bosses, some of which pulsate so strongly that they may be mistaken for aneurysmal dilatation of the carotid or subclavian, and the amount of stroma and solid tissue is considerably and irregularly increased. Many of the cysts are filled with broken-down blood- clot and tissue debris, and the changes these undergo in course of time add con- siderably to the varied character of the morbid appearance. Disease of this kind GOITRE. 841 may remain unchanged for years, sometimes growing larger — when the patient is out of health — and then again diminishing, without apparently ])roducing any constitutional effect. In one or two cases, however, secondary deposits of a simi- lar character have made their appearance in distant parts of the body, as if the primary growth had in some way infected the blood stream. Fibroid and fibro-cystic goitres may attain an immense size. Generally one element is very greatly in excess of the other, but they rarely occur entirely by themselves. The shape and density of the swelling, and the symptoms it causes by pressing upon neighl)oring organs, naturally differ according to its character and direction. Diagnosis. — All thyroid swellings move up and down with the larynx in swallowing. Accessory thyroids (which sometimes undergo a similar transforma- ^'! -...-■ \ Fig. 359. — Cystic Bronchocele. tion and develop into gigantic tumors) present the greatest ditticulty. They may occur in any part of the neck, naturally most often in front, but sometimes under the mucous membrane of the trachea or larynx, or below the upper border of the sternum. Bursal cysts develop in connection with the thyro-hyoid space ; con- genital cysts and such rare tumors as tracheoceles, can hardly be mistaken. Treatment. — A very great deal may be done for recent parenchymatous goitres and for some forms of pulsating bronchocele. Even when fibroid or cystic degeneration has set in, the size of the swelling can be considerably reduced, but the prospect of perfect resolution is not nearly so good. Graves' disease, in which the affection of the thyroid occurs as part of a general disorder, stands on a differ- ent basis. Nothing is of much use so long as the patient lives in a goitrous district. 54 842 DISEASES AND INJURIES OF SPECIAL STRUCTURES. ^^'hatever may l)e the reason, there is no question that goitre occurs endemically in certain localities ; that otherwise healthy peoi)le moving into them are often affected, and with somewhat acute symptoms (possibly the ejtidemics among troops in France are due to this), and that if they remove in sufficient time the swelling is very likely to disappear again. The only precaution is never to drink the water of the district in any form ; but it has not been proved that this will prevent the disease. In recent goitre %\.\ovl% iodine liniment or iodide of potash ointment applied to the skin of the neck often effects considerable im])rovement ; and the iodide may be given internally with iron and other tonics. Hydrofluoric acid is said to be I)eneficial, but although I have tried it in a large number of cases I have failed to detect any result. It must be remembered that goitres of all kinds are very variable in size ; not merely after injury or when a person is out of health, but for entirely unknown reasons, they have been known to disappear suddenly of them- selves ; so that, unless the improvement is decided and permanent, it cannot be taken as evidence of the value of the drug. Biniodide of mercury ointment, as applied in England, does not appear to succeed. If this fails, or if the thyroid is already in a state of fibroid enlarge7nent, hard, irregular and dense, injections of a solution of iodine in alcohol (one part in twelve) may be tried. About half a drachm is injected into different i)arts of the gland once or twice a week, according to the severity of the reaction that follows. Care must be taken that the ])oint of the needle is really in the gland (this may be shown by making the patient swallow), not in the cellular tissue, and particularly to avoid the veins. The seat of the injection becomes slightly red and swollen, and the patient may comj^lain of vague sensations of pain ^^^-«ij«>^^ in the neck, but anything more serious very seldom follows. Suppuration may occur, but it is very rare, and eml)olism has been Fig. 36o.-Coiioid Degeneration of Thyroid. knowu to happen, SO that the i)rocedure is not entirely devoid of risk. Cystic goitre xwdiyhQ treated by aspiration, drainage, enucleation, or injection. Of these the first is of little avail, except as a temporary expedient in an urgent case, or as a preliminary to other measures. The fluid must be drawn off very slowly, or hemorrhage may occur from the delicate vessels in the walls of the sac and fill it even more tensely than it was before. Drainage and enucleation are more successful. A linear incision is made through the superficial structures, and the capsule of the gland freely exposed. If there is a large single cyst it can usually be enucleated by careful dissection, clamp- ing and dividing between two ligatures every vessel ; solid adenomata may be treated in the same way. If this is im])racticable, the cavity can be laid open and the contents cleared out, but the operator must be prepared for smart hemorrhage. Plugging with iodoform gauze may be necessary if it does not stop at once. It does not appear to be necessary to fasten the edge of the cyst to the skin or the cervical fascia; according to Clutton, if the superficial structures are not disturbed or displaced, there is very little risk of inflammatory infiltration. If there is a number of small cysts closely packed together, it is better to excise the part, so long as it is not too large, ligaturing the vessels one by one as they appear and taking especial care of the recurrent laryngeal nerve. Injection with perchloride of iron (25 per cent, solution) is very strongly advocated by Morell Mackenzie with the view of exciting limited suppuration without hemorrhage. The cyst is tapped, partially or comj)letely emptied, accord- ing to its size, and injected with a drachm or two of the solution, avoiding GOITRE. 843 manipulation as far as possible. The syringe is then withdrawn, the cannula plugged and left /// situ for about three days. At the end of that time the contents are allowed to escape, and if they are thin and serous, or if there is much blood — if, in other words, suppuration does not appear probable — a second injection is made. Poultices are applied to encourage this, and the cannula is retained as a drainage tube until there is no longer any fear of the opening becoming valvular. This plan is not devoid of risk l)y any means ; suppuration may be acute with high fever, and, although it is usually successful, the inflammation may cause serious misgivings for a time. Electrolysis has been used with considerable success in vascular goitre, even when there were definite exophthalmic symptoms. Duncan recommends a current of from 40 to 80 milliamperes, and relies chiefly upon the destructive action of the negative pole, moving it about freely from side to side as soon as it has produced a decided effect. Under certain circumstances operative treatment becomes imperative. The trachea may be compressed or distorted, causing marked tracheal stridor and dyspnoea on the least exertion. The recurrent laryngeal nerve may be irritated or stretched ; if this occurs on both sides the condition at once becomes very critical. Fig. 361. — Cystic Degeneration of Thyroid. A firm growth may extend downward between the trachea and the sternum, or embrace the trachea, or grow backward against it so as to compress it ; or there may have been already an attack of suffocative dyspncea due to sudden enlargement of the gland. The choice lies between tracheotomy, division of the isthmus, enucleation of the grow'th, and ligature of the arteries supplying the gland. Tracheotomy, of course, is only palliative, it may be necessary on the spur of the moment, a special tube, or, if this is not at hand, a gum-elastic catheter, being passed down the trachea through the constricted part. The difficulty of such an operation can hardly be exaggerated ; low tracheotomy is, of course, out of the question — even the upper part of the trachea may be concealed or pushed to one side, or flattened, so that it presents a sharp edge, or so covered with dilated vessels and portions of the growth as to be almost inaccessible. Bose's method (transverse division of the cervical fascia, and pulling all the structures forward and downward from off the front of the trachea) may be the only one practicable. Division of the isthmus, on the other hand, is exceedingly successful, and, in a large proportion of cases, has been followed by the unexpected diminution in 844 DISEASES AND INJURIES OF SPECIAL STRUCTURES. bulk of the rest of the gland. To some extent this may be (lue to the recession of the lateral lobes, but certainly this will not account for the whole, 'i'he incision is vertical, in the middle line; the skin and superficial fascia are divided ; then the layer connecting the sterno-hyoid and sterno-thyroid muscles (which are usually much flattened out) ; the veins that lie on the front carefully detached, and the isthmus sei)arated from the trachea by means of the finger and a director. A double ligature is then passed round the isthmus and the intervening tissue excised ; or the median part may simply be divided, and allowed to retract. This operation has been performed in exophthalmic goitre, for the relief of the dyspnoea; the lateral lobes were considerably reduced in size before the patient's death, some time after, from cerebral symptoms. No definite directions can be laid down for enucleation : it may be practiced either in the case of cysts or solid adenomatous growths, and sometimes consider- able portions may be removed in this way (the part left undergoes hypertrophy, so that the operation is practically free from the risk of myxoedema, unless the amount taken away is very large) ; but the greatest care is necessary if the growth lies any- where near the recurrent laryngeal nerves. On several occasions one has been divided, and in many others their function has been seriously impaired by the inflammation that followed. Ligature of the thyroid arteries has been tried ; but, at the best, it can only be palliative, and the result has not been sufficiently good to justify the risk. Malignant Disease of the Thvroid Gland. Sarcoma and carcinoma are both known to occur, but they are not common. The former may be either round-celled or spindle-celled, and may be recognized by the rapidity of its growth, and (when the cervical fascia has yielded before it) by its soft, almost fluid, consistence. The latter is stated to be either encephaloid or scirrhus. It does not occur until late adult life, and usually as a complication in goitre, the thyroid suddenly beginning to enlarge and become painful. The diagnosis cannot be made until the lymphatic glands or the neighboring tissues are involved ; and removal is out of the question. It is probable that the secondary pulsating growths, similar in structure to a cystic proliferating thyroid, and occurring in distant parts of the body, are really carcinomatous. INJURIES OF THE (ESOPHAGUS. 845 CHAPTER XVI. INJURIES AND DISEASES OF 7 HE PHARYNX AND (ESOPHAGUS. Malformations. Congenital occlusion of the pharynx is due to the invagination that forms the mouth failing to open into the anterior end of the primitive intestine. In con- genital stricture the defect is the same, but less marked. Diverticula may originate in the same way. Some of these are acquired (pharyngoceles) : a part of the wall is weakened by inflammation or injury to such an extent that the mucous membrane bulges out through the opening ; the larger ones, however, and especially those that occur in the region of the inferior con- strictor, are congenital in origin. When small they are not noticed ; as they increase in size they form a pear-shaped swelling by the side of the neck, pressing upon the great vessels, displacing the larynx, and often causing dyspnoea and vio- lent fits of spasmodic coughing from pressure upon the sui)erior laryngeal nerve. The nature of the sac is easily recognized from the variations in its size at different times, and from the way in which its contents (air and sodden food) are returned into the mouth when it is subjected to external pressure, or squeezed by the mus- cles around it. As it enlarges it displaces the oesophagus, becoming more vertical and drawing nearer the middle line, until the natural passage is thrust entirely out of its axis. In one of these cases Wheeler laid open the tumor from the outside, excised it, and successfully secured the margins of the opening with catgut sutures. Congenital dilatation of the cesophagus has also been described as affecting its whole length, but this is still more rare. A minor degree of the same disorder sometimes results from fatty degeneration of the muscular wall. As a rule, hyper- trophy and narrowing occur above a stricture. Injuries of the Oesophagus. The cesophagus may be wounded from the outside in cases of cut-throat, or from inside by corrosive fluids or hard and sharp-pointed foreign bodies. In rare instances rupture has taken place during vomiting, but probably only when the walls have been weakened beforehand by inflammation or fatty degeneration. Swallowing corrosive fluids is nearly always done with suicidal intent, the liquid (usually a mineral acid or a very strong alkali) being thrown quite to the back of the pharynx, so that the lips, mouth, and tongue are often not touched. [I have seen some cases where children produced cesophageal stricture by the swallowing of " Concentrated Lye."] The immediate effect is profound collapse with intense burning pain, followed by vomiting of mucus, blood, and sloughing shreds of epithelium, mixed with the contents of the stomach. If the result is not immediately fatal from perforation or collapse, the severity of the symptoms gradually subsides ; there is less blood and more mucus and pus in the fluid that is brought up ; the pain becomes less severe ; the swelling and thickening around the oesophagus diminish, and the febrile symptoms abate. Swallowing, however, causes very great pain, and if more than the epithelial surface has been destroyed, it rapidly becomes more and more difficult, until at length a traumatic stricture is established. The wall of the oesophagus contracts spasmodically on the irritant before it is vomited back, and thus it may happen that the whole of the tube, from the cricoid almost down to the cardiac orifice, is more or less eaten away. In cases of long standing: the walls become enormously thickened from inflamma- S46 DISEASES AND INJURIES OF SPECIAL STRUCTURES. tory deposit and fused witli the structures around. The interior is rough and irregular, marked by sloughs and cicatrices in all directions, and here and there the cavity may be completely obliterated, [(ireat emaciation follows.] Foreign Bodies in the Pharynx and CEsophagus. False teeth, i)ieces of unmasticated food, coins, fish-bones, pins, and the like, are not uncommonly impacted in the oesophagus — generally where it is narrowest, at the level of the cricoid cartilage — but sometimes immediately behind the arch of the aorta or the left bronchus. The symj)toms depend chiefly upon the size and shape. \i it is large and smooth, instant death may occur from its pressing upon the aperture of the larynx, or from spasm of the glottis ; if pointed and irregular, there may be dysphagia (and the feeling of soreness i)ersists long after the foreign body has been removed) or complete obstruction. Tenderness in the side of the neck, soreness behind the sternum, dyspnoea, and a constant discharge of saliva and mucus, are often pre- sent as well. Later, if the case is left to itself, inflammation sets in. Sometimes this leads to spontaneous expulsion, as the foreign body becomes loosened ; more frequently it makes matters worse by extending into the tissue around. Abscesses may form under the deep cervical fascia and spread into the pleura or i)ericardium. The walls of the carotid, and even of the aorta itself, may give way. The foreign body may ulcerate through into the trachea, and be coughed up, or it may be driven into the pericardium and even into the substance of the heart. When the foreign body is a large one there is seldom any difficulty in the diagnosis. The finger can explore the whole of the upper part of the pharynx, from the level of the soft palate down to the back of the arytenoid cartilages, and in children even lower ; and the mucous membrane may be thoroughly inspected by means of a laryngoscope mirror ; but when it is situated below this, and is of small size — a fish-bone, for example — its presence is often only a matter of infer- ence. In many cases the sensation persists long after the offending substance has been dislodged. Treatment. — A foreign body must always, if possible, be extracted through tlie mouth ; if it cannot be done it may be pushed on into the stomach, removed through a side opening, or left to itself, according to its nature and situation. Sometimes it is ejected dur- ing the retching and vomit- ing that accomjjany ex- ploration of the fauces, but emetics should never be given for the purpose. The " S ii Clih"' I I ■ tjesophagus has before now been ruptured by violent vomiting. Long-handled, curved forceps, such as are used for extracting similar bodies from the larynx, are the most useful, especially if it happens to be some- thing small and rough. Pins and fish-bones may be caught by an exjianding or umbrella probang (Fig. 362), but care must be taken not to drive them further in ; they may easily be forced into the carotid or i)eri- cardium. If smooth and firm and low down, the obstructing body can sometimes be pushed onward, especially as, after a i&w hours, it becomes coated over with mucus j and in the case of meat it has been proposed to soften the surface by Fig. 362. — Horseh.Tir Probang, expanded and unexpanded. Fir,. 363. — Coin-catcher DISEASES OF THE (ESOPHAGUS. 847 means of dilute acids. Irregular structures, such as false teeth, may be laid hold of by what is known as a coin-catcher (Fig. 363), a blunt, flat hook attached to a probang by a thin stri|) of steel, so that it can glide past an obstacle and then catch against it as it is withdrawn ; and considerable force may be used. If this fails, and if the foreign body is impacted in an accessible part of the fjesojihagus, it must be removed by operation. Unless there is some special reason — such, for example, as the projection of the foreign body distinctly to be felt — o^sophagotomy is always ])erformed on the left side. The head is turned in the opposite direction and an incision three inches long is made at the inner margin of the sterno-mastoid. The superficial structures are divided, the deep fascia slit up on a director, and the muscle pulled well toward the outer side, so as to expose the sheath of the great vessels. The dissection is then carried carefully between this and the trachea, avoiding the thyroid arteries and veins, the thyroid gland, and the inferior laryngeal nerve, until the (esophagus and the lower part of the pharynx are exposed. If the omo- hyoid muscle gets in the way it may be divided, and any veins that cannot be drawn to one side must be secured either by ligature or by pressure forceps, so as not to obscure the deeper parts. Generally a sufficient surface can be brought into view by pulling the trachea one way and the great vessels and the sterno-mastoid the other ; Imt sometimes part of the sterno-hyoid or sterno-thyroid requires divi- sion. If the foreign body can be felt from the outside, a longitudinal incision may be made over it and the finger introduced so as to ascertain its position more accurately. If this cannot be done, a sound is passed through the mouth and made to project into the wound. Afterwards the opening may be enlarged to a sufficient extent, and the foreign body withdrawn with appropriate forceps. If the impaction is recent and the wound in the oesophagus not bruised, the edges may be sewn together with catgut, the sutures being inserted only in the muscular wall, leaving the mucous membrane untouched. Under other circumstances it is better to leave the whole open, with a large drainage-tube in the superficial wound. For the first few days the patient should be fed with nutrient enemata only ; afterward an oesophageal tube may be used until the wound is sound. The thirst can be relieved, as Southam suggests, by allowing the patient to drink a boracic acid mixture (gr. x ad 5J). Most of it flows out through the wound (if it is not sutured), and helps to keep it clean. A fistulous opening often persists for a time, but in most cases it closes without requiring anything further. When the foreign body is low down the question is more difficult. Southam performed oesophagotomy successfully in a case in which a plate of false teeth was impacted three inches below the upper border of the sternum. In other cases the stomach has been opened and the foreign body dragged onward or pushed back, as seemed best at the time. Gastrotomy may be required if it has passed the oesophagus and is lodged in the stomach. Sometimes the foreign body can be felt through the wall of the abdomen ; if this is impossible its presence can usually be ascertained with a suit- able probang. In most cases, however, if it has once reached the stomach it is able to pass on through the pyloric valve without further trouble, although it may lodge again just above the external sphincter. Purgatives should never be given ; vegetable [such a& mashed potatoes] and farinaceous diet is the best, owing to its bulky character. Diseases of the CEsophagus. Inflammation of the mucous membrane may arise from injury (as already mentioned) or from specific causes, such as tubercle, syphilis, thrush, or diph- theria; but, with the exception of the first of these, the symptoms are vague, con- sisting merely of pain in swallowing, and rarely attract attention unless the ulceration is so extensive as to lead to the formation of a cicatricial stricture. Paralysis of the muscular coat of the pharynx or tesophagus is occasionally met with after diphtheria, and may in rare instances be due to alcoholic or lead 84S DISEASES AND INJURIES OE SPECIAL STRUCTURES. poisoning. Dysphagia is always present, but it differs from that which occurs in stricture, in that solids are swallowed more easily than fluids. Sometimes the food collects and is ejected after a time by coughing or vomiting. Hysterical pafalysis is much more common, the patient being convinced either that there is a foreign body in the oesophagus, or that there is a stricture (usually after having seen a case), and being unable to will the act of deglutition. It is chiefly met with in young women who present other hysterical symptoms, but it may occur in men. The suddenness and incongruous nature of the symp- toms, the history and a few days' careful watching, are sufficient to prevent a mistake. The greatest difficulty is in connection with foreign bodies; a fish-bone perhaps has been actually swallowed and scratched the mucous surface ; and the sensation arising from this, and intensified whenever anything passes, down, is a sufficient stimulus to keep up the suggestion of dysphagia in the patient's brain. It rarely happens, however, that there is any collection of food above the obstruc- tion ; either the patient keeps it in the mouth without attempting to swallow it, or, if it does pass over the larynx, it is immediately ejected again, often with an unnecessary display of energy. Closely akin to this, and occurring under the same conditions, is a form of muscular spasm which affects the pharynx rather than the oesophagus. It varies from merely a slight stammering of deglutition, such as might arise from simple nervousness, to violent ejection of the contents of the pharynx through the mouth and nose. In neither of these conditions, however, whether paralysis or spasm is the prominent feature, is there marked emaciation or craving for food ; the patient is usually fairly well nourished, though always complaining (differing in this respect altogether from those who persistently refiise to take any food), and not unfrequently it is found, on making inquiry, that it has already lasted many years, off" and on, long enough to negative absolutely organic contraction. Many of these cases are cured at once by faradization or the passage of a bougie, but unless the morbid state of the nervous system is in some way relieved, or the exciting cause of the hysteria removed, they nearly always relapse. Tumors of the CEsophaous. With very few exceptions, the only form of new growth that occurs in the cesophagus is squamous epithelioma. It is chiefly met with in men, very rarely under forty years of age, and forms an annular and rapidly contracting stricture. The surface ulcerates away, but, as in the intestine, the infiltration into the sub- mucous, and later into the muscular coats, increases so fast and contracts so rapidly that the calibre very quickly becomes narrowed. Later it involves the fibrous tissues and the other structures around (the trachea for example), spreading into them by direct extension, and, if it does not prove fatal fom starvation or pneu- monia, forms secondary deposits in the glands and elsewhere. The seat of election is behind the carotid cartilage or where the left bronchus forms a ridge in the mucous membrane — the places, in other words, in which the calibre is smallest and the walls most rigid. No part, however, is exem])t. The chief, and for some time the only symjjtom of which the patient com- plains, is the rapidly increasing difficulty in swallowing, first for solids and then for liquids. Emaciation speedily follows, but fortunately the sense of hunger, especially in the later stages, is seldom very distressing. Vomiting may occur, the saliva, with a certain amount of mucus, particles of food, and sometimes a little blood, collecting on the face of the stricture. Pain is rarely severe, although, particularly when the tissues around the cesophagus are infiltrated, attempts at swallowing or passing a bougie cause great discomfort. No external tumor can be felt, with rare exceptions, and often there is no distinct glandular enlargement until comparatively late. STRICTURE OF THE (ESOPHAGUS. 849 p: • 1 Stricture of the (Esophagus. Organic stricture may be congenital or acquired. The former is exceedingly rare ; the latter, which is very common, may be simple or malignant. Simple stricture arises nearly always from the swallowing of corrosive fluids. The mucous membrane sloughs and cicatricial contraction follows. Sometimes almost the whole length is obliterated in this way, but the effect is always greatest at the commencement. In very rare instances it may arise from some form of specific inflammation, such as tubercle or syphilis. Malignant stricture is always the result of squamous epithelioma, and is usually annular, tlie muscular coat above being considerably hypertrophied. Symptoms and Diagnosis. — Pain and difficulty in swallowing are the prominent symptoms. The former is exceedingly severe at the beginning in cases of traumatic stricture (in great measure owing to the inflammation around the cesophagus), and gradually becomes less as the cicatricial tissue becomes firmer. The latter is usually the only thing of which a patient complains when it is due to epithelioma. It may come on comparatively suddenly, an unobservant person not noticing any difficulty until the narrow channel is blocked by the impaction of a larger or harder fragment than usual, or, more frequently, it is gradual from the first, solids causing difficulty before there is the least obstruction to the passage of liquids. In a few instances deglutition is rendered almost impos- sible by fits of spasmodic coughing. The diagnosis can only be made certain by the passage of a bougie ; but, as dysphagia occurs in other affections in which a proceeding of this kind is not unattended with danger, an attempt must always be made to exclude them first. («) Muscular spasm or paralysis may simulate true stricture. There may even be a history of some foreign body having been swallowed ; but it is never the kind that causes traumatic stricture. Nor is there really any likelihood of mistaking spasmodic contrac- tion for malignant disease, for while the latter rarely occurs except in men, and never under the age of forty, the former is almost con- fined to young women, and is always marked by the peculiar incon- gruity of its symptoms. In diphtheritic paralysis, which is very rare, the food usually passes slowly down for some time before it stops, and solids are swallowed more easily than liquids. (J)) Compression of the CEsophagus. — Dysphagia arising from this is exceedingly common, and although the cause is usually suffi- ciently prominent, this is not always the case. Aneurysms of the aorta ; tumors of all kinds growing from the vertebrae, lymphatic glands, cellular tissue, or other structures near the oesophagus ; enlarged or accessory thyroids ; gummata (especially retro-pharyngeal) ; abscesses, connected with the vertebrae or not, and other conditions, may give rise to it. Aneurysms have been ruptured before now by the passage of a bougie, and that, too, without an excessive amount of force having been used. {/) In a few cases dysphagia has been traced to the presence of a pharyngo- cele dragging the orifice of the oesophagus out of its true axis. The diagnosis of simple from malignant stricture rarely gives rise to diffi- culty. Practically, unless there is a very clear history of a gumma or of tubercular disease, a stricture that develops after the age of forty without injury is malig- nant. If the presence of an external tumor pressing upon the oesophagus is negatived, a bougie must be passed, not only to verify the existence of a stricture, but to ascer- tain its locality, and, perhaps, its diameter. The patient should be seated on a straight-backed chair and the head supported by an assistant. It should rather be made to poke forward than upward, in order to straighten out the cervical spine ; if it is thrown back the bougie strikes against the bodies of the vertebras. Fig. 364. — Malig- nant Stricture of ffi<;ophagus laid open. 850 DISEASES AND INJURIES OF SPECIAL STRUCTURES. A medium-sized gum-elastic one (equal to No. 24 or 27 catheter on the French scale) should be chosen to begin with, warmed by dipping in hot water, and well lubricated with glycerine. The point should be bent down a little. The oper- ator then, standing in front of the patient, runs the forefinger of the left hand over the tongue, and guides the bougie, which is held in the right, over the base to the back of the throat. If protected like this, it cannot pass up into the naso-pharynx or enter the larynx. Nearly always it causes a certain amount of spasm as soon as it touches the mucous membrane, and when it comes near the cricoid it is not unfrequently gripped tightly and then forcibly ejected by retching, or suddenly pulled out by the patient. To some extent this can be prevented by a cocaine spray, or by brushing the surface of the mucous membrane over with a two per cent, solution, but nearly always, except in the case of very ignorant men, it can be overcome by patience, No force may be used under any circumstances ; I have more than once known pneumonia develop suddenly after a bougie had been passed. If the end is definitely arrested but not gripped, it must be withdrawn and a smaller one selected ; in some cases only a catgut will pass. Measured on a bougie, the cricoid cartilage is approximately seven inches from the teeth, the left bronchus eleven, and the opening in the diaphragm fifteen. Other methods of examining the oesophagus are of very little value. Auscul- tation (the stethoscope being placed by the side of the spine, while the patient drinks some water) may be tried, but it rarely gives any indication that can be interpreted. The condition of the lungs, especially the amount of bronchial irri- tation caused by the passage of a bougie, and the state of the cervical glands, whether enlarged or not, are very important factors in the prognosis. The treatment of stricture of the oesophagus depends upon the cause, whether it is traumatic or cancerous. In the former case the walls are usually very much thickened (although it may be a long time before the sloughing in the interior ceases), the patient is often young, and there is no danger but that of starvation ; in the latter, if the patient lives sufficiently long, ulceration always gains the upper hand and causes perforation, and even if starvation and pneumonia are success- fully prevented, the result must inevitably prove fatal within a few months from the malignant cachexia. (i) Traumatic Stricture. — In any case in which the interior of the oesophagus has been seriously injured, contraction must be prevented by the use of bougies. Treatment should commence as soon as the sloughs have separated and cicatriza- tion is beginning, the greatest care, of course, being used. Special instruments with rubber tips, one or two inches in length, so as to ensure thorough flexibility, and about the size of a No. 24 or 27 catheter, are the most useful. At first they must be pa.ssed every day, then, if the tendency to contract is not very marked, at gradually increasing intervals ; but, as it may be necessary to make use of them for the rest of life, the patient should learn as soon as possible how to pass them for himself. The food must, of course, be suitably prepared throughout. In old cases, in which the stricture has been allowed to contract, the difficulty is very much greater. Gradual dilatation is the most successful method, using slightly conical instruments. It may be necessary to l)egin with catgut, if the con- striction is very narrow, leaving it in situ for twenty-four hours, or making use of it as a guide on which a fine rubber tube can be slid down ; the patient can always swallow liquids by the side of it. Internal oesophagotomy (division of the stric- ture from within) is a very risky operation, and as the stricture must be a perme- able one to allow of its being done, can very seldom be advised. In exceptional instances an artificial opening has been made in the neck below the stricture (oesophagostomy), and the stomach has been opened and the stricture dilated through the cardiac orifice. Practically, if dilatation fails gastrostomy must be performed. The results, compared with those of the same o]>eration for malignant disease, show a far higher percentage of success, but it is not probable that all the unsuccessful cases have been published. STRICTURE OF THE (ESOPHAGUS. 851 (2) MaUi:;nant Stricture. — Excision of the growth has been ])racticed with success, an artificial opening into the (esophagus being left at the root of the neck ; but cases in which such a proceeding is i)ossible are very seldom met with. As a rule, all that can be done is to make an artificial opening below the stricture, either in the (esophagus or stomach, or to maintain the patency of the canal by means of tubes or bougies. {a) GLsophagostomy. — This can only be performed when it is certain that the growth is limited to the very commencement of the oesophagus — a condi- tion practically impossible to prove. The incision is the same as for oesophago- tomy, but lower down, and as the tube is collapsed and empty, covere(d with important vessels and in close relation with the pleura and thoracic duct, it is evi- dently more dangerous. (Ji) Gastrostomy. — The results of gastrostomy for malignant disease of the oesophagus are e.xceedingly bad. It is true that they have improved to a certain extent in recent years, and that in all probability if the operation were i)erformed earlier in the course^ of the complaint, before the patient was exhausted by starva- tion and the growth of the malignant disease, they would improve much more. But it must be remembered that gastrostomy is only a palliative, not a radical operation ; it does not pretend to cure the patient, but only to relieve him, and that, therefore, if the same results can be obtained in other ways, it is not justifi- able to run the risk. Symonds has divided the course of the disease into two periods : before and after the signs of bronchial irritation have set in. Of these the symptoms that occur in the former can be relieved as well by tubage (in all ordinary cases) as by gastrostomy; for those of the latter neither is of any real avail. If ulceration has once opened up a communication between the (jesophagus and the bronchi, or trachea, food can be prevented from passing down into the lungs, but nothing can prevent the entry of mucus, saliva, blood, and particles of the growth detached by ulceration, ^d these will inevitably cause a speedily fatal broncho-pneumonia. In a few exceptional cases gastrostomy may still be neces- sary, and then it should be performed as early as possible, while the patient still retains his strength ; but it rests with those who advocate it to show -that the immediate dangers attending tubage are more serious than those of gastrostomy, or that tubage tends to make the progress of the disease more rapid by irritating the growth. {c) Tubage. — Symonds' tubes are from four to six inches in length, and are made of gum-elastic upon a silk web, the outside and inside being as smooth as possible. The upper end is funnel-shaped so as to rest upon the face of the stric- ture and slightly flattened on one side that it may not press unduly against the back of the cricoid, and the margin is perforated in two places for the attachment of a silk thread. The other end is hollow, with a lateral opening. The tube can be introduced upon a bougie, but it is more easily managed with a proper whale- bone guide set in a suitable handle. The exact site of the stricture is ascertained first and marked upon the guide ; the greatest gentleness must be used, and as soon as the point enters the narrowed part the tube is slowly pushed onward until the resistance to the funnel is felt ; the guide is then withdrawn, and the silk thread attached to the tube tied round the ear or fastened with strapping. A tube of this kind can be left for two or three months without being changed, the patient swallowing liquid food through it. As a rule, however, it is necessary to remove the first after three or four days, as the stricture always dilates to some extent, and sometimes this must be repeated. Even if it sh uld slip through, it will pass/^r anum or remain lodged in the stomach withoo incon- venience. Compared with gastrostomy this method possesses very great advantages. There is little risk to life ; the presence of the tube does not appear to increase the rapidity of the ulceration, although in one or two instances, it is said to have caused circumcesophageal suppuration ; the discomfort is not greater, if so great, and a sufficient amount of food can be taken quite as easily. In either case the 852 DISEASES AND INJURIES OF SPECIAL STRUCTURES. end is the same ; as soon as lironchial irrital)ility becomes a prominent feature, as soon as the ulceration extends into the air passages, debris, mucus, and foreign matter of all kinds will make their way into the lungs and set up broncho-pneu- monia (all the more raj)idly because of the malignant disease), whether a short tube is worn or gastrostomy has been performed. When this final stage is reached the only course left is the introduction of a long tube made of thin rubber, so as to exclude, as far as possible, all fluid from the oesophagus. Krishaber's are too hard, and very soon cause ulceration at the back of the larynx from the constant friction. Soft red rubber ones may, however, be used for a considerable time. In ordinary cases, in which the malignant growth is situated high up, life may be prolonged in this way for a further period ; but when the disease is opposite the left bronchus, the thin partition very soon ulcer- ates through, pneumonia is sure to follow, and even gangrene of the lung may occur. INJURIES OF THE CHEST. 853 CHAPTER XVII. INJURIES AND DISEASES OF THE CHEST. INJURIES OF THE CHEST. Fractures and dislocations o'f the ribs or sternum, contusions of the wall of the thorax, and wounds involving the nerves, muscles, or vessels, may occur with or without injury to the subjacent viscera. In some cases it can be seen at once whether they have escaped or not; in others, it is a matter of the greatest diffi- culty ; but, if there is the least doubt, the case should be treated as if the graver injury were proved, and no attempt must ever be made, by probing or otherwise, to determine one way or the other. The finger may be used to explore for foreign bodies, or to ascertain the depth and extent of a penetrated wound, not to find out whether it penetrates or not. Injuries of the Wall of the Thorax. Contusions are very common, and are rarely attended by serious consequences. The shock, however, may be severe (it is said to have proved fatal by itself, with- out visible injury of any kind), and the extravasation, when it takes place in the deep planes of loose cellular tissue beneath the muscles, is sometimes very exten- sive, and is likely to be followed by suppuration. In many cases the muscles are badly bruised ; occasionally they are torn as well, especially the pectoralis major, which may be pulled in two by a sudden catch at something as the body is falling. When this occurs the signs are very definite ; a great gap appears at once, involving particularly the sternal part of the muscle ; there is very extensive hemorrhage, and, when this subsides, the torn ends retract as far as they can, and waste away. Nothing can be done for it when the muscles and fascia are torn completely through, but, if the injury is not quite so severe, a fibrous cicatrix forms and ties the ends down to the wall of the thorax, so as to make a new attachment. The deeper structures do not always escape when the external injury is ap- parently slight ; the pleura may be bruised and become inflamed ; there may be a contusion of the lung with hemorrhage into the substance, causing pneumonia and even traumatic gangrene ; or, without the pulmonary pleura being torn, the air vesicles may be ruptured, and the air forced into the cellular tissue of the lung until it appears at the root of the neck {interstitial emphysema) ; and in young patients particularly, when the ribs are still elastic, and the wall of the chest can yield without breaking, the lung and pleura may be lacerated, so as to cause pneu- mothorax or hfemothorax, without there being external injury of any kind ; even the pericardium and the heart may be crushed and torn. Fracture of the Ribs. The ribs may be broken by direct or by indirect violence. In the former case the position of the fracture depends upon the force, and the fragments are driven inward, for the moment at any rate. In the latter, if the chest is coni- pressed from before backward, they generally give way at the widest part of their curve — in the axillary line — and the ends are forced outward, so that there is less risk of the lung being wounded ; but this is very far from invariable. In rare cases the fracture results from muscular action. The first rib can only be broken by direct force, and then it is scarcely pos- sible unless the clavicle gives way as well. The last two escape, from their small 854 DISEASES AND INJURIES OE SPECIAL STRUCTURES. size and free mobility. Those that suffer the most frecjiiently are the long ones, attached at both their ends. One only may give way, or several may be broken on both sides, or they may be broken in more i)laces than one ; but this, owing to their elasticity, is unusual. In children, fracture is not common, and some- times, when it does occur, it is incomplete. As age advances, and the thorax becomes more rigid, the liability becomes more marked. In old people they break very readily, and this also occurs in general paralysis of the insane and in some other forms of lunacy, owing, in all probability, to a change in the chemical com- position of the tissue. Erosion by an aneurysm, or a secondary deposit of car- cinoma, may occasion so-called spontaneous fracture. Symptoms. — Except in the case of the first rib, or in very stout people, there is rarely any difficulty. Sometimes a sudden snap is heard at the moment of fracture ; the i)ain is immediate and severe, coming on with sharp stabs at every breath, so that respiration is shallow and carried on mainly by the abdomi- nal muscles. Coughing and local pressure make it tenfold worse. Close inspec- tion sometimes shows that one side of the thorax moves less than the other. Dis- placement in simple fracture without comminution is rare, but occasionally one side is depressed, the splintered end catching against the irregularities on the other half and holding it down. Crepitus is usually present. Sometimes when it cannot be felt it can be heard with a stethoscope. Laying the hand on the side of the thorax while the patient draws a deep breath is sufficient in most cases ; if this does not succeed, pressure may be made with the two hands alternately, one on either side of the supposed fracture. Sometimes the loss of sjjring can be detected in this way. Fracture is very probable when pressure upon a distant portion of a rib always causes pain at the same si)ot. Union generally takes place readily; sometimes the amount of callus thrown out is excessive, so that several ribs become joined together by bridges of bone (Fig. 365) ; occasionally it is fibrous only, or a bony ring is thrown out round the ends, holding them together, without there being any true union at all. The costal cartilages may be fractured in the same way as the ribs; or they may be torn away from the bone or dislocated from the sternum or from each other. Union generally takes place by bony callus /n^^A thrown out round the ends ; if they overlap, the angle is filled up by it, especially on the pleural surface ; but fibrous tissue, and oc- casionally bone and new-formed cartilage, have been found between them. Dislocation of the ribs from the verte- iv^^r::;^ br?e sometimes occurs in severe injuries of the ; spine, but hardly admits of diagnosis. Complications. — These may be im- mediate, due to injury to some adjacent structure, or remote, the conseciuences of Fig. 365. — Fmcturc of Ribs Welded Together by • ri ^- ^ni .- • 1 j j Callus. innammation. 1 he former include wounds of the skin, with or without the entrance of foreign bodies; rupture of muscles (the intercostals always, sometimes the pecto- rals and the serratus magnus too) ; laceration of the pleura ; wound of the lung (with emphysema, haemoptysis, pneumothorax, or haemothorax) ; wound of the heart or pericardium ; wound of the diaphragm, with the liver, spleen, or intes- tine ; or rupture of the internal mammary or intercostal arteries, or of some of the great ve.ssels in the thorax. The latter, so long as the fracture is simple, are of rare occurrence, though I have known suppuration even under these conditions ; when the injury is more severe, j^leurisy, pneumonia, and inflammation of other structures are not uncommon. Fractures of the ribs may be serious, especially in old people, from shock, or from bronchitis and broncho-pneumonia ; as a rule, unless several are broken, or some grave complication is present, there is no cause for anxiety. When the ^: INJURIES OF THE CHEST. 855 fracture is on one side only, great relief is given by restricting the movement of the thorax. The patient must empty his chest as far as possible, and then strips of plaster must be placed round it from the spine to the sternum, commencing below, and arranging them so that each covers at least half the jjrecetling one. Over this may be placed a flannel roller, which is prevented from slipping down by means of a brace over the shoulders. When, however, several are broken, especially if they are on both sides, compression is not unlikely to increa.se the patient's discomfort. In this case a sheet of gutta-jjercha may be carefully moulded to the sides, or the patient may simj^ly be placed in bed, propped uj) with a bed- rest, so that the breathing shall be interfered with as little as possible, and kept perfectly quiet. In severe cases this i>lan should always be adopted. Nothing can be done to remedy displacement. The air in the room should be kept warm and moist, so as not to cause any irritation ; the diet should be light and the bowels kept open ; stimulants are rarely required. If there is not much expectoration, but merely constant irritation and tickling, small doses of compound tincture of camphor or of chlorodyne may be given ; but when the respiration is difficult and embarrassed from the amount of expectora- tion, opium is better withheld, and replaced by iodide of potash, carbonate of ammonia, and stimulating expecto- rants. If the dvspnoea is verv severe, and cyanosis setting „ ^^ _ . - c ■ r-- ' ■ \ r 1 r 1 1 1 1 1 Fig. 366.— Strapping in Fracture in ; if It is evident from the frothy, blood-stained sputa of Ribs, and the presence of moist rales, etc., over the chest, that the pulmonary congestion is becoming severe, and if the pulse is hard and rapid, there should be no hesitation in having recourse to venesection, though this is more often required when the lungs themselves are injured. [In case of exten- sive emphysema, incision at the points of fracture and in various places through the distended skin may be tried.] Injuries of the Sternum. The sternum may be broken by direct violence, as in gunshot injuries ; by indirect, as in extreme flexion of the spine, when the chin is driven down on to the manubrium, and the vertebrae dislocated ; or by muscular action combined with over-extension of the back, as in parturition, when the two ends .seem literally to be pulled asunder. In the first case the fracture may be transverse, longitu- dinal, or comminuted, according to the kind and direction of the force ; in the two latter the line of separation is usually transverse, and lies near the junction of the manubrium with the gladiolus, and there may be either dislocation or frac- ture. If there is a well -developed joint between the two portions, with a soft central space, almost arthrodial, the former will occur ; if the two are firmly united, the separation may take place above or below. The displacement is nearly always the same, the lower fragment carried in front of the upper. The diagnosis as a rule is easy, owing to the marked character of the de- formity. Reduction can sometimes be eff'ected at once ; more often it is a matter of very great difficulty and sometimes quite impossible ; and it very rarely hap- pens, when the fragments have been restored to their normal relation, that they can be prevented from slipping back again. The prognosis, so far as the fracture is concerned, is good ; but the shock is often extreme, and laceration of the l)leura or pericardium, rupture of the internal mammary vessels, compression of the heart, and other grave complications, are not unfrequently present. Non-penetrating Wounds. Non-penetrating uwunds are rarely serious. If the muscles are divided, or if a large artery, such as the subscapular, is torn across, there may be free hemor- S56 DISEASES AND INJURIES OF SPECIAL STRUCTURES. rhage for a time, but it is easily checked. Sometimes, however, in punctured wounds a large ha^matoma forms in the loose cellular tissue under the scapula and proves dangerous from inflammation, and the same thing may occur with lacerated and gunshot wounds, which often, owing to the resistance of the ribs and the yielding character of the tissues that cover them, extend much further than is at first sight apparent. The greatest care must be taken not to convert them by needless examination into penetrating ones. In most cases the question can be settled without touch- ing the wound, its extent and the character of the weapon making it certain at once ; but sometimes the diagnosis is difficult, and I have known a considerable degree of emphysema caused by injuries which certainly did not penetrate, where, for instance, the spike of some iron railings ran obliciuely upward beneath a boy's scapula. Foreign bodies must be removed, even if they are fixed in the ribs, and the bleeding stopped as soon as possible. If the muscles are divided, catgut sutures may be passed through the fascia investing them, in the hope of drawing them together, and the greatest attention must be paid to position, so that there may be no strain upon them ; but usually they unite either to the skin or to the tissue beneath. Drainage is very important, especially where the deep planes of cellular tissue are opened up ; and the chest should either be strapped or fixed as far as possible, or, owing to the want of rest and the constant movement of the ribs in respiration, union is very likely to be delayed. Injuries of the Thoracic Viscera. Rupture of the Pleura. Rupture of the costal pleura by itself probably occurs in every case of frac- tured rib or severe contusion of the thorax, but owing to the skin being unbroken the injury is repaired at once, with only a transient or local pleurisy at the most ; and though such complications as haimothorax from rupture of an intercostal or internal mammary artery and pneumocele may occur, they are very rare. When there is an external wound the pleura alone may be injured, without the lung, if the weapon is blunt and enters the thorax slowly, so that it pushes the lung in front of it, or if the wound is in the tenth or eleventh interspace ; for though the pleura usually extends as low as the last rib, the lung, unless it is emjihysematous, only reaches the tenth. In this case, however, the diaphragm and the subjacent viscera are very likely to suffer. Other complications depend upon the size and extent of the wound. If it is merely a puncture or a small incision the diagnosis is often never made ; but if it is extensive the lung may protrude without injury through the opening {hernia) ; it may collapse and fall back, leaving the pleura full of air {pneumothorax) ; the cavity, as already mentioned, may be partly filled with blood, and the air may either pass in and out freely through the wound {traumatopmva), or it may be forced into the cellular tissue under the skin, and spread over a considerable area {emphysema). This, however, is .seldom extensive unless the lung is wounded. Finally, at a later period, pleurisy may set in, and even run on to empyema. Injuries of the Lung. These may occur, as already mentioned, from mere contusion or compression of the thorax ; they are very common as a result of fractures of the ribs : and oc- casionally they are met with as a result of external wounds, penetrating from the outside. The wound may be superficial or deep, it may be punctured, incised, or lacerated, with or without the entrance of foreign bodies, and it may be so trivial that it is never diagnosed, or it may cause instant death. The simpler forms of wound heal at once by the first intention, without any inflammation and with very great rapidity. Severe contusion, owing to the extravasation into the INJURIES OF THE THORACIC VISCERA. 85 7 air vesicles, is attended with a greater amount of consolidation and witii rusty, blood-stained sputa for several days, hut the dullness rarely extends and there is little or no fever. If, however, the extravasation is very great, or there is an external wound, so that the blood decomposes, intense septic pneumonia and even gangrene may follow; but there is always such an amount of pleural effusion, and the lung, as a rule, in these cases is so collapsed and compressed against the back of the thorax that the physical signs are very obscure. Symptoms. — The two characteristic signs of wound of the lung are hemor- rhage and the escape of air. The former may take place into the bronchi, so that the sputa consists either of pure blood or of a frothy, bright red mixture, which in a day or two becomes rusty and black ; or it may collect in the cavity of the pleura (hsemothorax) and gradually soak into the surrounding tissues, so that the skin on the loins becomes dark and ecchymosed ; or it may escape externally, mixed with air, or almost pure. So with the air. In very rare instances, where the vesicles alone are torn without the pleura being injured, it may escape into the cellular tissue of the lung and make its way along the outside of the bronchi into the mediastinum, and so gain the root of the neck ; or it may collect in the pleural cavity, entering at each expiration, until it distends the thorax to its utmost and compresses the lung against the back ; or, what is far more common, without entering the pleura at all, it finds its way across into thecellular tissue and gives rise to surgical emphysema ; or, finally, if there is a large open wound, it is sucked in and out of the chest at each respiration, mixed more or less with blood. Besides these, other symptoms are usually present. The shock of such an injury is severe and sometimes fatal, even when the amount of bleeding is not great; anxiety and distress are always marked ; sometimes the dyspnoea is slight, but usually it is severe, and if the lung becomes rapidly collapsed it may be extreme ; there is a constant sense of irritation and tickling in the throat, with an intense desire to cough, but the deep, fixed pain in the chest prevents it, and if the hemorrhage is severe the patient may sink rapidly into a state of collapse. Wounds of the Heart. In comparison with the lungs, the heart, as might be expected, is very rarely injured. The pericardium, however, may be torn, the valves ruptured, and even the substance of the heart rent across in violent compre.ssion of the thorax ; the sternum or the costal cartilages may be broken and driven down into it, or it may be wounded from the outside by stabs or gunshot injuries. In a very few cases the pericardium only has been injured, or the surface of the heart. Much more frequently one of the cavities (the right ventricle especially) is laid open. Besides this, the pericardium and even the heart may be wounded by foreign bodies, fish- bones, etc., driven through the wall of the oesophagus. Death may take place immediately from shock or from blood collecting in the pericardial space and stopping the action of the heart. If the patient escapes these, secondary consequences — continued hemorrhage, and, later, inflammation — are almost sure to prove fatal. Recovery is stated to have taken place in about fifteen per cent., but, probably from the interest attaching to such cases, this esti- mate is too high, even, for civil practice. Foreign bodies, however — even bullets — have been found post mortem embedded in the substance of the heart, or pro- jecting into one of its cavities ; and fibrous cicatrices, with a thickened and adherent pericardium, have been demonstrated in many cases. Wounds of the auricle appear to be more fatal that those of the ventricle. Signs. — In the absence of an external wound, the only signs are extreme shock with very great distress, and rapid, sometimes almost instantaneous failure of the circulation. Dyspnoea is very common, possibly pointing to pericardial hemorrhage and compression of the heart. Sometimes it is immediate, at others it does not come on for some minutes. Pain is very variable ; it may be acute, 55 858 DISEASES AND INJURIES OE SPECIAL STRUCTURES. or it may he masked completely by the shock and distress. The heart sounds are usually inaudible, but in a few cases splashing and other abnormal ones have been heard. When there is an external wound the blood may pour out in a stream that is almost immediately fatal, or, especially in stabs where the opening is small or valvular, and when the wound in the heart is in the direction of the fibres, there may be very little. The only treatment that' is likely to be of any avail is absolute rest, cold, and opium ; venesection has been recommended to relieve the heart, but it can very rarely be necessary. The external wound may be closed in the hope of arresting hemorrhage ; but it must not be forgotten that accumulation of blood in the peri- cardium is one of the common causes of death. On one occasion I attempted to close the wound with sutures. The great vessels may be injured in the same way ; and, as a rule, accidents of this kind are even more rapidly fatal. Punctures of the aorta inside the peri- cardium, through the second intercostal space, and wounds of the coronary artery, end by allowing the blood to accumulate around the heart and compress it. In- juries to the other viscera in the thorax are more rare. A very few cases are recorded in which the oesophagus has been wounded from the outside. It is not uncommon to find foreign bodies driven through its wall from the inside, into the pleura, pericardium, and aorta. The thoracic duct has been divided, leading to a profuse flow of milk-like fluid during digestion ; and it has also been ruptured without external wound, so that the pleural cavity became distended with chyle. Rupture of the diajjhragm is sometimes met with, on the left side, from extreme compression ; and, of course, it may be injured anywhere by stabs, gun- shot wounds, or fragments of ribs driven in. In most cases the neighboring viscera are fatally injured, but sometimes they escape, and the stomach or intes- tines may be squeezed up through the opening into the thorax, leading to great distress, with vomiting and dyspnoia. When the rent is small, they may be stran- gulated at once. If this does not happen, traumatic diaphragmatic hernia persists for the rest of life, as the wound, if it is of any size, is never repaired. It may be distinguished from the congenital form by its situation and by the absence of a peritoneal covering. Primary Co)nplications — Hemorrhage. This may come from arteries in the wall of the thorax (the intercostals or the internal mammary), from the lung, or from the heart and great vessels, and the blood may escape either internally (into the pleura, pericardium, or mediastinum) or externally. To diagnose one from the other, it has been recommended that a folded card should be introduced deep into the upper angle of the wound with its concavity outward ; blood from a wounded intercostal will escape along the channel of the card, that from the thorax will pour out behind it. {a) External Hemorrhage. — The intercostal arteries for the most part of their course are so protected under the margins of the ribs that they are rarely injured ; at the back, however, they cross the interspaces obliquely. When they are divided in gunshot injuries or in resecting portions of ribs, the amount of hemorrhage is seldom large, but a few cases are on record in which it appears to have been very serious. If the wound leads down to a rib, the bleeding point should be well exposed, and an incision made on to the lower margin of the bone to ensure the artery being completely divided ; then the soft structures ma)- be j^ushed to either side with the finger-nail, so that the vessel may have a chance of retracting, and firm pressure may be kept up with the finger for a few minutes. If this does not succeed, the periosteum may be dissected back, carrying the artery with it, or for- cipressure may be used, or as a last resource the wound may be plugged either with a dilatable india-rubber ball or by laying over it a piece of antiseptic gauze, filling the centre of this with pledgets of cotton, and forcing it into the wound, so that when it is slightly drawn out it expands in all directions, and compresses the vessel against the rib. Passing a ligature around the rib, close to its inner surface, INJURIES OF THE THORACIC VISCERA. 859 and resecting a portion of the bone, have l)een recommended when the hemor- rhage could not be checked in any other way. Wound of the internal mammary, owing to the size of the vessel and the free- dom of its anastomoses, is much more serious, and in many cases has proved fatal either at once or later from secondary hemorrhage, even when no complications were present. The blood may escape externally, or into the mediastinum or pleura ; and the only effectual method for arresting the flow is to cut down upon it and tie both ends, removing, if necessary, a portion of the costal cartilages or of the margin of the sternum. In the first three spaces this is fairly easy, but lower down it becomes more difficult, until in the fifth and sixth it is almost impossible. When external bleeding comes from a wound in the lung, the diagnosis is generally only too easy ; usually it means that a large, and therefore deep, vessel is torn across ; air rushes in and out at the same time, and cough, dyspnoea, haemop- tysis, haemothorax, and great distress are present as well. The external wound mu.st be carefully but quickly cleansed ; any accessible foreign body removed ; and then the opening must be closed, the patient laid upon his injured side, and the most absolute rest enforced, in the hope that, as the blood collects and the heart beats more feebly, a coagulum may form and block the vessel. Tight constric- tion of the thorax is not well borne, but the injured side should be immobilized as far as possible. Stimulants should never be given ; inhalation of turpentine, or subcutaneous injections of morphia and ergotine, may be tried ; and apparent benefit has been derived from giving ten minims of tincture of ergot every hour, but the power of these remedies is not very great. Venesection was extensively practiced in the Crimea for the purpose of procuring collapse, but since then has been almost abandoned. If the patient survives, the amount of food and drink for the next few days should be reduced to the barest possible. If the pleura is filled with blood, so that the lung is collapsed against the posterior wall of the chest, and if the dyspnoea is very extreme, the wound may be opened, and the blood (or if it has coagulated, the serum) allowed to escape ; but this can very rarely be required, and it must be remembered that it may always lead to fresh hemorrhage. {b) Internal Hemorrhage. Hcenwthorax. — Pleural extravasation nearly always comes from the lung ; exceptionally it may proceed from the arteries in the wall, or from the heart or great vessels. The blood i)ours down at once to the lowest part of the cavity (depending, therefore, upon the position of the patient, whether he is sitting up or lying down) and soon coagulates. If the quantity is small and no air is admitted, it is absorbed again, and except for slight dullness and diminu- tion of the breath sounds at the base, there is no way of diagnosing it. If, on the other hand, the amount is large, and if air gains access to it (pneumo-hsmo- thorax), inflammation, with a great increase in the pleural effusion, and suppura- tion, are almost sure to follow. When the air is filtered through the lung, instead of entering directly through an opening in the thorax, this danger is not so great. When the extravasation is large, there are always symptoms of severe hemor- rhage, in addition to the physical signs. The face and lips are white, the skin cold and moist, the patient sits propped up, rocking himself backward and for- ward, or throwing his arms from side to side, gasping for breath, and on the verge of syncope. The pulse is small and thready, too quick to be counted ; there is intense thirst, the pupils are dilated, and often there are attempts at vomiting. In such cases death may ensue at once, partly from the loss of blood, partly from the difficulty of respiration, or after a time the severity of the symptoms may diminish and the pulse gradually recover. Generally, when this is the case, ecchymosis makes its appearance in the loins after a few days, due to the blood-color soaking through ; sometimes the whole is absorbed, but more frequently the temperature begins to rise ; perhaps there is rigor, the area of dullness increases, the dyspnoea becomes more marked, and it is clear that inflammation is setting in. The early treatment of haemothorax is not materially different from that of S6o DISEASES AND INJURIES OF SPECIAL STRUCTURES. wound of the lung with external hemorrhage. The first indication is to stop the bleeding. If it can be proved that this arises from one of the intercostal arteries or from the internal mammary, exploration would be justifiable, but hjemothorax under such conditions must be very rare. There is nothing at first but rest, cold, opium, ergot, and restricted diet; gallic and sulphuric acids and acetate of lead also enjoy a certain amount of reputation. Where the dyspncca is extreme, and it is evident that it is due to collapse of the lung, relief may be given by inserting a fine cannula and allowing some of the serum to escape slowly, so as not to relieve the pressure on the wounded vessel too suddenly ; but though this is not unfre- quently necessary in pneumo-hajmothorax, it is very rarely required where there is only blood. Later, after three or four days, if the effusion shows any signs of increasing, or if there is any rise of temperature, this method of treatment is of very great service. It is very improbable, after such a lapse of time, that the increasing dullness is due to hemorrhage ; much more likely it is the result of pleural effusion, consequent upon the tension ; and allowing some of the fluid to escape under its own pressure not only diminishes the amount {\i it is going to suppu- rate) but assists the absorption of the rest by allowing the lymphatics to act again. This may be repeated on several occasions, as the blood coagula slowly breaks down, but no force may be used to draw the fluid out. Accumulation of blood in the pericardium or in the mediastinum is very much more rare ; the former is nearly always associated with wound of the heart or the first portion of the aorta, the latter with injury to the internal mammary artery or the great vessels at the root of the neck. Hczmoptysis. — If a large vessel is injured this may be jjrofuse, the blood pour- ing out from' the mouth and nose in gushes, until the patient sinks into a state of syncope. When profuse, it always points to injury of the lung, but the blood must be intimately mixed with the air, and bright red in color, for it to be con- clusive. If it is not, it may have come from the larynx, or even have trickled down from the nose or some other part, and been coughed up again. After a day or two it becomes rusty and dark, more like the sputum of croupous pneumonia. Pneumothorax. Air may enter the pleural cavity either from without through an external wound, or from within through a rupture of a lung or the bursting of a cavity in its substance. In the former it enters during inspiration, in the latter during expiration, the air being driven out of the lung into the pleural cavity so long as the tension in it is less than that of the trachea, but neither can occur unless the wound is of some size or very irregular. The adhesive force between the two layers of the pleura is such that, in spite of the elasticity of the lung, it requires some pressure to separate them. In incised wounds of the chest the pulmonary pleura has been seen in contact with the costal, gliding on it as the lung expanded or shrank, but not separating from it ; and in punctures from ril)s, where emphy- sema of the subcutaneous cellular tissue is exceedingly common, pneumothorax is exceedingly rare. If there is an external wound the diagnosis of pneumothorax is evident at once ; when due to penetration or rupture of the lung, the physical signs are the same as when it is produced by the rupture of a tubercular cavity. The chest on the injured side becomes over-distended, the intercostal s])aces are bulged out, and the viscera displaced, the ribs remain motionless in respiration, there is tympan- itic resonance over the whole of the front, but often, owing to the effusion of fluid, slight dullness at the base behind ; and breath-sounds are entirely wanting unless they are transmitted along the wall of the other lung. On shaking the patient, metallic tinkling and splashing may be heard, if there is any fluid present as well as air, and when a coin is placed upon the skin and struck with another, a clear, bell-like sound is transmitted to the ear placed on the opposite side. The treatment depends upon the amount of distress. Dyspnoea is always INJURIES OF THE THORACIC VISCERA. 86 1 severe, but if it is not extreme, the patient should merely be kept perfectly quiet in bed, propped up in the easiest position, until the air is absorbed. The rent in the lung becomes very small when it is colla})sed ; repair takes place readily, the air soon disappears, and the lung quietly expands again. If, however, the dififi- culty of breathing becomes very great, especially if signs of congestion of the opposite lung — frothy blood-stained sputa and moist rales — make their apj^ear- ance, a fine cannula should be introduced, and some of the air allowed to escape under its own tension ; and this may be repeated as often as required. Venesec- tion is seldom necessary. Later, as already mentioned in hajmothorax, if there is fluid mixed with air at the bottom of the cavity, as much of it as possible should be allowed to flow away in the same manner. Ej7iphysetna. In wounds of the thorax air may find its way into the subcutaneous cellular tissue, and be driven further and further by the movement of the muscles, until it spreads all over the body, and renders the features perfectly unrecognizable, the scalp, the palms of the hands, and the soles of the feet alone being exempt. The looser the skin the more distended it becomes, but it remains soft and white, and when it is touched there is a fine crackling sensation as the bubbles of air are driven through the meshes of the areolar tissue. The same thing apparently is met with in decomposition from incipient putrefaction, but the other conditions are very different. Surgical emphysema may be caused in various ways, but there is only one, when it is due to the ribs being broken and driven into the substance of the lung, in which it attains any importance. 1. It may occur in the case of a simple valvular wound of the skin. 2. From wound of the pleura only, when air is sucked in during inspiration, and, owing to the obliquity of the opening, is unable to escape freely in expira- tion. 3. From rupture of the air vesicles, without the pleura being torn. This, which is distinguished as interstitial emphysema, is more likely to occur from injury to the apex of the lung, whether from external contusion or from violent compression of the thorax. The air gradually finds its w^ay into the mediastinum, and from there to the root of the neck. 4. From fracture of the ribs. Owing to the cohesion of the pleural surfaces, the air, without ever really entering the pleural cavity, is forced across it by each act of expiration into the cellular tissue, and is driven further and further until it may extend over the whole body. Pneumothorax very rarely occurs \ the wound in the pulmonary pleura, as it glides backward and forward, corresponds twice in every breath to that in the costal, and the air passes directly from one to the other. Emphysema can be recognized at once by the peculiar crackling sensation when the skin is pressed. Generally it is limited to the region of the wound ; those instances in which it is extensive are of comparatively rare occurrence. As a rule, it requires no treatment ; the air soon becomes absorbed ; when it is caus- ing great inconvenience small punctures may be made in the skin, or pressure may be used to try and restrain it ; but this is not very successful, and, fortunately, is seldom required. It is said to have proved fatal from interference with the respiration.^ Hernia of the Lung. Pneumocele, hernia, or prolapse of the lung is an occasional but rare compli- cation of injuries of the thorax. It may be either immediate or secondary. In [* A case of fracture of two rilis with emphysema from lung rupture was admitted into the United States Marine Hospital, Chicago, 189I. Death resulted on the third day. The skin over the neck was distended until it was completely separated from the underlying fascia.] S62 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the former case there is generally a wound of some extent in the parietes, and the lung is forced out through it hy a violent effort at expiration when the glottis is closed. It may be injured itself or it may not, but as soon as it is S(iueezed out through the rent it expands so that it cannot return, and rapidly becomes con- gested. In extreme cases it may be strangulated. If seen shortly after the accident an attempt may be made to return the protrusion, and, if necessary, the wound may be slightly enlarged for the pur])0se ; but if some time has elap.sed, and the tissue is very much congested, it is better left where it is to slough off and granulate over ; or its separation may be a.ssisted by ligature or actual cautery. .V very few instances are recorded in which, owing to extensive injury of the thorax, an immediate prolapse of the lung has occurred without an external wound. The consecutive variety may not make its appearance until some considerable time after the receipt of the injury, and if there has been a wound it must have healed first. It forms a soft circumscribed tumor ])rojecting through the wall of the thorax under the skin, swelling out on expiration and shrinking on inspiration. On coughing there is a distinct impulse ; if it is pressed upon it collapses readily with a feeling of soft crepitation, and the margins of the opening can be plainly felt. It is resonant on percussion, and the respiratory murmur is loud and coarse in comparison. In some cases it is the result of extensive rupture of the inter- costal muscles ; in others, where its formation is very gradual, it is pro1)ably due to chronic inflammation weakening the wall of the thorax at one spot, and allowing the lung slowly to force its way through. The ^only treatment required is a belt or truss, according to the size and situation of the protrusion, to restrain it and protect it from injury. Foreign Bodies. Bullets and other weapons impacted in the wall of the thorax present no special peculiarity ; they should be removed as soon as convenient, but it must be remembered that doing so may give the first proof that the injury involves the cavity of the chest as well as its wall. If the foreign substance is lodged in the pleura, it may either (as in the case of fragments of clothing, wadding, splinters, etc.) remain in the neighborhood of the external wound, or if it is heavy, like a bullet, sink down to the bottom, and rest upon the surface of the diaphragm, near the spine. Occasionally under these circumstances it becomes encysted ; much more frequently acute inflammation, running on to suppuration, sets in, and the foreign substance is discharged through the opening made to evacuate the pus. The same thing occurs when it is lodged in the lung. Instances are recorded in which bullets, fragments of bone, or of metal, and other similar substances, have remained quiet for years, becoming surrounded by fibrous tissue and encysted, or at length have caused a certain amount of chronic suppuration, leading to their discharge either externally or through one of the bronchi. As a rule, however, the termination is not so successful : either acute septic pneumonia, running on to gangrene, occurs, or chronic inflammation, ending in phthisis, follows. The question of extraction depends entirely on whether the foreign body is accessible or not. No attemj)t should be made to remove it from the pleura, unless there is a distinct indication as to locality ; and in the case of the lung the greatest caution must be exercised ; fatal hemorrhage sometimes follows the ex- traction of a weapon, but if there is a reasonable suspicion that anything is left the external wound should not be closed. Seco7idary Complications. The secondary troubles that occur after injuries of the chest are for the most part the result of inflammation, which may involve the walls of the thorax, the pleura, pericardium, lungs, or heart. Extra-mural Suppuration. — Abscesses may form as the result of contusions, either in the superficial tissue or deeper under the muscles, when they often spread INJURIES OF THE THORACIC VISCERA. 863 for long distances before they point. In all cases they should be opened at once ; the deeper ones can often be reached from the axilla, along the margins of the muscles, but if this cannot be done the opening must be made wherever the drain- age is likely to succeed best. If there is any doubt as to the existence of pus, or the direction of important vessels, Hilton's method should be employed. Necrosis of the ribs or sternum is not unfrequently assigned to injury. Some- times it may be due to this alone, but in most of the cases in which this comjjli- cation is present there is a distinct history of tubercle or syphilis. Abscesses sometimes form between the pleura and the ribs, or in the medias- tinum. The former are generally associated with necrosis and soon point exter- nally, though they have been known to burst into the i)leura. The latter may attain a very large size and cause comi)ression of the vessels and severe constitu- tional disturbance before their nature can l)e determined. Usually they i^oint just to the left of the sternum, and if pulsation is communicated to them from the heart they may easily be taken for aneurism ; in other cases they work their way out through the bone, or pass upward into the neck, or downward along the internal mammary artery ; or extend into the pleura or pericardium. No time should be lost in opening them as soon as the diagnosis is made. Pleurisy and Empyema. — In fracture of the ribs and in most cases of severe contusion of the thorax, a certain amount of effusion is thrown out by the costal pleura, leading to thickening- of the membrane and sometimes to the formation of adhesions between the two surfaces. If, however, there is a large extravasation of blood, or if air or other foreign substance finds its way in, the inflammation is more severe ; and if the irritation is kept up, or if it is of a very intense character, it ends in suppuration (empyema or pyothorax). When this occurs the suppuration may be very acute, ushered in by rigors and high fever ; or it may be chronic, the effusion gradually increasing, and becoming more and more purulent, as when empyema succeeds serous pleurisy. In most cases it is general, but it may be local at first. The physical signs are usually well marked. If there is no wound the side of the thorax is enlarged and the neighboring viscera displaced, the breath sounds are either altogether lost over the lower part of the chest on that side, or, if the effusion is not so great, they are replaced by weak and distant bronchial breathing. Over the same area there is absolute dullness, the level rising day by day, and varying a little with the position of the patient ; and sometimes jegophony can be heard at the upper margin. When there is an open wound the pleura is filled to a great extent with air, and there is a profuse discharge of fluid, sometimes pure pus, sometimes broken-down blood-clot, according to the amount of hsemothorax that preceded the empyema and the length of time since the accident. The pleurisy that occurs in connection with simple fracture nearly always gets well of itself; if fluid does collect, and is not absorbed, it may be withdrawn with an aspirator. If suppuration sets in, the first consideration is to ensure per- fect drainage, so that the pus cannot be pent up and decompose. When there is an external wound it must be enlarged, carefully examined, and explored with the finger to ascertain if there is a foreign body which has been overlooked, or any other cause ; and in most cases it is advisable to make a second opening at once. When there is no wound aspiration may be tried ; but if the fluid is of such a character that it cannot be evacuted in this way (if, for example, it consists largely of blood-clot that has not yet become liquid) ; or if, after a certain amount of success, the cavity begins to fill again, it must be drained. If it is done at once, before the pleura has become condensed and thickened, the lung will ex- pand again and become adherent to the wall of the thorax. Pneumojiia. — Simple wounds of the lung, as already mentioned, generally heal by the first intention, with very little consolidation or effusion. If, however, there has been much contusion or extravasation ; if there is an external wound ; and particularly if a portion of some foreign substance, such as clothing or wad- ding, has been carried in, or has entered through the larynx, decomposition may 864 DISEASES AND INJURIES OF SPECIAL STRUCTURES. set in, and excite intense intlainmatic^n and suppuration. Sometimes even then it ends in a local abscess, the pus suddenly hurstinj; into one of the bronchi, or working out through the wall, along the track of the original wound, or even dry- ing up and ultimately becoming caseous or calcareous ; but much more often it runs on until the greater jjortion of the lung or of one of the lol)es is involved ; and occasionally it is so acute as to end in gangrene. The locality of the pneumonia depends upon the seat of injury. The i>hysi- cal signs, when they can be made out, are the same as those of the ordinary croupous form, but they are usually obscured by the presence of empyema, pneu- mothorax, or other comjjlications. The sputa may be rust-colored, even when there is no inflammation from traumatic hemorrhage into the air vesicles. High fever, however, following a severe injury to the lung, renders its presence practi- cally certain. The prognosis depends upon the amount of lung involved and upon the cause. Very little can be done in the way of treatment ; constant inhalation of moist air impregnated with some volatile antiseptic, may be tried to limit the amount of decomposition ; but if the condition of the breath indicates that gan- grene has set in, almost the only hope lies in incision and drainage. Too often, however, the condition of the patient is practically hopeless. For the rest, all that can be done is to maintain the strength of the patient, and, if there is exten- sive pleural effusion, relieve the breathing by tapping. Diseases of the Chest Wall. Chronic Abscess. — This may arise from a suppurating hasmatoma, or follow the caseation of a tubercular deposit. Very often it originates in connection with a carious rib. The symptoms are usually distinctive, but care should always be taken to prove that the sac has no communication with the thorax. The cavity should be laid open freely to allow the contents to escape, explored with the finger, washed out with perchloride solution, and drained. The tube reepiires re- moving upon the second day ; after that the wound may be covered with wood- wool and left until it is sound. Tubercle may affect the subcutaneous tissue, leaving long sinuses lined with pale, flabby granulations (in one case under my care they extended across the front of the chest from one axilla to the other), or it may commence in the sub- periosteal layer of the bones. It should, in any case, be thoroughly scraped out, and the wound well powdered with iodoform. Fortunately the pleura becomes so thick that there is very little risk of an empyema following. Ginnmata are of frequent occurrence upon the sternum, leaving deep, circular, punched-out sores, with the bone beneath bare and rough. In addition, all forms of tumors that develop in connection with fibrous or connective tissue, bone, or cartilage, are met with ujjon the thorax. The treat- ment, of course, depends upon their character; in some cases their removal is comparatively simple ,; in others it may be necessary to excise the subjacent bone and expose the pleura or even the pericardium. Sarcomata can sometimes be shelled out, but great care must be taken to ascertain whether they have any deep connection. OPERATIONS UPON THE THORAX. Paracentesis. Paracentesis of the pleura is performed either for exploration (to ascertain the presence or the nature of fluid), or to relieve the tension in the cavity, so that the lung may expand again, and the balance between absorption and secretion be once more restored. For purposes of exploration a large hypodermic syringe is the most suitable OPERATIONS UPON THE THORAX. 865 instrument. Care should be taken that it is absohitely clean (it is not sufificient to draw even a strong carbolic solution through the needle ; all cannulae before using should be boiled in licjuor potassii: ; nothing else will ensure freedom from putrid grease in the interior), and unless it is intended to emjjty the cavity, only a small amount should be withdrawn. It is very easy by means of reiteated punc- tures to convert a simple pleurisy into an empyema. The locality selected de- pends upon the physical signs, but the thinnest part of the chest wall that is avail- able should be chosen ; the skin should be pulled a little to one side, so that the opening may be valvular ; and care should be taken to pass in over the upper border of a rib. If it is intended to withdraw the fluid an aspirator should be used, adopting the same precautions, and keeping up a uniform but slight amount of suction. The operation may be required for hasmothorax ; for jileurisy, if the effusion is so large as to interfere with the action of the opposite lung or with the heart, or if, though it is not large enough for this, it fails to diminish under other methods of treatment ; for hydrothorax occurring on both sides (as sometimes in Rright's disease) ; and for empyema. The usual situation is in the seventh or eighth space, just in front of the angle of the scapula. An anaesthetic is not required ; if the patient is very nervous the ether spray may be used. The semi-recumbent position is the most convenient ; the patient cannot lie upon, the sound side on account of his respiration, but a finger must be kept upon the pulse, as sometimes syncope occurs if a large quan- tity of fluid is withdrawn, or if it comes away rapidly, probably from the viscera being unable to accommodate themselves at once to the altered conditions. A small incision should always be made through the skin with a scalpel ; the walls of the thorax, even when it is full of fluid, are apt to yield a little ; the trocar, how- ever sharp it may be, does not penetrate readily ; and if it does not enter smartly it may jjush the thickened pleura in front of it, and fail to reach the cavity. At the same time it must be guarded with the thumb, so that it may not be driven across the pleura when the resistance ceases. The quantity of fluid withdrawn must naturally be guided by the circum- stances of the case, but no attempt should ever be made to empty the cavity, and if the pulse becomes weak, or any blood appears in the aspirator, or the patient begins to cough, the needle should be withdrawn at once, and the puncture sealed with collodion. It very rarely happens that any serious consequences follow, but syncope, embolism (from the pulmonary veins), and oedema of the lung (owing in all probability to the paralysis of the walls of the vessels, caused by prolonged ansemia) have been known to occur ; and, owing to the feeble nutrition of the tissues and the inflammation already present, there is distinct danger of the fluid becoming purulent. Drainage. Drainage of the pleura is very rarely required except for empyema. In the traumatic variety (that which is caused by a foreign body entering the bronchi, by haemothorax, or by the rupture of a cavity) it is nearly always necessary. On the other hand, when an empyema follows simple pleurisy, aspiration maybe tried first, unless it is already pointing. In children, in particular, it is often successful, and although the chance is less in the case of adults, it is always worth the attempt. The cavity, of course, is not emptied, and the residue of the pus must be removed by absorption. In addition to the physical signs pointing to fluid in the pleural cavity, the presence of pus is indicated by rigors, hectic, or oedema of the skin ; but it should always be suspected, especially in the case of children, if after any of the acute specific fevers or an operation, or, indeed, any serious illness, recovery is unaccount- ably delayed, and the patient, instead of improving, begins to fail and go back. If, under such circumstances as these, there is any indication of fluid in the pleura, there should be no hesitation in using an exploring syringe. 866 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The chances of an empyema getting well of itself are very remote ; nearly always it continues to increase until either the skin or the lung gives way and the contents are discharged externally or into the bronchi. In rare cases the pus works its way down behind the diaphragm and bursts into the stomach or intestines, or enters the psoas and i)oints first in the groin. The longer it is left the more collajjsed the lung becomes and the thicker the pleura, until at last, in an old- standing case that has been allowed to break of itself or has not been opened until late in the course of the disease, the pleura is dense, almost cartilaginous in its hardness, and perhaps an inch in thickness, while the lung is compressed and bound down against the vertebral column in such a manner that expansion is hopeless. Death may occur suddenly from synco])e ; the heart is so much displaced and its cavities so compressed, that at the best it can only work at a grave disadvantage, and the least exertion may suddenly turn the scale ; from asphyxia, owing to oedema of the opposite lung, or from the pus being discharged into the bronchi in such quantity that it cannot be coughed up ; or from gradual exhaustion. If the em- pyema bursts it may prove fatal from acute septicaemia, the contents of the cavity becoming putrid (this is less likely to occur when the opening is into the lungs than when it is external) ; or, after many weeks or months, from hectic and albuminoid disease. If the lung cannot expand, the chest wall falls in (causing a lateral curvature, concave on the affected side, with compensatory curves above and below) ; the heart and the other lung are displaced, and the diaphragm is forced up. Sometimes, between them, the cavity is obliterated ; the lymph upon the costal pleura adheres to that upon the lung, and the sac disappears as such, leaving a deformity which, especially in the case of children, diminishes to a certain extent in course of time. Much more often, if the lung is once tied down and the pleura thickened, sufficient displacement is impossible (the upper part of the thorax, where everything is more rigid, is always the last to contract) and a sinus is left, leading to what is practically an old abscess sac. If this is small and the opening straight, the discharge may be so trifling as to cause practically no inconvenience ; more frequently the prolonged drain tells at length upon the health, and albumi- noid degeneration sets in. An anaesthetic is advisable, although special care is required, and chloroform is to be preferred to ether. The position of the patient is the same as for aspira- tion. In children and recent cases, and in small localized empyemata, a single incision may suffice ; under other conditions two should always be made, as it is impossible for such a cavity as the pleura, when the lung is contracted, to drain efficiently through one. The usual site is in the axillary line (in front of the latissimus dorsi in the seventh or eighth space) and the two may be close together. It is better, however, to have one of them higher up in the fourth or even the third, as the lower part of the pleural cavity often becomes obliterated in a few days, so that the tube is forced out. If there is an old sinus or the pus is localized, the question, of course, is entirely different ; and it may even be necessary to open the cavity behind the scapula, though this should be avoided if possible, not only on account of the depth, but because of the obliquity of the intercostal arteries. The position of the intended opening should always be marked out upon the skin before the arm is abducted from the side. A vertical incision an inch and a half in length should be made through the skin and the superficial fascia, down to the intercostal muscles, and then either the scalpel itself (with the blade turned i)arallel to the ribs) or a shari)-pointed steel director thrust through the wall into the fluid beyond. The opening can then be enlarged to a sufficient extent with a pair of dressing- forceps. If the intercostal artery bleeds it is usually because it is punctured, not divided. In ordinary cases a drainage tube, as large as the space between the ribs will admit, should be introduced at once ; a second opening made if it is thought ad- visable ; the cavity allowed to empty itself as the patient comes round from the anaesthetic, and then the side covered in with many layers of wood-wool or some OPERA TIONS UPON THE THORAX. 867 other absorbent dressing. By degrees the margins of the ribs become aljsorljed by the pressure of the rubber, so that there is no fear of its being nijjped and com- pressed, even if the thorax collapses. When, however, there is an old sinus to deal with and the ribs are already pressed clo.sely together, overlapping like the slates on a roof; or when it is thought advisable, owing to the presence of a foreign body or from other causes, to e.xplore the interior with the finger, this is not sufficient. In the former case a circle may be cut out from the bony cuirass with a trephine, removing portions of two, or, perhaps, three ribs ; in the latter, a definite segment of one may be excised. The superficial incision should be sufficiently long to expose it thoroughly ; the periosteum divided along the convexity of the bone and detached from it (with especial care where the lower border is concerned), and the two ends of the exposed portion severed with curved force])s or a fine saw. The deep layer of the periosteum and the pleura can then be torn through at the bottom of the wound. The broken rib undoubtedly increases the pain for the first few days, but in a very short time it becomes welded by callus to those on either side of it. Except in the case of foreign bodies or of localized empyemata, there is no object in the introduction of the finger ; and probing the cavity should be avoided, as it makes the walls lileed and tends to separate recent adhesions. Washing out the pleura with antiseptics is dangerous and unnecessary. Even when the pus is foul and putrid the absorption ceases and the temperature falls as soon as free drainage through two openings is established. Specially made rubber tubes (like tracheotomy-tubes, only with the closed end and lateral openings) may be used, or they can be fashioned as required out of drainage tubing, by passing it through a piece of stout rubber three or four inches square, slitting one end down on three sides, and securing the branches to the face of the shield with a suture. The length of time they are necessary varies, of course, in each case. Usually, as the openings become lined by granulations, the tubes can be shortened until they are only just long enough to project through the wall ; then the question is determined by the amount of discharge. It is better to leave them in until they are practically- forced out from within ; if they are left off too soon, the opening begins to con- tract immediately ; drainage is checked, and the temperature begins to rise. Re- placing them, even after three days, may be a matter of considerable difficulty, requiring trephining or excision. Occasionally the exposed surface of the rib necroses, but, although this may check the healing of the wound, it rarely causes any serious trouble. Thoracoplasty. In old cases of empyema the lung is so firmly bound down that in spite of the aid it receives from the collapse of the walls and the displacement of the vis- cera, it is unable to expand sufficiently to fill the cavity. Nearly always this is due to the operation having been delayed, and if the discharge is more than a very minute quantity it is almost sure to end sooner or later in albuminoid disease. Something can be done by allowing the patient to sit up as soon as he can, en- couraging him to move about, and perhaps by systematic exercises and the inhala- tion of compressed air, but it is not probable that this can do much. Practically the only course, if it is clear the cavity cannot contract any more, is to divide the external wall so that it may yield sufficiently. This is usually known as Est- lander's operation, or thoracoplasty ; it involves the removal of a considerable length (often six or seven inches) of every rib (it may be seven or eight) that enters into the formation of the wall of the cavity, and naturally should never be performed unless it is absolutely certain that obliteration in any other way is im- possible. Moreover, the condition of the heart, the other lung, and the kidneys must be taken into careful consideration first ; adherent pericardium (which is not an uncommon complication in cases of empyema), phthisis or albuminoid degen- eration, if it is distinctly present already, are practically prohibitive. The first thing is to ascertain the shape and size of the cavity as accurately 868 DISEASES AND INJURIES OF SPECIAL STRUCTURES. as possible with the finger and a probe. Usually it runs upward and backward across the general direction of the ribs, so that it may be necessary to commence at the second and remove portions of five or six ; the first, of course, should never be touched. .\ single vertical incision is usually sufficient; occasionally two mav be necessary, or it may answer better to raise the soft tissues in a flap [Schede's ope- ration]. As a rule, the ribs lie so close together that it is impossible to slip the finger nail between them, and the preliminary section must be made with a saw, commencing over the cavity at its anterior margin. As soon as a portion of one or two has been excised, a better idea can be formed as to what is re(]uired. Ac- cording to Pearce Gould, the whole of the bone that forms the outer wall of the empyemic cavity must be taken away, a free opening being first made in front, and then the rest of the wall divided from within by means of cutting forceps. [Subperiosteal resection of the ribs is a much less serious operation, and it may be performed with comparatively little hemorrhage, and often without wounding the intei-costal vessels or pleura. Not only does the chest wall collapse, but the bony rib is reproduced. This ideal result I had the pleasure of seeing in a case at the United States Marine Hospital, Chicago, 1891.] Pneumoxotomv. Incision of the lung may be practiced, according to Godlee, in cases of gan- grenous cavities, abscesses caused by the extension of suppuration from other parts into the lung, abscesses connected with foreign bodies, bronchiectatic cavities, provided they are single (multiple ones can hardly receive nmch relief this way), and tubercular cavities, if there is only one, and the cough is very hara.ssing. In one or two cases a similar operation has been practiced for hydatid disease, and a few instances are recorded in which tumors have been removed from the lung. The localization of the disease and the treatment of the pleura are the chief diffi- culties. No incision may be made until the existence and accessibility of the cavity have been proved by puncture, and even then the greatest care is rerjuired, for the lung, unless it is consolidated by inflammation, is so yielding that a thick-walled sac can easily be pushed to one side. As a rule, cavities should not be approached from behind, for the large vessels run for the most part along the posterior surface of the bronchi. The size of a cavity cannot be estimated from the amount of fluid that is coughed up ; according to Godlee, upward of a pint may come within twenty-four hours from a space that would not hold as much as two ounces. If a cavity is found, the lung tissue should be incised, and explored as far as possible with the finger, part of a rib being removed if necessary, and a large drainage tube inserted. The shape is always very irregular, and it must be a long time before the sloughs have separated, and cicatrization can jjrocure its obliteration. The treatment of the pleura presents unusual difficulties. There can be no doubt that it is not advisable to incise a i)utrid cavity in the lung unless the pleural surfaces are adherent. If there is localized gangrene, and if it has already lasted for some time, the danger is not so great ; adhesions are usually present under these conditions, and the lung is so consolidated by inflammation that it is in but slight danger of collapsing ; but in acute cases and in bronchiectasis it is impos- sible to be certain. An attempt may be made to find out by ascertaining the mobility of the lung; if a needle is driven through an intercostal space into the pulmonary tissue, it will show to a certain extent by its movement whether the lung is fixed or not, but it is very easy to place too much reliance upon this. In some instances it may be possible to suture the two surfaces together and wait for a week, or to ]jrocure adhesions by means of the cautery applied to the intercostal muscles, but often it is imjiossible to wait so long, and even then the adhesions are so soft and delicate that the greatest care must be taken not to break them down. [Dr. E. Wyllis Andrews, of Chicago, showed to the Chicago Medical Society, OPERATIONS UPON THE THORAX. 869 in 1892, several large calcareous concretions taken from the human lung by in- cision. At the date of the report, the patient had much improved subsec[uent to the operation.] Paracentesis ok the Pericardium. This may be required for serous effusion, when the quantity is increasing to such an extent that the action of the heart is failing, or for a collection of pus, such as is not uncommon in the pygemia that complicates acute necrosis. It may be performed in any interspace from the third to the eighth (the fourth or fifth is usually recommended), preference being given to that which shows the clearest indication of fluid, and a spot should be selected about one inch from the edge of the sternum, so as to avoid the internal mammary artery on the one side and the pleura on the other. The direction of the puncture must depend upon the locality ; if it is on the left of the sternum, the needle should be pushed backward and toward the right. The right ventricle of the heart has been perforated on several occasions. A preliminary incision should be made through the skin and a fine aspirator needle used. If the fluid is clear and serous, the cavity should not be emptied ; removal of part will probably give sufficient relief; if, however, it is purulent (this is often indicated by cedema of the skin), the incision should be gradually deepened until the pericardium is exposed sufficiently to introduce a drainage tube. 870 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER XVIII. INJURIES AND DISEASES OE THE ABDOMEN. SECTION I.— INJURIES OF THE ABDOMEN. Contusions. Blows upon the abdomen may affect the walls, or the viscera, or both together. They are always accompanied by a very severe degree of shock, and it is said that a fatal result has followed without any structural lesion having been discovered at the autopsy. Certainly death may result from such apparently trivial injuries as rujjture of the i)arietal peritoneum without hemorrhage, or puncture of a small hydatid cyst of the liver, probably owing to reflex paralysis of the heart. Owing to this peculiarity it is often impossible to form a conception as to the extent of the injury (the viscera may be reduced to pulp without the skin showing a sign of bruising, as in what used to be called wind contusions, from spent round- shot), and the prognosis must be very guarded. The shock may pass off within a few minutes or a few hours, or it may prove fatal, or it may be followed, without any break or interruption, by signs of hemorrhage or of rupture of some of the hollow vi.scera. {a) Contusion and Subcutaneous Laceration of the Wall of the Abdomen. — A hgematoma may form in the subcutaneous tissue, or in the sheath of the muscles ; in some cases the extravasation is very extensive, usually it is absorbed (leaving, if the muscle has been much injured, a weak spot in the wall of the abdomen through which a hernia may take place subsequently), but occasionally suppuration sets in. Abscesses of the abdominal wall caused in this way are characterized by the enor- mous amount of induration that surrounds them, and not unfrequently, even when they have no communication with the viscera, by the ftetid nature of their contents. Laceration of muscles, especially of the rectus abdominis, is not a rare occur- rence. It may be caused by a sudden effort, as, for examjjle, in parturition, or by a blow when the muscle is rigidly contracted. In tetanus it is not uncommon, and it is said to be of fre(][uent occurrence after typhoid fever, owing to the degene- ration of the contractile substance. The signs are characteristic, but, unhappily, if the rupture is complete, nothing can be done to secure union of the ends, and an abdominal support must be worn afterward. Laceration of the diaphragm can only be recognized, if the patient lives, by the subsequent occurrence of traumatic phrenic hernia. The parietal peritoneum sometimes gives way by itself, owing to its want of elasticity, but this is not so common as in the case of the visceral layer, probably because of the presence of the subperitoneal fatty tissue. It may be followed by peritonitis. (J}) Rupture of the Viscera. — A very slight degree of force is enough some- times ; an enlarged spleen, for example, or a distended bladder with atrophied walls, tears at once, and the latter, at least, will give way under the mere pressure of the muscles. Most instances, however, are due to extreme degrees of violence, the worst being what are known as buffer accidents. The liver suffers the most frequently, on account of its size and position ; sometimes the gall-bladder is torn as well. The stomach may give way (especially if it is distended), usually near the pylorus. The small intestine may be torn across (generally at the end of the duodenum, for here the most movable part is joined to the most fixed), the spleen may be ruptured, the kidney, its pelvis, or the ureter lacerated, and the mesentery, INJURIES OF THE ABDOMEN. S71 with its blood-vessels, rent in any direction. The pancreas, owing to its position, usually escapes, unless, as sometimes happens, the contents are completely crushed. The diagnosis of many of these injuries is impossible until secondary conse- ciuences have^made their appearance. The patient simply lies utterly prostrate, and it is not possible to tell whether his condition is due to shock alone or to shock combined with hemorrhage, or rupture of the viscera. The bladder may be excluded by passing a soft catheter ; if it is empty at the time of the accident it is almost certain to have escaped (unless the pelvis is fractured too) ; if it was full, and has 'dven way, nothing but a little blood-stained fluid follows when the catheter is passed. Hemorrhage into the peritoneal cavity may be diagnosed by the increasing intensity of the collapse, the yawning and jactitation of the patient, IScdlBladder Z/miilicUs 4<:^LuinhX Cac Po u parts Miy Fig. 367.— Diagram Showing the Position of the Abdominal Viscera. and by the dullness in the flanks, the level of which continues to rise, and varies with the position ; but this gives no information as to whether it is simple rupture of some mesenteric vessel, or a hopeless laceration of the liver. In rupture ot the stomach there may be blood-stained vomiting ; but, again, this may arise Irom simple bruising of the mucous membrane, or, particularly when the rent is exten- sive, it may not occur at all. The rapid accumulation of gas m the peritoneal cavity, causing obliteration of the liver dullness, points in the same direction. It the intestine is lacerated vomiting may occur, but the passage of blood per anum is more decisive. Prof. Senn proposed, in cases of this kind, to inflate the rectum and large intestine with hydrogen or some other unirritating gas, and undoubtedly in the case of bullet wounds, where there is an external aperture, and the gas that escapes can be collected and identified, this proceeding is of some benefit, in 872 DISEASES AND INJURIES OF SPECIAL STRUCTURES. other cases it can only be considered an indication if, after it is injected, resonance makes its appearance in some locality into which the intestines do not usually pene- trate, as, for example, between the liver and the anterior abdominal wall. Treatment. — In the vast majority of these accidents active measures are out of the (luestion. The patient must be kept perfectly (juiet in bed, well under the influence of opium, and with a large ice-bag over the injured part, so arranged that it does not rest its weight too much upon it. Stimulants should be avoided if possible ; sometimes, when the heart is distinctly failing, they must be given, but if there is any hemorrhage, they are only likely to precipitate the end. Only a little ice (in small fragments, and not too often) may be allowed by the mouth ; any food that is considered advisable in the first forty-eight hours should be given in the form of suppositories or small enemata. In exceptional instances it may be possible to form a more accurate diagnosis. If, for example, there is clearly some fracture of the ribs over the liver, and the hemorrhage is serious, or if blood-stained vomiting and rapid distention of the peritoneal cavity with gas are followed within a few hours by peritonitis, indicat- ing rupture of the stomach or intestine ; or if the bladder contains but a small quantity of blood-stained urine, in spite of the fact that none has been passed, it is undoubtedly justifiable to open the abdomen, try to find the seat of injury, deal with it as it requires, and wash out the cavity thoroughly with hot water. The spleen and kidney have been removed for hemorrhage ; rents in the liver have been sewn up ; the bladder has been sutured many times successfully, and life has been preserved even after f?ecal matter has been extravasated into the peritoneal cavity. Unfortunately, the proportion of cases in which such a proceeding can be recommended is a very small one ; in by far the majority, opium is the only resource. Wounds. Wounds of the abdomen are divided into those that penetrate the peritoneal cavity and those that do not, and the former again into those that are accompanied by injury to the viscera and those which only implicate the wall. 1. Non-pcnctrating wounds may be incised, punctured, or lacerated. If there is any doubt as to the peritoneum being involved, and the wound is more than a puncture, or if the instrument with which it was inflicted is dirty, the patient should be placed under an anaesthetic and the opening carefiilly enlarged, each layer of tissue being divided successively upon a director until, if necessary, the subperitoneal fat is exposed. In other respects the wounds must be treated on ordinary principles, deep sutures being used to bring the various layers together after the tissues have been thoroughly cleansed, as, owing to the constant movement of the part, it is very difficult to maintain accurate apiwsition in any other way. If the wound is of any size ventral hernia is very likely to follow, unless an abdominal support is worn. 2. Penetrating Wounds. — In all wounds that involve the parietal peritoneum (except needle punctures) the injured tissues should be thoroughly examined (the skin wound being enlarged, if necessary), cleansed, and accurately brought together with the serous surfaces in contact. A continuous catgut suture should be used for the peritoneum (so as. to make sure of immediate union), if from the amount of bruising or from other causes it is doubtful whether the other tissues will heal at once. On the other hand, with a clean incised wound, the sutures may be passed through everything, peritoneum, muscles, and skin, as after an operation. Opium is usually advisable, and the dressings must be abundant and elastic (a sponge wrung out of carbohc solution may be placed next the skin with wood-wool over it and all around it), so as to ensure the parts being kept at rest and in accurate apposition. {a) When it is certain the viscera are not hurt nothing further is required. The patient must be kept perfectly quiet in bed, on liquid food, until the wound is sound. INJURIES OF THE ABDOMEN. 873 (/') When they are injured they must be dealt with accortling to circum- stances. They may either protrude or not ; in the former case there is the addi- tional risk of strangulation (owing to the lessened pressure upon the extruded part it always becomes intensely congested) ; in the latter, of some of the contents of the hollow viscera (if they are hurt) entering the peritoneal cavity. Whichever it is, there should be no hesitation in enlarging the external wound if there is not sufficient space, or making another if it is not conveniently situated. The omentum should be thoroughly cleansed with a dilute antiseptic and returned. If it is too dirty and badly torn, or if it is very much congested, it may be treated as in an ordinary case of hernia — ligatured in successive portions with silk, cut off, and the stump, after it is certain there is no bleeding, reduced. The hollow viscera, if the wound involves the peritoneal surface, must be made secure by means of sutures. If there is only a small puncture, the mucous coat often prolap.ses and plugs the opening, so that there is no escape ; but it is not wise to trust to this ; it is much safer to replace the everted edges and unite the serous surfaces over it with Lembert's suture. Clean incised wounds should be treated in the same way. Even contused wounds, such as are caused by bullets, may be sutured so long as the internal diameter of the intestine is not reduced to half its normal size, and sometimes it may be possible to render them more secure by making use of omental grafts, after Senn's fashion. If, however, owing to the amount of bruising or the situation of the injury, it is not possible to effect this without causing too much contraction, or if there are numerous wounds close together, it is safer to resect the injured portion, removing it altogether, or, in addition to sewing up the wounds, to establish what is known as an intestinal anastomosis — graft one piece into the side of another. Finally, if this is imprac- ticable, or if, from the patient's condition, it is not likely that he would stand so prolonged an operation, an artificial anus must be made, the two ends being adjusted side by side, so that in case of recovery a further operation can be per- formed at a later period. In those rare cases in which the extra-peritoneal portion of the bowel is involved, the external opening should be enlarged and made as direct as possible, introducing a drainage tube, so that the contents of the bowel may escape at once. Gangrenous intestine must be treated as in an ordinary case of hernia. If the solid viscera, such as the liver or the spleen, are wounded, the hemor- rhage is usually very severe. It may be possible sometimes to check it in the case of the former by means of deep catgut sutures, and the spleen and portions of the liver have been excised. The gall bladder, if it is wounded, should be sutured in the same way as the intestine. If any fjecal matter, bile, foreign substances, or even any large quantity of blood has entered the peritoneal cavity it should be thoroughly cleansed. Hot water (105° F.) and boracic lotion are the least injurious. The sides of the wound are raised, and the fluid directed into all parts of the cavity by means of glass tubes, moving the bowels gently with the hand so that the whole surface may be bathed in turn. If a syphon irrigator is used the force of the stream is easily regulated by raising or lowering it. The excess can be removed from Douglas's pouch with a sponge, but usually in these cases a drainage tube is advisable for twenty-four hours. In many cases it is difficult to tell whether the viscera have been injured or not, and if they have, in how many places. Upward of a dozen perforations may be caused by a single bullet. It is impossible to follow the track of a ball across the peritoneal cavity, although, of course, its direction may help a little, and it is equally impossible to overhaul and examine bit by bit the whole of the intestine. It is in these circumstances, according to Senn, that inflation by hydrogen gas is likely to prove of most service, the tube being introduced into the anus and the lowest puncture found first ; then into this one for the next, and so on until the whole intestine is proved sound. The at'ter-treatment of these cases must be carried out on general principles. 56 S74 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Shock is always very severe and must be treated by warmth, and, if the heart shows signs of failing, stimulant enemata. Opium is absolutely necessary, as it is imperative to keep the bowels confined and as quiet as possible. Nothing should be given by the mouth for at least twenty-four hours. If there is very great thirst it can be relieved by a warm water enema with much less disturbance. As a rule, there is very little urine secreted, and if the bladder is emptied at the time of the operation it can usually be left for twenty-four hours. If at the end of that time the patient cannot pass it without straining, or if there is a complaint of distention and discomfort, the catheter must be used again. Small quantities of dilute beef- tea may be given on the second day, or a little weak arrowroot. Milk is better withheld, as it is apt to pass into the small intestine in curdled masses. Injuries of the kidneys, bladder, etc., are dealt with elsewhere. SECTION II.— SURGICAL AFFECTIO.NS OF THE STOMACH. Operations on the Stomach. A considerable variety of operations may be performed upon the stomach. It may be opened and stitched to the wall (gastrostomy), or to the adjacent intes- tine (gastro-duodenostomy or gastro-jejunostomy) ; it may be opened (either for the removal of foreign bodies or for operations upon its mucous surface), stitched up again, and returned into the peritoneal cavity; or it may be opened, part of its wall excised, and the wound secured by sutures. I. Gastrostomy. — This may be performed for cancerous, traumatic, or syph- ilitic stricture of the oesophagus, when dilatation by bougies or tubage is either impracticable or inadvisable. Until within the last few years, the mortality, especially in cases of carcinoma, was appalling, the patients dying either from peritonitis or exhaustion. Of these the former can be prevented ; the latter can only be avoided by operating before the patient's strength is too much reduced. It must, however, always be recollected that this operation is in no sense a cura- tive one; it merely treats a symptom, and if this can be done equally well with less risk to life in some other way, that way should certainly be preferred The line of the incision is parallel to the margin of the ribs upon the left side. The opening must, as Greig Smith points out, be as high as possible, so as to avoid traction upon the stomach ; but it must be at least an inch from the edge of the liver and from the ribs. This point marks the middle of the incision, which is about two inches and a half in length. The skin and superficial struc- tures are divided, the sheath of the rectus exposed, and, as recommended by Howse, opened in a vertical direction. If this is done, and the fibres of the muscle separated from each other in the same line with the handle of the scalpel, the orifice is surrounded by muscular fibres, and the risk of jirolapse of the mu- cous membrane and escape of the contents of the stomach diminished. The subperitoneal fat is then exposed, divided, and the peritoneal cavity opened in the usual way. If the stomach is distended it may present at once ; nearly always, however, it is empty and collapsed, hidden between the liver and the colon. When this is the case the fingers must be introduced, and passed along the under surface of the left lobe ; the first structure they touch after leaving it must be the stomach. The opening in the stomach should preferably be near the cardiac end ; but if this causes the least traction, it must be made in the most convenient situation. The further stages depend upon whether the stomach is to l)e opened at once or not. If the time can be afforded, there is no doubt the latter is advisable ; even twelve hours will often seal the surfaces together ; in two days the lymph will be comparatively firm ; but when the patient is exhausted from the combined OPERATIONS ON THE STOMACH. 875 effects of carcinoma, starvation, and shock, it very often happens that this is impracticable, and that food must he introduced at once. Rectal enemata will maintain existence if the patient is already well nourished and is kept perfectly warm in bed, without beinj,^ exposed to injurious influence of any kind ; but under conditions such as these they are exceedingly unsatisfactory, 'rhe tempera- ture is the best guide : if it is in the least subnormal there is no time to waste. If it is not intended to open the stomach for some days, it need only be held up against the edges of the abdominal wound ; the serous surfaces grow together, and by the time the supporting structure is removed, the lymph is sufficiently firm. Two hare-lip pins will answer; the serous and muscular coats of the stomach are pinched up together and transfixed, and the ends of the pins (protected with a piece of drainage tubing) are allowed to rest upon the skin. Sutures are advisable in most cases. One must be passed through the serous and muscular coats of the stomach opposite the centre of the opening. It gives something to hold the stomach by, so that it does not fall back, and later it marks the spot for the puncture. The others must traverse the whole thickness of the abdominal wall, but only the serous and muscular coats of the stomach. I'hey may be interrupted, two long ones or four short ones being used, or continuous, so as to secure adaptation all the way round, the skin in either case being pro- tected by passing a piece of rubber tubing under the projecting loop. In addition a second set of sutures may be inserted, securing the serous and muscular coats of the stomach to the cut edges of the parietal peritoneum and the skin. If the stomach is to be opened at once, or within twenty-four hours, this is essential. The wound should be protected with some non-adhesive dressing, and cov- ered with abundance of wood-wool. The patient must be kept as warm as possible and fed by means of enemata ; a certain amount of stimulant is always advisable (in spite of its tendency to make the patient lose heat), as not unfrequently the heart suddenly gives out. Traction upon the stomach alone is sufficient to make it stop, and when the patient's reserve is almost used up the greatest care is re- quired. According to Howse, five days is the usual time for opening the stomach. The extent of the adhesions depends partly upon the strength of the patient, partly upon the amount of disturbance the structures have been subjected to, and the accuracy of adaptation. Occasionally when the exhaustion is very extreme, as in advanced carcinoma, they hardly form at all. No anaesthetic is required ; the suture that has been left marks the spot (otherwise it may be very difficult to make it out), and all that is needed is a puncture with a very sharp double-edged tenotomy knife. A blunt one may fail to penetrate the mucous coat. A small catheter is then introduced by the side of the knife : this is withdrawn and some warmed and peptonized milk injected. The catheter should be secured in the wound, or it may be difficult to find the opening again ; the irritation of the acid gastric juice can be prevented to some extent by using dressings soaked in carbon- ate of soda. After a time the size of the catheter may be increased, or it may be replaced by a soft red rubber tube provided with a flange, somewhat similar to those used for tracheotomy. 2. Gastro-diiodenosfomy or gastro-jejunostomy may be required in cases of stenosis of the pylorus, whether simple or malignant. Of the two the latter is to be preferred, as the first loop of the jejunum is covered over with peritoneum and can be brought without any undue traction into contact with the anterior surface of the stomach. A communication is made between the two viscera, and their serous and muscular coats accurately sewn together all round. In order to effect this they must be brought up well into the wound, and, as Barker recommends, the suturing on the posterior surface should be completed as far as possible before any opening is made. It is probable, however, that in any operation of this kind in the future, either Senn's decalcified bone-plates (as described in opera- tions upon the intestine) or some modification of them will be employed, as the adaptation is much more perfect and secure, without requiring one-fourth of the 876 DISEASES AND INJURIES OF SPECIAL STRUCTURES. time ; and it does not seem unlikely that this operation will almost supersede pylorectoniy for carcinoma. 3. Gastrotomy. — Hy this is understood a simjjle incision in the wall of the stomach, for the jjurpose of removing a foreign body, dilating the u;so])hagus or pylorus, or curetting a carcinoma. 'I'he wound is a temporary one, and after the purpose for which it was made is accomplished, is sewn u]) again. It must not be confused with laparotomy, which is confined to an incision into the abdominal cavity. The stomach (imless there is some contra-indication) should first be washed out with a solution of boracic acid. Some may be left in if it is thought desira- ble that the cavity should be partially distended, but it is not in any way neces- sary. The parietal incision may be in the middle line or i)arallel to the costal margin on the left side, having its centre opposite the eighth or ninth rib. The stomach is found in the same way as before ; brought to the surface and secured by two temporary sutures passed through the serous and muscular coats. The incision (which should not be made until every precaution has been taken to j)re- vent any of the contents escaping) should be parallel to the vessels, vertical, that is to say. Afterward the wound is secured by Lembert's suture ; the stomach allowed to fall back, and the parietal incision closed in the usual way. This may be required for the removal of a foreign body from the stomach or the lower end of the asophagus ; in cases of (non-malignant) stenosis of the pylo- rus or oesophagus (Loreta's operation, or dilatation of the contracted orifice from within by means, first of one finger, then of two, until it feels as if further disten- tion would result in tearing) ; or for the scraping away of a malignant growth from the interior by means of a curette [as proposed by Bernays, of St. Louis]. So far as the operation is concerned it has proved very successful, but, of course, in the last-mentioned case, it can only be palliative in its action, and it is ques- tionable whether some form of anastomosis with the intestine would not be pre- ferable. 4. Fylo7-ectomy. — In this the pylorus, with the adjacent parts of the stomach and duodenum, is excised, and the orifices ap]:)roxi mated and fastened together with sutures. It is only required in cases of malignant disease, and then is only advisable when there are no adhesions or enlarged glands. If either of these complications is present, the removal of the growth will not cure the patient ; and gastro-jejunostomy affords as fair a prospect of relief with infinitely less risk. The pylorus must be isolated ; the great omentum detached and ligatured in successive portions without endangering the blood supply of neighboring structures more than can be helped ; the stomach opened and divided on the proximal side of the growth ; and the duodenum on the distal. As soon as the mass is removed and all bleeding stop]:)ed, the wounds must l)e .secured. As that in the stomach is much the larger of the two, it must be sewn up independently, until the orifice is con- tracted to the size of that of the duodenum. Many of the sutures may be passed from the inner surface; but, if possible, a second set, joining the muscular and serous coats only, should be used as well. The operation has on many occasions taken several hours to perform ; the number of sutures, if leakage is to be pre- vented, is enormous ; the risk of gaping, especially where the peritoneal coat is not firmly adherent, is very great, and in by far the majority of instances the patient has either never rallied from the shock or has died shortly after from peri- tonitis. 5. In addition to this, gastrorraphy has been performed for perforating ulcer, the stomach being drawn forward and the opening secured by sutures. HERNIA. 877 SECTION 111.— HERNIA. The escape of any of the viscera from its natural cavity is a hernia, provided it passes through an abnormal or accidental opening ; but when untjualified, it is usually applied" to the abdomen only. Internal hernia, in which a portion of the intestine is disj^laced inside the peritoneal cavity, is treated of with internal stran- gulation. Causes. — These may be immediate or predisposing. 1. Immediate or Exciting Causes. — Hernia may nearly always be traced to the action of the abdominal muscles upon the viscera. It is more common among those that follow laborious occupations with constant heavy strains, than among those who lead a sedentary life, and it may be caused either by a single sudden effort or by continual repetition ; even the straining in calculus of the bladder, or phimosis, are sufficient in those who are predisposed to it. 2. Fredisposing Causes. — Certain parts of the abdominal wall are naturally weaker than the rest : the umbilicus, for example, the crural ring, especially in the adult female, and the inguinal canal. In many there is a distinct bulging over the internal abdominal ring on coughing or straining; the internal oblique is poorly developed ; or it does not arise from Poupart's ligament in front of this spot ; the openings are large, or the conjoined tendon and the intercolumnar fascia are thin and weak. Congenital malformations are not infrequent ; late descent of the testes, for example, and patency of the tunica vaginalis ; defective development of the dia- phragm ; or separation of the recti from each other in the linea alba. In other cases there are acquired defects : the muscles have been torn or bruised ; the fasciae divided in operations ; inflammation has caused softening and yielding of the wall ; there has been repeated distention, as in pregnancy or ascites ; or sudden emaciation has led to absorption of the fat from over the crural ring. The length of the mesentery is of some assistance. In infancy it measures one- fifth of the body (taking it from the root to the convex border of the intestine), at puberty one-eighth, and in adult life one-ninth ; and its root lies much lower on the right side than on the left, which accounts in part for the greater frequency of the congenital variety upon that side. But probably it is never too short to allow a hernia to descend. Instances are recorded in which a piece of intestine, which normally could not touch the internal ring, has been forced into it by acci- dental pressure. The general laxity of the pelvic peritoneum during child-bearing may account in some measure for the frequency of femoral hernia at that time of life ; and there is no doubt that the descent of a hernia for the first time is greatly favored by diarrhoea and other disorders which might reasonably be imagined to cause relaxa- tion of the mesentery. Prolapse of the mesentery is very important. It rarely occurs before late adult life and is always associated with a peculiar and easily recognized bulging of the lower part of the abdomen. The epigastric region is flat and hollow : be- low there is a great projection, not only in the middle line, but at the sides, form- ing a sort of triple bulging, due to the yielding of the muscles at their weakest part. This always means that the root of the mesentery has glided down, possibly owing to the degeneration of the suspensory muscle and ligament at the end of the duodenum, and that any measure for radical cure that aims at merely strength- ening the abdominal wall must fail. Very often in these cases prolapse of the kidneys and of other viscera occurs at the same time. Hernia, there is no doubt, is hereditary, or rather the conditions that predis- pose to it. Men are more liable to it, especially the inguinal forms, than women ; 878 DISEASES AND INJURIES OF SPECIAL STRUCTURES. on the other hand, the femoral and unibihcal are more common in the latter. Owing to the freciuencyof the congenital inguinal variety, hernia is met with very often during the first year of life ; and at this time it is more common on the right side than on the left. Then the number falls off rapidly and continues to diminish until after puberty. From that time it grows larger, until it has been said that one in four of those over sixty years of age suffer from it. Prolapse of the mesen- tery, as years advance, tends to eciualize the frequency on the two sides, so that at five and forty left hernia is as common as right, and a little later double hernia more common than either alone. Anatomy. A hernia is generally enclosed in a sac continuous with the peritoneum, and surrounded by prolongations of the various layers that form the wall of the abdomen. I. The Sac. — Except in cases of rupture of the wall of the abdomen, hernia of the bladder, and sometimes of the colon, a peritoneal sac is always pre.sent. In congenital inguinal hernia it exists already ; the hernia descends into the open vaginal process of peritoneum in front of the spermatic cord. In all others it is formed gradually by the pressure of the viscera upon the inner surface. At first Fig. 368. — Oblique Inguinal Hernia. Bubonocele on right side, but passing through external ring on left. Fig. 369. — Direct Inguinal Hernia. there is a simple depression with a wide orifice; then, as the protrusion extends further and reaches more yielding structures, the peritoneum becomes stretched and displaced until it forms a globular sac communicating with the normal cavity by a narrow neck. In this stage the lining is still unaltered, merely thrown into folds at the neck, owing to the shape of the parts, and the contents can only be strangulated by the contraction of the structures that lie around. Later, the neck becomes thickened, hardened, and condensed ; the folds grow together and fuse with the fibrous structures outside until they form a ring of dense cicatricial tissue, and this keeps on contracting, until sometimes, if the hernia is prevented from descending, it closes completely. Not unfrequently, however, before this stage is reached, while there is still a small aperture in the centre of a dense fibrous ring, a knuckle of intestine is scjueezed down through it, and is so tightly held that the circulation in it is stopped : in other words, it is strangulated. Sometimes more than one constriction is present. The original neck may have been pushed down by a fresh protrusion, and a second neck formed above it ; or the sac may have been constricted at the same time in two places, at the internal and the external rings, for example ; or, in the congenital variety, a constriction may make its appearance in the tunica vaginalis on a level with the upper part of the testicle, so that the cavity assumes the shape of an hour-glass ; and any one of these may be the seat of strangulation. HERNIA. 879 Diverticula also are sometimes fouiul, especially in the congenital form, and not untVeciucntly they are very large, extending upward in the front wall of the abdomen between the muscles, or behind them in front of the fascia. These intraparietal sacs are of great importance, for if a hernia descends it may easily be returned into the diverticulum instead of the abdomen, leaving the strangulation, if one is present, unrelieved. Hydrocele of the sac is a very rare condition. Several pints of fluid may collect in it when the orifice is temporarily obstructed by a hernia ; but the term hydrocele should be reserved for those cases in which fluid accumulates after the neck of the sac has l)een completely and permanently closed. It has been met with in femoral and in inguinal hernicX, and it may render the diagnosis very difficult. 2. The Contents. — With the exception of the pancreas, all the viscera of the abdomen have been found in hernial sacs at one time or another ; the most common is the ileum, especially the last few feet, and then the omentum. The caecum and colon, which come next, are much more rare, and the others are only met with in congenital malformations. When the i^rotrusion consists of intestine it is called an enterocele ; when omentum, epiploccle ; if both are together, entero-epiplocele. In this case the intestine nearly always lies behind the omentum, concealed by it; in some rare instances, however, it is in the middle, in a kind of inner sac. Cystocele, gastrocele, and other similarterms, are occasionally used. 3. The structures that cover a small hernia are but little changed ; they merely stretch and yield, and the sac can still be easily reduced. As the size increases, however, this becomes different. The subserous fat wastes and grows fibrous ; the sac becomes adherent ; it is thickened in some places from the irritation of the truss, and thinned ^^ in others ; the coverings become matted together, •^"' "* so that their structure can no longer be distin- guished ; and at length the parts around are hope- lessly distorted from the continued traction, so that, for example, the internal inguinal ring is dragged opposite the external. Symptoms. — A hernia often causes griping and colicky pains in the abdomen, probably from the way in which it drags on the mesentery and impedes peristalsis ; while dyspepsia and a feeling of discomfort on exertion and after meals are f.g. 37o.-Femorai Her,„a. nearly always present ; but in many cases either this is not noticed or is put down to other causes. The character of the swelling depends upon its contents. When the main bulk consists of intestine the surface is uniform and elastic ; a distinct impulse can be felt when the patient coughs or strains ; and if it is of any size and the walls are not too tense, it is resonant on percussion. Omentum, on the other hand, feels hard and doughy ; the surface is uneven, and though there is a certain degree of impulse in most cases communi- cated from the abdomen, the swelling does not become tense and expand in all directions in the .same way as intestine. The method of reduction, too, is dif- ferent ; the intestine slips back suddenly, often with a peculiar gurgling, and the patient experiences at once a feeling of relief; omentum disappears more gradually, and if both are down together, is almost always the last to go. The sac can only be reduced in the early stage of a hernia, before it has acquired a definite shape and contracted adhesions to the surrounding structures. Treatment. — A hernia must be prevented from descending, either by means of a suitable contrivance (a truss or belt), or by closing the aperture through which it has escaped. The former is only palliative, although, if it is adopted suffi- ciently early in children and carried out with proper care, a permanent cure may generally be looked forward to; the latter is known as the radical cure, and aims at allowing the patient to dispense with a truss altogether. 88o DISEASES AND INJURIES OF SPECIAL STRUCTURES. I. Trusses. — A truss consists of a pad or cushion attached to a metal spring surrounding the body, so arranged with straps that its position remains unaltered in the most varied movements. Inelastic trusses, made of a leather band (as the Moc-Main truss) instead of a spring, are of use in large irreducible herniae, but cannot be relied upon for ordinary work ; they fail to exert sufficient pressure when the patient is stooping, the jjosition of all others in which the hernia most easily descends. The pad is generally made of cork, covered with flannel, linen, and wash- leather ; but rubber, water, and air cushions may be used where pressure is painful Fig. 371. — Truss for Inguinal Hernia. or the surface irregular. For an oblique inguinal hernia it should be pear-shaped, about three inches long, two inches at its broadest part, and three-quarters of an inch in thickness; the outer surface is flat, and has two studs upon it for the attachment of the straps ; the inner is slightly convex, looking upward as well as backward, especially when the abdomen is protuberant, and lies upon the internal ring and the inguinal canal, not touching, though it may come quite close to, the pubic spine. If the hernia is congenital, the pad should be prolonged downward between the scrotum and the thigh, tapering off gradually (rat-tail truss; ; and if it is direct; or if it is an old oblique one with the rings dragged nearly opposite each Fig. 372. — Single Circular Spring Truss for Congenital Scrotal Hernia. Other, a cross-bar may be added over the upper border of the pubic symphysis, so that the pubic spine lies, as it were, in a recess. In these ca.ses, however, it is usually advisable for the patient to wear a double truss ; very often, especially in the direct form, there is a certain amount of weakness on the other side as well ; the inconvenience of a double truss is no greater than that of a single one ; and if the two pads are held together by a strap or cross-bar over the pubes, the security is very much greater. Wood's pads are based on a different princijjle ; they are made of boxwood, ivory, ebonite, or some other firm, non-absorbent material, and they are shajied so HERNIA. 88i that the pressure falls, not upon the opening, but all round it. The pad for an oblicpie inguinal hernia, for example, is cut like a horse-shoe with one side (that which covers the inner pillar) longer than the other ; the spring is fixed to the geometric centre ; the spermatic cord and the pubic spine fit themselves into the interval between the sides of the shoe ; and the rupture is i)revented from descend- ing by the tension across the opening ; that for a direct hernia is in the form of a ring, the centre of which corresponds to the axis of the hernial opening. In either case the tissues j^roject upward in the centre, where there is no pressure ; and this and the double bearing greatly diminish the chance of slipping. For a femoral hernia the pad is smaller, beveled a little on the outer side to avoid pressure upon the femoral vein, and above so that it may fit well up under Poupart's ligament and bring the walls of the canal together. If an operation has been performed, and Gimbernat's ligament freely divided, this is not enough ; in such cases a thigh-belt, laced up around the upper part of limb, with a trian- gular pad over the saphenous opening and filling up the greater part of Scarpa's triangle, is required, and even this will only prevent the hernia increasing in size. Umbilical herni^e are best kept in place by a shallow concave plate, which at the same time supports the lower part of the abdomen. Nipple-shaped projec- tions only make the opening larger. Pads with spiral springs are very comfort- able, but cannot be relied qn where strength is required, as they are apt to yield if the strain is severe. The pad in most cases is rigidly attached to the spring ; but in some, as in Salmon and Ody's, there is a ball-and-socket joint, and in others it can be shifted Fig. 373. — Double Femoral Truss with Circular Spring. upward or downward and fastened in any position. The spring passes round the rim of the pelvis, fitting closely to the figure, just belo\v the iliac spines, and above the glutei. If the truss is a single one the free end is beaten out flat, and shaped so as to cling round the opposite hip. Its strength is regulated by the muscular condition of the patient and the size of the rupture, and it should ahvays exert slight pressure, even when the body is at rest. Where the employment necessitates great exertion, it may be advisable to have two trusses of different strength. The under strap, which prevents riding up, should always be fastened to the lower stud, and in the erect position should be moderately tight. Measurements. — In young adults with a flat abdoiiien it is sufficient to give the measurement from the pubic symphysis to the anterior superior spine, and from this round the back to the opposite one ; but in all other cases the exact line of the truss should be followed, from the ring to the spine of the ilium, from this to the opposite one, and then back to the ring again ; and when there is any peculiarity of structure, such as an oblique pelvis or pendulous abdomen, this should be mentioned, and the direction in which the pad is to press carefully noted. The vertical distance of the internal ring, from a line joining the two anterior superior spines, is often useful. In addition, full particulars must be given as to the size and nature of the hernia, the side on which it is situated, the muscular condition and the employment of the patient, and the age and sex. To test the truss, the patient should be seated on the edge of a chair, with the knees separated so that the structures around the rings are relaxed, and di- 882 DISEASES AND INJURIES OF SPECIAL STRUCTURES. reeled to strain downward. If tlie rupture does not escape, the pad fits the open- ing and the spring is sufficiently strong. Too strong a one is injurious, and its pre.ssure tends to cause absorption of the tissues beneath. For the first week the truss is generally exceedingly uncomfortable, but it must be worn all day, and, in some instances, at night as well, though a lighter one is sufficient then. In any case it should be adjusted in the morning while the patient is still lying down, care being taken that the hernia is completely reduced. U the skin becomes tender, it may be bathed with eau de Cologne and dusted with violet powder. Waterproof trusses, covered with india-rubber, are required for bathing. Innumeral)le modifications have been devised for special hernice. An excel- lent one consists of a .semi-circular spring with a broad flat plate on the sacrum, and a movable pan over the ])rotrusion ; and it should be adjusted around the opposite side of the trunk. Pads filled with sand, or moulded on the spot itself, are often of use if the skin is tender and a water-pad is not available. Irreducible hernia may be enclosed in a hinge-cup, made of a rim-plate covered with leather, or supported in a laced bag truss, in the hope that the size may be diminished by the continued pressure. Belts may be required for umbilical or ventral protru- sions. A skein of Berlin wool may be used for the congenital hernia of children, as described by Coates, of Salisbury. It consists of about twenty threads tied to- gether at intervals to prevent their separating, with the loop-end of the skein placed over the abdominal ring ; the other end is carried across the pubes round the opposite side behind the body, and brought down in the fold of the groin to pass through the loo[) ; it is then taken between the thigh and the scrotum under the limb, and brought up behind it to be fastened to the horizontal portion. The loop, with the skein passing through it, forms a pad resting on the inguinal canal ; the wool is sufficiently elastic to exert reasonable pressure, and cannot gall the skin Moreover, it can be renewed as often as required, and when it is thought that the truss may be left off the strength can be gradually reduced by diminish- ing the number of strands. Irreducible Hernia. A hernia is irreducible when, without the circulation or the passage of faeces being impaired, it cannot be returned into the abdomen. In a few cases this is due to changes in the tissues around or in the sac ; nearly always it is the result of the condition of the rupture itself. The size may be the obstacle, as in large, neglected scrotal or umbilical hernige. The shape may pre- vent it, especially if it consists of omentum ; this assumes the form of an inverted mushroom, tough and fibrous at the neck, wide and expanded in the body of the sac. Much fluid renders it difficult, owing to the way in which it protects the intestine from manipulation ; but this is usually only temporary, and can be easily removed by tapping. Adhesions are exceedingly common and are much more serious. They may form between the sac and its contents, or between the struc- tures inside, so that they cannot change their relative position. Finally, in some cases it is due to anatomical peculiarities, such as the absence of a peritoneal cov- ering, as in hernia of the bladder. Irreducible hernic^, if left to themselves, tend to increase in size until almost the whole of the intestines may find their way into the sac. Even when they are small they cause extreme discomfort ; dyspepsia, dragging pains, and colic are of frequent occurrence, especially after food, from interference with the movement of the stomach ; when large, they l)ecome a serious source of danger. Constipation may lead to the accumulation of faeces, and this to obstruction ; strangulation may occur, either gradually, as in consequence of obstruction, or suddenly, from the descent of a fresh portion. This is especially frequent in the femoral ej^iplocele of women ; irreducible omentum is in them of common occurrence, and, from its giving rise to no serious symptoms, often receives no attention ; but the band running down from the stomach to the crural ring acts as an inclined plane, which, as the intestines sweep round the peritoneal cavity, guides them infallibly HERNIA. 8S3 into the orifice. Besides this, an irreducible hernia is constantly liable to become inflamed, as, owing to its size, it is very much exposed to injury ; and even rupture of the intestines or of the sac may occur from accidental violence. Treatment. — This must be guided by the age and condition of the patient and the size and nature of the rupture. Where the patient is old and feeble, not likely to undertake vigorous work, the hernia should be enclosed in a bag-truss, laced up on one or both sides, or in a cup made of soft leather supported by a metal rim. Sometimes, as suggested by Bryant (Fig. 374), the pad may be made of metal moulded on a cast taken from the hernia when it is at its smallest. In this way the rupture can always be pre- vented from increasing, and sometimes can be materially reduced in size. In younger people, if the rupture consists of omentum only, an attempt may be made to reduce the size by procuring absorption of the fat. The patient should be confined to bed, on diet consisting very largely of lean meat ; an ice-bag should be placed upon the swelling, and small doses of iodide of potash given. Sometimes under these conditions the size is so much reduced in the course of ten days or a fortnight that taxis suc- ceeds under an anaesthetic ; but the smallest ad- hesions are suiificient to prevent it. If this fails, a truss may be fitted over iti but if there is much inconvenience, either from this or from gastric trouble ; or if the patient is, as most of them are in the lower classes of life, too careless to be trusted ; or if they are likely to be placed in cir- cumstances in which they could not at once ob- tain advice, it becomes questionable whether an operation should not be undertaken. Great difificultv is experienced sometimes •■1 -i u u' 11 J 4. 1 ^ Fig. ^74. — Pad and Truss for Irreducible With sailors, who have allowed an enterocele to ' Hernia, attain an enormous size, and perhaps become ex- tensively adherent, before applying for relief. In such a case, however, an opera- tion should never be lightly undertaken ; it usually involves prolonged dissection, and it may be found, after all, impossible to complete it. Obstructed Hernia. A hernia is obstructed or incarcerated, when, without the circulation being affected, the passage of the faeces is arrested, either from accumulation in the in- terior or from the impaction of scybala. This can only happen with large hernise, and probably only with those that contain some portion of the colon ; the contents of the small intestine are too liquid. The most typical example occurs in the neglected umbilical herniae which are so common after middle life in women who have had large families. A large pen- dulous mass hangs down over the edge of the umbilicus, sometimes tympanitic, but more often hard and uneven ; generally speaking, it is not very tender, though it is often the seat of a griping pain, and the coils of intestine can be felt and even seen working in it. Constipation is complete, unless the sigmoid flexure and the rectum contain faeces ; the tongue is thickly furred and inclined to be dry ; the appetite is lost ; nausea is common, though the patient seldom is actually sick ; and, although there is great discomfort, and perhaps painful colicky spasm in the abdomen, there is an entire absence of the depression characteristic of strangula- tion. The danger is that the veins may become compressed, and the return of blood impeded, until the congestion passes into strangulation. I have known a patient suffer from an obstructed umbilical hernia on four occasions, at intervals of a few months ; the last time the movements of the intestine suddenly ceased, and the patient began to sink \ strangulation had set in. 884 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Treatment. — Position in these cases is most important ; so long as the hernia liangs down it is hard, tense, and often (edematous at the lowest part ; when it is raised over the orifice from which it has escaped, it becomes soft and flaccid. This should be assisted by warmth and kneading day after day, so as to empty part of the bowel ; the colon should be thoroughly evacuated with enemata ; the diet small in quantity but fairly nutritious ; and opium only given if there is severe pain ; afterward the bowels must be kept relaxed until the size of the hernia is reduced again. Inflamed Hernia. Irreducible herni?e, especially those containing omentum, may become in- flamed from the pressure of an ill-fitting truss, from taxis, or other forms of injury ; much more rarely from the impaction of faeces, or as a result of enteritis. In most cases the sac is empty, but the walls are thickened and softened ; the endo- thelium disappears ; in its place there is a roughened surface coated with lymph, and all the contents are congested, swollen, and cjedematous. Sometimes the sac is filled with a turbid fluid. Sup]niration, fortunately, is rare (unless the bowel is strangulated) ; nearly always the inflammation subsides, and the lymph becomes absorbed, leaving a few adhesions between the structures inside. The skin over the sac is reddened, edematous, and adherent to the fa.scia beneath ; the pain is very severe, with marked tenderness on pressure ; and the sac feels swollen and tense, but there is still an impulse on coughing, and some- times in a large hernia the finger can be passed along the pedicle for some distance. The patient is ill and feverish, with nausea and abdominal tenderness, especially in the region of the sac ; but there is no collapse ; the face is not anxious or the tongue dry, and the pulse has not the small, wiry character characteristic of strangulation. The treatment is the same as in local peritonitis ; the patient must be placed in bed and kept on milk diet; small doses of opium may be given every few hours at first, then at longer intervals. An ice-bag should be placed over the swelling, until the temperature is reduced, but in old people it should not be kept on longer than this. Afterward, the bowels must be carefully regulated, and the hernia protected from further injury. Strangulated Hernia. A hernia is strangulated when it is so tightly constricted that the circulation is stopped. The whole circumference of the gut may be caught ; or only one side of a loop, as in Littre's hernia, so that the channel is not completely closed : or the intestine itself may be free, and the omentum only involved ; the symptoms are essentially the same, though they differ in intensity. Causes. — Strangulation may occur during perfect health, suddenly and with- out warning ; in many instances, however, there is a history of some previous in- testinal trouble, dyspepsia, diarrhoea, or colic ; and it is possible that this increases the liability, either from the general malaise and want of tone in the abdominal muscles, or from the relaxed state of the mesentery. The immediate cause is usually a sudden effort, lifting a heavy weight, or straining at stool with the thighs in such a i)osition that the abdominal rings are relaxed and unprotected ; but strangulation may be gradual, and it has been known to occur during sleep. Where there is a congenital sac, the hernia may be stran- gulated the first time it descends, and then, especially if the patient is a young adult, the effect is very characteristic : a loop of intestine is suddenly squeezed through a narrow channel into a wider space beyond, and the circulation is stopped at once. The same thing hai)|)ens if the sac is an old one and the hernia has not descended for some considerable time, and very often these cases are the worst, from the unyielding nature of the tissues at the neck. When there is already an irreducible hernia, especially if it consists of omentum, and a fresh loop STRANGULATED HERNIA. 885 is squeezed down behind it, the constriction is rarely tight enough to cut off the circulation at once ; the veins only are compressed, and blood continues to enter, until the walls of the intestine become black and almost solid from the amount they contain. The same occurs when a hernia that is already obstructed becomes strangulated, only the onset is then even more gradual. In recent hernia, in which the sac has as yet no existence of its own, but is merely a temporary depression of the ])eritoneum, the constriction is necessarily caused by the tissues outside it. In older cases it may be the same, but more often the hernia is caught by the neck of the sac, which has become hard and unyield- ing. In rare instances the intestine is strangulated by bands inside the sac passing across from one wall to the other, or by its slipping through an accidental open- ing in a piece of unreduced omentum. A\'hether the strangulation is rapid or slow, the effect is always the same ; the onlv difference is in the length of time and the amount of congestion. Pathological Appearances. — The intestine may be free, or adherent to the body or the neck of the sac. Its color may be but slightly changed ; generally it is redder than natural, with distended veins, and sometimes it is purple and almo-st black with blood e.xtravasated between its layers. In the early stages its walls are firm and dense, thicker than natural, and rigid from the congestion. Later, as its vitality begins to fail, the surface becomes dull and loses its polish ; it may look granular or be coated over with lymph ; later still the walls become soft and Collapsed and bloodless tal end. Neck of sac. Fjg. 375. — An Unstrangulated Hernia. Fig. 376. — A Strangulated Hernia. flaccid, yielding to the least pressure, the color changes to an ashy gray or green, and gangrene sets in. Sometimes the sloughing commences in the loop ; more often, especially when the edge of the constriction is sharp, like Gimbernat's liga- ment, the mucous membrane gives way first in a line corresponding to the band, and the feeces are extravasated into the sac. If the strangulation is relieved before this, a deep groove may be found run- ning round the whole or part of the bowel, often so marked that traces of it are present for weeks. Above the strangulated loop the intestine is distended and deeply congested ; below it is empty, pale, and flaccid. At the ring itself the peritoneum may be unaltered if the hernia is recent, or thickened and opaque if it has descended many times. If the intestine is inflamed it is usually firmly adher- ent at the neck ; unless it has given way inside the abdomen above the stricture, or inflammation has been caused by reducing some of the contents of the sac, these adhesions protect the general cavity of the peritoneum so thoroughly that anything more than local peritonitis is exceptional. When omentum is present it undergoes similar changes, whether it has recently descended and is soft and delicate in structure, or is old, tough, and fibrous. The blood-vessels become distended ; it swells up and becomes oedema- tous ; and unless the constriction is relieved it grows darker and darker until it forms a slate-colored, offensive, and putrid mass. The sac nearly always contains a certain amount of fluid, which varies accord- S86 DISEASES AND INJURIES OF SPECIAL STRUCTURES. ing to the condition of the hernia and the vigor with which taxis has been applied. When quite recent it is bright and clear ; as the congestion increases it becomes blood-stained from the giving way of small vessels, especially if any force is used ; and occasionally there are coagula. Flakes of lymi)h are sometimes present, and in the worst cases, when gangrene has set in, it is filled with jnis of the most offensive description and mixed with gas. Occasionally, even when there is no perforation, there is a distinctly faecal odor, just as there is sometimes in abscesses of the abdominal wall. A peritoneal sac is very rarely wanting, but in the case of the colon there may be only a partial one. Sometimes it is so thin that the contents can be seen through it without difficulty : in old cases, especially when a truss has been worn, it may be so thick that layer after layer of fibrous tissue is divided, under the im- pression that each is the last. In a itw instances portions of the subserous fat still retain their connection with it, so that it has a deceptive resemblance to omentum. In recent hernia it can be isolated from the structures around ; in old ones, however, it is closely incorporated with them, especially at the neck. J Fig. 377. — Extreme Venous Congestion and Iiiici^,i.t.,.l il<.i of the Bowel. le Effects of Severe Strangulation The tissues outside the sac may be unaltered ; but not unfrequently they are bruised or inflamed from the severity of the taxis. When the contents of the sac are gangrenous and suppuration has set in, the apj>earances are simj^ly those of an abscess. Symptoms. — The symptoms of strangulation are collapse, vomiting, and pain. Where the patient is young and in vigorous health, and where the strangu- lation is sudden and complete, the symptoms begin instantaneously and with great severity ; where, on the other hand, the patient is feeble and anaemic, or where there is already a large epiplocele protecting the intestine from too great pressure, they set in very gradually, and some hours may pass before they reach their full intensity. In addition, it is not improbable that the part of the intestine involved is of some importance. The collapse and the vomiting are due, entirely at first, to the effect of the strangulation upon the nerves, especially upon the great plexuses in the abdomen, and, though, perhaps, to a less extent, this is true of the pain as well. It is not improbable, as Treves has pointed out, that the jejunum with its muscular walls, copious blood supply, well-developed nerve jilexuses, and vig- orous functional activity, would resent an injury more energetically than the lower STRANGULATED HERNIA. 887 ileum, where the muscular tissue is more scanty, the blood supjjly less free, and the functional activity less pronounced. The aspect of the patient changes almost at once. The face is drawn and pinched, the cheek blanched, the lips white, the eyes sunken and surrounded bv dark rings, and the forehead covered with perspiration ; the patient looks prema- turely old, and the expression is that of intense distress. The skin, especially on the extremities, is cold, the temperature is sul)normal, and the pulse small, feeble, and com])ressible, often as many as 120 and even 140 beats in the minute. The tongue at first is white, but it soon becomes dry and brown ; there is intense thirst, and the amount of urine secreted is far below normal. Like the other signs of collapse, this is due to the disturbance of the abdominal nerve-plexuses, and is acute in proportion to the extent to which they are involved. VomHiiti:; may come on at the moment of strangulation, or not until later. When it has commenced it rarely ceases, its character gradually changing as the contents of the stomach, duodenum, and small intestine are successively ejected. At first it may consist of undigested food ; very soon it becomes bilious in char- acter, and, after three or four days' strangulation, it comes up in great gushes, a dark-brown, muddy liquid, intensely offensive in odor, sometimes distinctly faecal. It is probable that the peristaltic action of the intestine is reversed, although apparently in intestinal obstruction, when the proximal part of the intestine is thrown into violent colic, the contents, even of the ileum, can be ejected without. Pain varies considerably. In some it is local, and comes on at the moment of descent, caused by the stretching of the ti.ssues around the sac, and when the strangulation is sudden it may be very severe. In others it is scarcely noticed, and the patient may be almost unaware of the existence of the rupture. A fixed, dragging pain, referred to the umbilicus, is nearly always present, probably due either to traction on the mesentery or to the effect upon the great nerve-plexuses. Besides these there are usually wandering colicky pains all over the abdomen, caused by the violent and irregular movements of the bowels above the strangula- tion, and made worse by any attempt at taxis. Constipation is nearly always present, caused not by the obstruction, but by the effect upon the nerves, for even when the sigmoid flexure is full the bowels are rarely opened after strangulation has set in. Exceptions to this, however, some- times occur, and there may be one or two motions when the lower bowel is full. In Littre's hernia the interior of the intestine is sometimes closed by the kinking opposite the strangulation, but often it is patent all the way through. Constipation, however, is the rule in this as well as in other forms, although in a {t\\ cases (three out of fifty-three) Treves found that there was diarrhcea, and in several of the others the bowels responded to aperients. The local symptoms are generally very prominent, but occasionally the patient is not aware of the existence of a hernia, although it may have been in a state of strangulation for forty-eight hours. Obturator and sciatic hernise especially are so small and so deeply placed that the tumor often cannot be made out, even after careful examination. If the hernia is an old one, that has been down many times, the size is likely increased, but it may be impossible to obtain exact information. Small hernise, when strangulaftd, are hard and tense, or doughy if they con- tain omentum ; large ones, especially those that are irreducible, are often fairly soft, as the strangulated part may be simply a loop at the back covered in by the rest. In many cases the tumor is dull on percussion, although it contains intestine, partly because of the liquid in the sac, partly because the amount of air is so small and the walls so thick. Absence of impulse on coughing or straining is the chief local feature; the contents of the sac are shut off from the abdomen, and nothing more can enter. In large hernia the impulse can sometimes be felt as low down as the neck, there it ceases abruptly. The skin may be tender, but, as a rule, this is not marked unless the sac is inflamed or taxis has been too vigorous. As the case progresses and gangrene becomes imminent, the constitutional 888 DISEASES AND INJURIES OF SPECIAL STRUCTURES. symptoms grow more distinct. The vomit is intensely offensive, or dark, like coffee-grounds, and it comes without effort in great gushes ; there is constant and painful hiccough, the pulse becomes intermittent, the abdomen begins to swell and become tympanitic ; it is not very painful as yet, but the whole surface is tender; the mind begins to wander, the face becomes more haggard, the patient tosses restlessly about, growing colder and colder, and at length sinks exhausted. Occasionally, before the end, the local pain ceases, the tenseness of the tumor disappears, and it slips up almost of itself, making the abdominal symjjtoms tenfold worse. More fre^iuently the swelling increases, and becomes resonant as the gases of putrefaction collect; the skin becomes livid and oedematous, and at length gives way, allowing the intensely foetid contents to escape externally, and leaving, if the patient survives, either a faecal fistula or an artificial anus. It very commonly happens, especially in an irreducible femoral epijjlocele, that after the sac is laid open, nothing but omentum is found, although the symp- toms of strangulation may have been well marked. It is possible that in some of these a small knuckle of intestine has been strangulated behind the rest, and reduced by taxis before the operation, without its having been noticed ; the size is small, and it may be quite concealed, but there is no doubt that strangulated omentum can give rise to the same symptoms as intestine, though less marked and less acute. The pain is not so severe or the vomiting so constant ; constipation is less complete and the constitutional symptoms are milder. The local distress is also inconsiderable, the tumor feeling harder, and permitting manipulation more freely than when it contains intestine. As time progresses, however, the symptoms become as severe as in other forms. The same thing has been known when only peritoneum was involved. The time that elapses before gangrene or ulceration of the mucous membrane occurs is very variable. Erichsen mentions a case in which the vitality was destroyed in eight hours ; in other instances the intestine may recover even after five or six days. It depends, to some extent, upon the kind and size of the hernia and the tightness of the constriction, but there is no doubt that a great deal of the injury inflicted on the bowel is due to ill-advised and violent taxis. Symptoms of an almost identical character may be caused by other condi- tions of the bowel. Internal hernia and strangulation by bands or through aper- tures, are, of course, really the same ; the seat of strangulation differs, and that is all, but very acute symptoms may occur in volvulus, acute intussusception, stric- ture and impaction of feces or gall-stones, sometimes with, sometimes without previous warning. The real cause of the symptoms is the effect, not upon the blood-vessels (though this forms a convenient standard to judge of the vitality of the tissues), but upon the nerves of the peritoneal covering, and this is borne out by many isolated facts. I have met with cases of external hernia in which all the symptoms of strangulation were well marked without the bowel being either very tightly gripped or deeply congested ; and the same thing has occurred from the simple retention of the bowel in a colotomy wound (Davies-Colley), and from hernia of the subperitoneal fat dragging upon the peritoneum. The Diagnosis of Strangulation. — Inflamed and obstructed irreducible herniae are occasionally attended by symptoms*resembling those of strangulation ; there is constipation with pain, and perhaps vomiting, but this never attains the persistence or the character of the sickness of strangulation ; there is no collapse, and an impulse on coughing can always be detected. Acute peritonitis is more difficult ; the vomiting may be persistent and very offensive, the patient may be in a state of extreme collapse and the bowels abso- lutely confined. In such a case the diagnosis must rest chiefly upon the absence of relation between the sac and peritonitis, and upon the physical character of the hernia itself. A few cases are recorded in which the vomiting of pregnancy and that which sometimes attends the late descent of a testis have been mistaken for that of stran- gulation. In all cases of doubt an operation should be performed. STRANGULATED HERNIA. 889 Treatment. — The strangulation must be relieved either by taxis or by opera- tion with the least possible delay. I. Taxis. — The method depends upon the anatomy of the part, but the ])rin- ciple is the same in all. The structures around the hernia must be relaxed as far as possil)le, the neck of the sac must be steadied with one hand, sometimes, as in the inguinal variety, pulling it slightly down so as to straighten it out, and then the gentlest pressure u.sed, squeezing it a little from side to side, and kneading it carefully with a view of emptying the hernia of some of its contents, or of return- ing the piece of intestine that came down last. Intestine slips up with a sudden rush and the patient experiences complete relief at once ; omentum does not dis- appear ([uite in the .same way, but as it yields it leaves behind it a distinct sense of something gone. Of all the aids to taxis there is only one, an anaesthetic, that can always be relied upon, and that one may only be used when, should taxis fail, everything is ready for immediate operation. It is manifestly unfair to the patient to expose him a second time, with a short interval, to the depressing influence of an anaes- thetic, and to run the risk of making the vomiting and the other symptoms worse in the meantime. Morphia maybe given to quiet a very restless patient and pre- vent exhaustion, but it is of no help in other ways, and great care must be taken that the symptoms of strangulation are not obscured by it without the constriction being relieved. An ice-bag, or Leiter's coil with ice-cold water, is of some use if applied within a short time of the descent ; the bulk of the mass is reduced, and occasion- ally, if taxis is tried then, it succeeds almost at once, but cold is not advisable for old people with feeble nutrition, or where the hernia has already been cutoff from the circulation for some time, for fear of accelerating gangrene. Over omentum it has much less power. A hot bath maybe used in large inguinal herniae if there is much spasm and the patient cannot leave off straining ; but it must not be for- gotten that a bath of the temperature of 100° F. or 102° F. kept up for half an hour may cause very great depression. From time to time other aids are recommended for special cases. Inversion of the patient, for example, raising the pelvis well above the shoulders, so that the intestines gravitate toward the diaphragm, is highly spoken of in some cases of large inguinal hernia. Care must be taken to keep the hips well flexed if it is tried. Aspiration of the intestine is exceedingly risky, but the fluid in the sac may some- times be drawn off with a trocar and cannula with advantage. Enemata should never be used, and purgatives are the worst things possible. Taxis is more liable to succeed with an inguinal than with a femoral hernia; the constriction in the one is muscular, in the other mainly ligamentous ; but the tension of the obliquus externus has an immense influence upon the size of the crural ring ; if the finger is placed in the canal while a patient is straining or vomiting, Poupart's ligament descends upon it with immense force. In the same way taxis is more successful in acquired inguinal hernia than in the congenital form, but here the length and obliquity of the neck are additional reasons. Very small and very large hernire and those which are tense and hard are more difficult of reduction, other things being equal, than those which are lax and moderate in size. Accidents from Taxis. — Taxis is responsible for a very large proportion of the fatal results of hernia. The bowel is intensely congested ; its walls are rigid and almost solid with blood ; it is prevented from returning by a constricting ring with an edge sometimes almost as sharp as a knife, and over which it bulges in all directions ; the vitality of the tissues is seriously impaired ; no fresh blood has passed through it for hours or even days ; and while it is caught like this an attempt is made to force it through. Sometimes by careful attention to position, and by using every endeavor to relax the tissues, the ring may be so widened that some of the blood in the walls or of the gas in the interior is squeezed out, and then the rest may follow ; but if the congestion is severe and the walls rigid and 57 890 DISEASES AND INJURIES OF SPECIAL STRUCTURES. solid, it is impossible for tlieni to yield sufficiently, while, on the oilier hand, they bruise with the greatest ease, l^ven when the constricting band is divided and manii)ulation applied directly to the intestine, and to the proper end of the loop, not indiscriminately to the outside of the tumor, reduction is often very difficult ; and I have heard of a case in which it was necessary, although the neck of the sac had been freely incised, to open the abdomen and make use of traction from the interior. Bruising of the skin and cellular tissue, ecchymoses in the walls of the intes- tines or in the omentum, and hemorrhages into the bowel or the sac, are common results of taxis, and often cau.se inflammation. Other consequences, not so fre- quently met with, are more dangerous ; rents in the serous coat, for example, rupture of the bowel, bruising to such an extent that sloughing ensues, and injuries of the sac, which may lead to the serious mistake that the hernia has been reduced while the strangulation still persists. Of these last the two most common are reduction en masse and rupture of the sac. It is, however, only fair to say that in the majority of instances they have been the result of the patient's own violence. In the true reduction en masse (Fig. 378) the sac is separated from its sur- roundings, and with its contents still unreduced, is pushed bodily into the sub- peritoneal space. It can only occur in tolerably recent hernia, in which the sac is not adherent, and is most common in the direct inguinal form. lUit it may be imitated easily in femoral hernia if the sac is freely separated from the tissues around and an attempt made to reduce the contents without opening it ; suddenly the whole may slip through the crural ring into the abdomen. The extent of the displacement is not so great in the other forms. In one (Fig. 379), which appears to be more common in congenital inguinal hernia, the neck of the sac only is detached and forced in (carrying with it the strangulated portion of intestine), while the rest still j)rotnides in the inguinal canal ; in another the sac is hardly detached at all ; but the unreduced intestine is so pushed up the canal, sometimes into a kind of diverticulum lying between the peritoneum and the fascia transversalis, that reduction is complete, so far as external appearance is concerned (Fig. 380). These diverticula may either be formed at the time by partial displacement of the sac, or they may be congenital, and then they frequently attain a very large size. Rupture of the sac may l)e associated Fig 378.— Reduction en v,asse,\\iv. Sac entirely ^yjth this, or it may occur independently (Fig. detached from its former site (as shown by the ' n t i dotted hne), and pushed into the Subperitoneal 381). 1 he rent USUally lieS UpOU the pOStC- ^'^'"^- rior aspect, near the neck, and the intestine is gradually squeezed out through it into the subserous tissue. The symptoms in all of these are very nearly the same. The contents of the sac do not slip back, they are gradually pushed to one side, leaving a certain degree of fullness over the neck ; sometimes even a distinct tumor can be felt, dull on l^ercussion, and very painful. In a few ca.ses the mass has been felt repeatedly, returning into the abdomen with the least pressure and descending again as soon as the patient coughed or strained, but not disappearing altogether. The consti- tutional symptoms, so far from being relieved, are generally made a great deal worse by the injury inflicted upon the contents. If any of the conditions is suspected, the sac must be exposed and oi)ened at once. The incision may be made in the ordinary situation, or, if the tumor can- not be distinctly felt, in the middle line ; all the ordinary apertures can be easily explored from this. The neck must then be divided freely, the bowel drawn out STRANGULATED HERNIA. 891 and examined, and the finger passed well up into the abdomen and down to the bottom of the sac, so as to make sure the condition is relieved. In a few instances an omental sac, with the bowel strangulated in it, lies inside the peritoneal one, and it is possible that this may be reduced bodily, intestine and all, into the abdomen. If this occurs the symptoms persist in the same way, and the abdomen must be opened to ascertain the cause, as in other cases of inter- nal hernia. Taxis, even when successful, is sometimes followed by serious consequences. Of these the most common is peritonitis ; the intestine is either inflamed at the time of reduction or becomes inflamed after being so long anaemic, and allows infective irritants to work their way into its walls. Suppuration and sloughing may set in, or adhesions form, binding down the bowel, or stricture may develop from the injury the coats have sustained. Sometimes a patient progresses favor- ably for three or four days and then sinks suddenly into a state of collapse, from the separation of a small gangrenous patch, and death may occur from shock, especially in the case of stout, middle-aged women, whose circulation is already embarrassed. I have known this happen on several occasions in which, as an anaesthetic was not administered, nothing else could have been held responsible. The length of time taxis may be applied before further measures are resorted Fig. 379. — Reduction into the Can.il. Fig. 380. — Intraparietal Hernia. FiG, 381. — Rupture of the Sac. Three different varieties of Imperfect Reduction. to cannot be laid down in an absolute manner ; it depends upon the size and kind of hernia ; whether it is tense or lax ; how long it has been down ; whether any previous attempts have been made, and whether there are any signs of inflamma- tion. If there is a small tense knuckle of intestine lying in the crural canal, with- out any impulse on coughing, and if it has just descended, a single trial may be made, and then an ice-bag laid on the swelling for four or five hours. If at the end of that time it appears unchanged, and does not yield at once, the patient should be placed under an anaesthetic and herniotomy performed. If the symp- toms are very acute, indicating a severe degree of strangulation, as, for example, in congenital inguinal hernia in young adults, even this is not advisable ; it is better, for the sake of the intestine, to give an anaesthetic, and if, when the mus- cles are relaxed, a very brief attempt does not succeed, operate at once. On the other hand, a large scrotal or umbilical hernia, the contents of which are soft and lax, consisting largely of omentum and without acute symptoms, may be manipu- lated wnth considerable freedom. If the skin over the hernia is red or tender ; if the strangulation has lasted for two days acutely, or three under any circumstances ; if the constitutional symptoms are severe ; or if there is the least suspicion as to the condition of the intestine, taxis should not be employed at all. The subsequent treatment, if the intestine has been strangulated, requires as S92 DISEASES AND INJURIES OF SPECIAL STRUCTURES. much care as after an operation. A spica or a truss must be applied at once to prevent the descent of the rupture again ; the patient must be placed in bed ; no food allowed for twenty-four hours, and nothing but a little ice until the vomiting from the anaesthetic has ceased ; and a hypodermic injection of morphia or some tincture of opium should be given to keep the intestine at rest for at least forty- eight hours. Herniotomy or Kelotomy. — If taxis fails, or it is not thought advisable to try it, the constriction must be divided. The patient is placed under an anresthetic, with the shoulders slightly raised and the knees flexed ; and the skin shaved and thoroughly cleansed. The incision is over the neck of the sac ; in inguinal hernia, over the external ring in the direc- tion of the canal ; in femoral, over the upper part of the tumor immediately below Poupart's ligament ; and the tissues between the skin and the sac are divided layer by layer until the outer wall of the latter is reached. In recent hernia the sac is readily recognized. It has a bluish appearance, like a thin-walled cyst, and is covered with a layer of loose cellular tissue, devoid of fat ; and, unless adherent, it can usually be thrown into folds and made to move over the subjacent structures by pinching it up with the forceps. In other cases the intestine, or the yellow fat of the omentum, can be seen through it, so that there is no doubt when it is reached. In old herniae, however, over which a truss has been worn for years, the difficulty may be very great ; the sac may be thick, dense, and fibrous, so that layer after layer is divided, each one apparently the last; or it may be so closely adherent to the structures around that its definition is impossible. Sometimes there is a cyst lying over it (generally a bursa) which may be opened by mistake; or, as in encysted or infantile hernia, there may be a definite peritoneal sac in front. The difficulty is especially serious when the sac is flaccid or empty, or surrounded by subserous fat ; under these conditions, especially if it has been bruised by taxis, it may resemble congested omentum very closely. In other instances it does not contain any fluid, or the intestine is adher- ent to its inner surface over the front, so that it is in danger of being wounded ; and, what is perhaps most serious of all, the sac may be partially or entirely want- ing. In this case (which rarely happens except with the bladder and some por- tions of the colon), the hernia rapidly forms adhesions to the cellular tissue around, and, unless the muscular wall is recognized as it is aj^proached, there is great dan- ger of its being incised by mistake. In certain cases — large scrotal or umbilical hernise with subacute symptoms — the attempt to reduce the hernial mass en bloc should be made, though in the lat- ter it is not likely to succeed, owing to the extraordinary thinness of the walls; there is considerable danger in exposing a large quantity of intestine to cold or to the irritation of sponging; but it should never be thought of in small herniae with acute symptoms ; in those of a mixed character — entero-epiploceles, for example — as there might be an omental sac inside ; or in any case in which, either from the condition of the skin, the history, or the constitutional signs, there is the slightest suspicion as to the state of the contents. If the operator has decided upon opening the sac, it should be done before dividing the constriction outside, for fear of a yjiece of intestine slipping back unawares. Great care is needed while opening the sac to avoid injury to the structures beneath. Part of the wall should be pinched up with the dissecting forceps, and opened with the knife on the flap, not cutting toward the interior. Fluid usually escapes at once. A director should then be introduced into the opening, and the sac freely divided up to the neck. The subsequent proceedings depend upon the condition of the contents. If there is intestine and it is not seriously injured, the stricture is divided and the hernia returned at once. The incision is made in the same way, whether the seat of strangulation is outside the sac and is divided without opening the latter, or whether it lies in the neck : either the finger nail, or a flat director, is insinuated under the margin of the band (and often it is so tight that this is a matter of con- STRANGULATED HERNIA. 893 Fig. 382. — Method of Dividing the Constriction. siderable difficulty) and then a licrnia knife or a blunt-pointed bistoury, with the greater portion of the edge protected with wrapping, i.s gently slipped under, and a very small incision made, without any cutting, simply by the pressure of the blade. As soon as this is done the difficulty disajjpears : the nail can be intro- duced more easily, and either the original wound enlarged, or, what is far to be preferred, two or three small ones made. Large incisions are not only more likely to injure adjacent structures, such as an abnormal artery, but weaken the abdom- inal wall and lead to a very intract- able form of hernia. Care must be taken, when the sac is opened, that the intestines do not bulge upward by the side of the director and get in the way of the knife ; it is to prevent this that the hernia director is especially broad. Occasionally, as already men- tioned, there is some difficulty in re- ducing the intestine after the stricture has been divided, owing to the thick- ness and rigidity of the walls ; but this may generally be overcome by applying ta.xis first to that end of the loop which was the last to descend. If this fails the intestine may be drawn slightly downward ; so long as reasonable care is used this may be done without fear, as the difficulty only occurs when the walls are unusu- ally firm and solid. Aspiration of the bowel should not be attempted. The condition of the intestine, whether it is fit to be returned into the abdo- men or not, is determined by its consistence and color. If it is soft and flabby, instead of firm and resilient, if there are ashy-gray or green spots upon it, or if the fluid is turbid and very offensive, it certainly is not. The difficulty is greatest where the intestine is almost black, and has lost its lustre, or is coated over here and there with flakes of lymph, or where, without any evidence of gangrene, it shows that it has been very tightly constricted ; undoubtedly it stands a better chance of recovery inside the abdomen than if it is left in the sac ; on the other hand, it is almost sure to set up a certain degree of peritonitis. Probably in this case it is best to return it, having first passed a catgut loop through the mesentery, so that it may be retained near the orifice. Possibly then, if sloughing does set in, adhesions may form around and faecal extravasation be prevented. [When there are evidences of inflammatory action in the loop of intestine, it is well to irrigate it with a warm antiseptic solution before returning it.] Where the condition of the bowel is hopeless, it may either be left /// situ, so that if the patient survives an artificial anus is formed, or it may be drawn down at each end until the whole of the gangrenous part is exposed, resected, sutured and returned. Which of these methods should be adopted depends upon the cir- cumstances of each case ; as a rule the patient is too feeble and exhausted to stand so prolonged an operation as enterectomy, and in femoral hernia, in which gan- grene is most common, there is the serious objection that it practically entails division of Poupart's ligament. If the intestine is kept in situ the stricture should be interfered with as little as possible and the adhesions around the neck of the sac should not be touched ; they are the only safeguard against a certainly fatal peritonitis. The wound should simply be left wide open ; as the congestion and swelling subside the faeces find their way out through the upper orifice, and either a faecal fistula or artificial anus is formed. Peritoneal rents in the coat of the bowel should be sewn up with catgut. A pin-hole perforation, if the surrounding part is healthy, may be treated in the same way. Recent adhesions, unless the intestine is gangrenous, can be broken down with the fingers ; older ones, if not too extensive, may be dissected off. In large irreducible herniae, however, this is often impossible without endangering the bowel ; and the rupture must be left in situ after the strangulation has been re- 894 n IS EASES AND INJURIES OE SPECIAL STRUCTURES. lieved. Later, when the wound has healed, the hernia may be fitted with a suit- able truss. Omentum must be thoroughly unraveled before anything is done with it ; a small knuckle of intestine is often concealed behind it or in its substance, and may be easily overlooked. If it has only recently descended and is not congested, it maybe returned ; but if it is old and fibrous, or if it is already much injured, it should be secured with a clamp or forceps, cut off and ligatured bit by bit. As soon as it is certain that there is no risk of hemorrhage, the end should be returned well within the peritoneal cavity ; if it is left at the neck of the sac it does not act as a safeguard and plug the opening, but encourages the descent of a fresh jjortion by guiding it to the weakest spot, and, by leaving a band extending from the stomach to the groin, exposes the patient to the danger of internal strangulation. [Some operators stitch the omentum to the peritoneum on the inside of the inter- nal ring, in order to have an additional safeguard against recurrence.] The wound in the sac, after the contents are reduced, must be treated in the same way as other wounds of the peritoneum ; but in addition to closing the ori- fice into the peritoneal cavity, an attempt should be made to strengthen that part of the wall so that the descent of another hernia at the same spot may be pre- vented. [In all cases where a strangulated hernia has been operated upon, it is well to close the ring, and conclude the operation as would be done in an opera- tion for radical cure.] When the intestine is gangrenous no attempt should be made to close the wound. In other cases it should be thoroughly cleansed, dried, and sutured with catgut, leaving a drain at the most dependent orifice. An alxsorbent dressing should then be carefully packed over it, so that the sides are pressed together, and a bandage applied over this. The tube should be removed the next day to clear it of any coagula, and, if need be, introduced again through the superficial part of the Avound. Afterward the dressing need not be disturbed until the wound is sound. No food should be allowed for twenty-four hours, only a itw fragments of ice to allay thirst ; but if the patient is collapsed and the pulse failing, small quanti- ties of brandy with soda water, a teaspoonful at a time, may be given at frequent intervals, until the skin is beginning to grow warm again. Meanwhile hot flan- nels and hot-water bottles should be placed all round, and every effort made to maintain the temperature. As soon as consciousness returns, one-third of a grain, .02 gramme, of morphia should be given hypodermically to check peristalsis, and if the bowel was much injured, or if from the purgatives the patient has taken there is any fear of diarrhoea, small quantities of opium must be given two or three times a day until the danger is past. Milk, beef-tea, and arrowroot may be al- lowed after twenty-four hours, provided there is no sickness, and at the end of four or five days, if all goes well, a little custard or fish. If the bowels are left to themselves they are usually opened as soon as the patient begins to take solid food, at the end of five or six days ; or, if not, an enema may be given. In many cases they remain confined for much longer periods without causing any distress. [Opiates must be given with caution and only in case of necessity. Their fre- quent administration leads to ballooning of the intestines from tympanites, which not only adds to the patient's distress, but greatly disturbs the vital processes by mechanical pressure]. Death may be due to shock or to exhaustion, especially if, owing to the pur- gatives that are .so often taken before advice is sought, diarrhaa begins as soon as the hernia is reduced. In most cases, however, the immediate cause \?, peritonitis ; the symptoms that were present before the operation persisting, and growing worse, until collapse sets in. The intestine may have given way. causing faecal extravasation ; or the coats of the bowel, after being so long deprived of blood, may have become inflamed, as soon as the circulation was restored ; or their vitality may have been so impaired that, without actual rujjture, infective material can pass through them into the peritoneal cavity ; or the contents STRANGULATED HERNIA. 895 of the sac may have been septic at the time. In any case the symptoms are characteristic. The i)atient lies with the knees and hii)s flexed; the peculiar haggard and anxious aspect on the face continues and grows more distinct ; there is not, when the effects of the anaesthetic wear off, that e.xpression of relief significant of suc- cessful reduction ; the tongue remains dry and brown ; the pulse becomes more rapid and thready ; the vomiting and constipation persist; the temperature may rise a few degrees, but very commonly, es])ecially when there is gangrene, it either remains stationary or becomes subnormal ; and the patient, overcome by septic poisoning, falls into a semi-unconscious state, resembling typhoid. Sometimes the abdomen is distended, firm, hard, and intensely painful when touched, while the respiration is confined to the upper part of the thorax ; more frequently, although the surface is always tender, the collapse is so profound that there is no complaint of pain ; and the abdomen, although its walls are tense from the contraction of the muscles, is empty rather than distended, and moves a little when the patient draws a deep breath. In such a ca.se it is usually iouxxd post-mortem that there are flakes of lym[)h upon the serous membrane, and no adhesions ; nothing but an intensely irritating, semi-purulent, and turbid fluid. In other cases the symptoms of strangulation, the vomiting, collapse, and con- stipation persist, it may be, for one or two days, before peritonitis sets in or the last stage is reached ; and then it becomes a question whether the strangulation has reafly been relieved, or whether there may not be some further cause which has not yet been ascertained. Reduction en masse may have occurred, or the intestine may have been incompletely reduced ; slight volvulus, owing to the elongation of the me.sentery, may have followed ; or there may be a second hernia, either external, at some other of the abdominal openings, or internal, through the omentum, perhaps; or, finally, the strangulated portion of intestine, without becoming gangrenous or setting up peritonitis, may have been so injured that it is no longer capable of doing its work {ileus paralyticus^). In such circumstances there should be no hesitation in exploring the abdomen ; it is the only course left ; if any tumor or hardness can be detected, as in reduction en masse, the incision should be made over it ; if there is no guide, the abdomen should be opened in the middle line, the seat of the original operation examined first, then the other situations in which hernia commonly occurs, and if this does not reveal anything, the collapsed intestine, below the injured part, must be found and traced upward until the cause is ascertained. Care must be taken not to mistake the vomiting that arises from the anaes- thetic for that which is due to the persistence of strangulation. As a rule, there is little difficulty, for even when it continues for more than a few hours, and is not checked by giving small fragments of ice to suck, or by warm applications to- the abdomen, it is never offensive or faecal in character, it does not come up in great gushes, and the retching is much more severe. Sequelae, — Strangulation of intestine may be followed by after consequences of a more or less serious description. Local peritonitis is very common and is often preservative. The intestine, after reduction, has become inflamed, or may have sloughed and adhesions formed around it to prevent the extravasation of faeces ; but this may lead to serious results at a later period. The intestine may be tied down in a loop ; or it may be dragged upon at one spot until it forms an angle in the interior, obstructing the passage of the contents ; or the peritoneum may be so thickened that peristalsis is rendered difficult ; and even stricture may result. In other cases stricture is due to the injury sustained by the mucous mem- brane. It ulcerates opposite the sharp edge of the constricting band, especially in femoral hernia, and after reduction, when it cicatrizes, it sometimes narrows the canal to a very serious extent. Volvulus, or twisting of the intestine, causing very acute symptoms, sometimes 896 DISEASES AND INJUR J ES OF SPECIAL STRUCTURES. happens, the regularity of the movements being broken and thrown out of order by the elongation of the mesentery and the formation of adhesions. When gangrene sets in and the contents of the bowel are discharged exter- nally, either an artificial anus or 0. /(real fistula is formed, according to the extent of the slough. If it is the whole circumference of a loop, so that the two ends DiatfiitJrd jTiwfl ebote Sirfr/i/rr ^ Fig. 383.— Stricture of the Sm.-iU Intestine after Strangulated Hernia. open on the surface side by side, it is an artificial anus ; if, on the other hand, only one side gives way, so that the f?eces in part find their way externally, in part follow the natural route, it is d, /cecal fistula. In a few instances a communi- cation has formed between two loops of the bowel, inside the abdomen — 2l fistula bimucosa. SPECIAL HERNL^. Inguinal Hernia. Inguinal hernia protrudes through one or both abdominal rings. There are two classes : the external, oblique, or indirect, the neck of which lies outside the deep epigastric artery ; and the internal, or direct, the neck of which lies to the inner side. I. Oblique Inguinal Hernia. In this the intestine enters the internal ring, passing in front of the deep epigastric artery, and lies in the inguinal canal, in front of the spermatic cord. If it does not emerge through the external ring, it is called a bobonocele ; if it project it is complete, and if it descend sufficiently far it is scrotal or labial, ac- cording to the sex. The sac may be congenital or acquired ; in the former case the bowel lies in the tunica vaginalis, which has either not been closed or has been forced open again ; in the latter a new sac is formed out of the peritoneum covering the internal ring. a. Congenital Inguinal Hernia. — The peritoneum which lines the lower part of the abdomen in the fcetus, and that which is attached to the gubernaculum testis, descend with the testis between the eighth and ninth months, the testis and peritoneum coming down together, or the pouch preceding the testis. This pro- cess of peritoneum is the tunica vaginalis ; at birth it very commonly communi- cates with the general cavity, and it may continue to do so for a few months or even for the whole of life, though the opening may be so small as only to admit serum (congenital hydrocele). As a rule it becomes obliterated, first at the internal ring, then immediately above the testis, leaving an isolated sac in between, and finally this disappears. The right testis descends later than the left ; often it does not reach the scrotum until the ninth month ; and consequently the changes that INGUINAL HERNIA. 897 take place about the inguinal canal, are later on the right side. For this reason, and because of the lower attachment of the mesentery on the right, congenital inguinal hernia on the left side, by itself, is very rare ; it may, and very com- monly does, occur on both ; but if it is met with on one only it is almost sure to be the right. Hernia into the tunica vaginalis is called congenital, because of the condition of its sac. Naturally it is frequently met with at, and shortly after, birth ; but it may not occur until adult years; and the pouch may remain open for the whole of life without the intestine ever entering it. There are two varieties of congenital hernia, depending upon the mode of closure of the canal : — 1. When the tunica vaginalis is open the whole way down, so that the intestine can descend as low as the testis and come into contact with it (Fig. 384). 2. When the sac is closed above the testicle. In this case the hernia descends into the funicular portion of the tunica vaginalis only, and rests upon the top of the testicle without touching it (Fig. 385). Occasionally the closure at this point IISI1 / / vW, ^^^^ ■'^ -v^^^ Fig. 384. — Congenital Hernia into the Tunica Vagi- nalis testis. The intestine and testis in contact. "SSivics.^rcSS!' Fig. 385. — Congenital Hernia into the Funicular portion of the tunica vaginalis. The same diagram would answer equally well for an acquired hernia. is incomplete ; there is a constriction, but nothing more, so that if a hernia de- scends and passes down to the bottom it assumes the shape of an hour-glass. Congenital inguinal hernia is also common in female children, the protrusion passing down in the canal of Nuck ; and is sometimes met with in adults, consti- tuting the ordinary form of labial hernia. {F) Acquired Oblique Inguinal Hernia. — This is rare before adult life and is much more common among men than women. It enters the internal ring, gradually pushing the peritoneum in front of it, forming a bubonocele first, and then becoming complete. Its progress, therefore, is gradual, while that of the congenital variety is rapid and sudden ; in course of time it may attain a very large size, and by its weight drag one ring so near the other that the inguinal canal, as such, is destroyed, and the rupture appears to come directly out of the abdomen. There are two varieties, one exceedingly rare ; the other, the most common of all, depending upon the size and relation of the tunica vaginalis. I. It occasionally happens that the tunica vaginalis is closed at the internal ring and nowhere else, so that there is a great pouch of peritoneum investing the 898 DISEASES AND INJURIES OE SPECIAL STRUCTURES. testicle below, extending up the inguinal canal, and only shut off from the abdo- men by a thin septum. If an obli(]ue hernia develops under these conditions, a fresh sac is pushed down either l^ehind this or into it (invaginating it), so that when the intestine is exposed by an incision from the front three layers of serous mem])rane are divided — the anterior and i)Osterior walls of the tunica vaginalis and the anterior wall of the hernial sac. This is the infantile hernia of Hey (Fig. 386). The encysted hernia of Astley Cooper is probably the same ; the cicatricial septum which was supposed to stretch across the orifice of the canal having been shown by Lockwood to have no exist- ence. 2. In the other, the common form of acquired oblicjue hernia, the tunica vagina- lis is in no relation with the peritoneal sac. A fresh one is formed, which generally de- scends in front of the spermatic cord, but occasionally in its substance, and the testicle is at first below, then below and behind the hernia, becoming more prominent as the sac grows tense. Fig. 386. — Infantile Hernia. 2. Direct Inguinal Herfiia. In this the protrusion usually takes place through the structures that lie immediately behind the external ring, the conjoined tendon and the triangular ligament being stretched or split ; occasionally, however, the neck of the sac is higher up, on the outer side of the obliterated hypogastric artery, between it and the epigastric, and the hernia lies, for a very short part of its course, in the canal. The coverings are the same as in the oblique form, except that the conjoined tendon (when it is not split) takes the place of the cremasteric fascia. The cord, however, lies more to the outer side of the sac ; the hernia is usually smaller and more globular, and, after it is reduced, the finger seems to pass straight into the abdominal cavity. Diagnosis. — Inguinal hernia must be distinguished from : — 1. Swellings in front of the inguinal canal, such as enlarged glands. These may be recognized by their relation to the external ring. If the tip of the fore- finger is placed at the bottom of the scrotum and pushed upward, invaginating the skin, behind the spermatic cord, it rests first upon the front of the pubes, then on the ring itself; and the swelling, if it is a gland, can be lifted away from the front of the canal. 2. Tumors below the inguinal canal. Of these the most important \s femoral hernia, which often curls up over Poupart's ligament ; the neck of an inguinal hernia, however, if the finger is placed on the spine of the pubes, always lies in- ternal to it ; that of a femoral one always external. 3. Hydrocele, hcematocele and tumors of the testicle are distinguished by the line of separation between the scrotal swelling and the external ring. The only exception is that form of hydrocele which occurs in infants and young adults, in which the tunica vaginalis is closed only at the internal ring, and the swelling extends through the external one into the canal. The swelling, however, begins in the scrotum and the tumor is translucent. 4. Enlargements in the canal are the most difficult, and if there is the least doubt, and symptoms of strangulation are present, an operation should be per- formed at once. Eatty tumor or sarcoma of the cord, encysted hydrocele, and the testis descending late, are the most common, but though their position in the in- INGUINAL HERNIA. 899 guinal canal can l)e altered to some slight extent, none of them can be reduced in the same way as a hernia. It is said that varicocele may be mistaken for hernia, although the difference in the consistence and feeling, and the way in which a varicocele disappears when the patient lies down and rea])pears when he stands up, no matter what pressure is made upon the ring, must make such a thing almost impossible. Direct hernia is distinguished from indirect or oblicpie by its globular shape and the absence of fullness along the canal. In old oblicpie hernia the internal ring may be dragged so far to the inner side that the rupture appears to come straight out from the abdomen ; but this never happens unless the size is very con- siderable. It is sometimes possible, when the opening has been stretched by long- continued traction, to feel the deep epigastric artery. An oblique inguinal hernia is probably congenital if it occurs before puberty (though it is not confined to this period of life), or if it made its appearance sud- denly ; in the acquired form it takes some time, often months, to stretch the tissues sufficiently. The relation to the testis is not a certain guide ; if the intestine is plainly in contact with it, and envelops it, the hernia is probably congenital ; but the converse is not true. The neck of a congenital inguinal hernia is never shortened in the same way as that of an acquired one ; and partly from this, partly from the suddenness of its occurrence, it is very mijch more likely to be strangulated. Treatment. — i. Taxis. — The shoulders and the pelvis should be slightly raised to relax the abdominal muscles, the thigh flexed and adducted, and the patient directed to breathe as cpiietly as possible, and avoid straining. The fingers of one hand grasp the neck of the sac and pull it slightly downward ; the other manipulates the hernia. In direct and old acquired ones the pressure is applied from before backward ; in those that are recent or congenital it follows the course of the canal. If the hernia is reduced, it must be kept from descending again, either by means of a pad and a spica bandage (put on while the limb is flexed) as a tempo- rary measure, or a truss, the pad of which lies upon the internal or external ring, according to the variety, and presses either directly backward or backward and upward, according to the shape of the abdomen. It must not touch the pubic spine or rest upon the cord, and the spring must be so adjusted that while it does not press injuriously when the patient is at rest, it is sufficiently strong to retain the hernia even when he strains downward with the hips partially flexed. In the congenital variety, if the hernia is prevented from descending, the neck of the sac usually closes of its own accord, and, with sufficient care, a permanent cure may be looked forward to in most cases under ten years of age. Owing to the fact that the mesentery does not grow in proportion to the body, the tendency for the rupture to descend diminishes rapidly ; but if it comes down once all the good is undone. When the hernia is irreducible but not strangulated, either the rup- ture must be supported and prevented from increasing by means of a bag-truss, or, if the patient's age and constitution allow it, and the hernia is not too large or too extensively adherent, an attempt may be made to return it and effect a radical cure. When there is an undescended testicle the treatment depends upon the situa- tion and condition of the organ and the age of the patient. As a rule, if the testis does not descend within a i^w months of birth, it remains quiescent until puberty. Then it may come down, but whether it does, or whether it remains in the inguinal canal, hernia is an exceedingly common complication and strangulation not unfre- quent. If the testis can be pushed either back into the abdomen or out through the ring, a truss can usually be worn, and ultimately a cure may result ; but if it remains in the inguinal canal it rarely happens, even with water or air pads, that it is able to accommodate itself sufficiently well. Under these circumstances it is usually advisable to perform some radical operation, and either transplant the testicle, or if it is small and shrunken, or extensively adherent, remove it altogether 900 DISEASES AND INJURIES OF SPECIAL STRUCTURES. and stitch up the pillars of the ring. The same treatment should be adopted when a retained testis is met with in an operation for strangulated hernia. If strangulation is acute, particularly if the hernia is congenital, the patient should be placed under an anaesthetic, and unless taxis succeeds at once an opera- tion be performed. If, on the other hand, the rupture has been down many times before, and the symptoms are not severe, an ice-bag or a hot bath may be tried and a delay of a few hours sanctioned. 2. Herniotomy. — An incision two inches in length is made over the long axis of the tumor, opposite the external ring, and the skin, sujjerficial fascia, and super- ficial external pudic vessels divided (Fig. 387). The margins of the ring are then defined. In some cases the sac is deeply grooved by the fibres of the external oblique, and if these are divided the constriction is relieved without anything further. More frequently there is only a shallow mark, no real constriction, and layer after layer of tissue is divided on a director until the sac is exposed. This is opened with proper precautions, the forefinger passed along the anterior surface of the protrusion as f^ir as the internal ring, and the seat of stricture felt. The finger nail is slipped beneath it and a curved blunt-pointed hernia knife passed along the finger with the blade laid flat, until it can be guided beneath the con- stricting band. The edge is then turned upward and a very small incision made parallel to the linea alba, so that, whether the hernia is internal or external, the deep epigastric artery may not be wounded. The contents of the hernia must then be dealt with, the sac removed, ligatured or sewn into a pad according to circumstances, and the pillars of the ring sutured as in the operation for the radical cure. Radical Cure. By the radical cure of hernia is meant an operation that will not only perma- nently prevent the hernia descending, but will relieve the patient of the incon- venience of a truss. In certain cases it is admitted that some measure of this kind is either neces- sary or very desirable. After herniotomy, for example, if the bowel is not gan- grenous or the patient exhausted, an attempt should always be made to close the opening. In other instances there are special reasons why a truss is not desirable ; there may be, for example, an undescended tetsis fixed in the inguinal canal ; or a large mass of unreduced omentum over which a pad will not fit com- fortably ; or the hernia may be of such a nature that no truss is able to retain it ; or the patient may be too unintelligent or too careless, or he may be placed in such circumstances that were anything to happen to his in- strument it could not be re- newed. In such as these there is no doubt — the question is, how far an operation is advis- able as an alternative to a truss, and whether it can be relied upon to effect a permanent cure without too much risk. If the cases are properly selected it is certainly effectual. In children, for example, in whom, from carelessness or other reasons, a truss has failed to procure the closure of the canal, in young adults with a recent hernia, and in older men of sound constitution and wiry frame, in whom the inguinal canal has not yet been distorted, a cure is practically certain, and the risk is so small that it is a matter Fig. 387. — Incision in Inguinal Hernia. INGUINAL HERNIA. 901 of question whether it is really greater than that attendant on the wearing of a truss. On the other side, the presence of a hernia disqualifies from entering the Services, renders a man at the most active period of his life unfit for many kinds of employment, and exercises a definite restraint in everything he does. If, however, the patient has already reached middle life, is comfortable with a truss, and has lost the impulsive activity of youth ; or if he is old for his years ; or if the abdominal walls are thickened and fat, or shaped so as to suggest pro- lapse of the mesentery; or if there is the least suspicion as regards his general health — the cure might be effectual ; but the risk is too great, provided, that is to sav, the rupture can be kept up with a truss. When this cannot be done the ques- tion rests on entirely different grounds. {a) Subcutaneous Operations. — These, which met with very fair success in the hands of those who devised them, have given way almost entirely to the open ones. Injection. — The idea of plugging the canal with lymph by means of injec- tion has recently been revived, but not with great success. It may be done either through an incision or subcutaneously with an instrument devised by Keetley [or the Warren syringe]. The scrotum is invaginated with the forefinger, the sac pushed well up, and the needle of the syringe passed through the skin from above and outside the internal ring down toward the pubes, until it meets the finger in the canal ; when its position is assured, the finger is withdrawn and the fluid injected. Absolute alcohol (five minims) has been tried without confining the patient to bed, but the injection had to be repeated many times. Glycerine and tannic acid produce more reaction ; the tissues around swell up, the groin becomes full and tender, and a good deal of lymph is effused. [Heaton, of Boston, used extract of white oak bark.] But, although the method may be safe, it is not certain. It may be impossible to injure the hernia with the needle pointing toward the pubes, but the injection maybe thrown into the spermatic cord, or some of it may escape into the tissues outside the canal, and the sac is not dealt with in any way. Some of these objections are overcome by sutures as well, but in this the open method throughout is to be preferred. ib) The Open Method. — In this the sac and the external ring are thoroughly exposed. As compared with the former, it is more precise and certain in its re- sults, quite as safe so far as the danger to life is concerned, and does not expose the cord to so much risk. It is, of course, the only plan admissible when the hernia is irreducible. The operation consists of two distinct steps, one dealing with the sac, the other with the canal. The patient must be carefully prepared, and the parts shaved and thoroughly cleansed ; the incision through the skin lies over the ex- ternal ring, or may, with advantage, be placed a little higher. The Sac. — The first step is to isolate this thoroughly. In congenital hernia, if the cord causes any difficulty, the plan suggested by ^IcEwen may be followed. The sac is opened and two longitudinal incisions are made in it, one on either side of the cord, parallel to it, so that this, with the strip that adheres, is left undis- turbed. If the pouch is open right down to the testicle, the lower end must be separated from the rest to form a tunica vaginalis ; but it is not necessary to sew this up ; the walls collapse and adhere to each other, or to the testis, almost at once. When the sac is separated it may be either cut off, the neck being tied and fixed by sutures at the internal ring, invaginated, twisted, or sewn up into a pad and pushed into the subserous space, so that it no longer lies in the canal at all. Of these, the two last are to be preferred ; in both the separation of the sac must be complete and the peritoneum continuous with it must be detached for at least half an inch inside the margin of the internal ring. {a) Torsion (Ball). — The sac is first examined to make sure that it is empty. The neck is grasped with a pair of broad catch-forceps, and, while the finger de- taches the tissues around, is twisted until it is felt to be quite tight and that any further torsion would tear it. A stout catgut ligature is then placed round the 902 DISEASES AND INJURIES OF SPECIAL STRUCTURES. twisted sac as high as possible, tied tightly, and the ends cut off short. The effect of this is to throw the peritoneum around the opening into a number of spiral folds, extending over such a distance that, in two cases, the opposite ring was narrowed sufficiently to prevent the descent of a hernia. Sutures are i)assed after- wards through the pillars of the ring and the twisted neck, so as to press the latter toward the abdominal cavity, and prevent anything like a funnel-shaped depression on the jx'ritoneal surface. No ill result has ever been recorded after this, but it must not l)e forgotten that, in some cases, strangulation of the jjarietal peritoneum (as in subperitoneal fatty hernire) has given rise to symptoms of the same character, although of less intensity, as strangulated intestine. {b) Folding (McEwen). — In this the sac is thoroughly freed, not only at the fundus and neck, but for half an inch further inside the constricting ring; it is then drawn down, examined to see that it is free, and a stout catgut suture fastened to its base. This is threaded on a needle and passed through the serous layers from side to side at very short intervals, working toward the neck, so that when it is drawn upward the sac is thrown into a series of l\W' M. . >*?: XT- >C' Fig. 388. — McEwen's Pad, as seen from the Inside. Fig. ■The Canal seen from inside, showing its valvular shape. {A/ier Astley Cooper.) short folds closely pressed together. The pad thus formed is jnished inside the ring, and fixed there by passing the suture through the muscles on the front wall of the abdomen from within outward. In this way, a solid block of invaginated sac is placed over the ring — not in the canal — projecting into the peritoneal cavity (Fig. 388), so that when the coils of the intestine are forced downward, they are thrown off on to either side. Owing to the way in which the margins of the ring are refreshed by detaching the peritoneum, the pad very soon becomes adherent at its new site. The Canal. — The second step is to suture this, and restore its valvular shape (Fig. 389)- . , Where it has not been shortened by the traction of the hernia, the simplest method is to pass aListon's needle, threaded with silk or well-seasoned catgut, up the canal along the finger until it perforates the inner boundary of the ring. It is then unthreaded, withdrawn (leaving the suture), threaded again with the other end, and pas.sed through the outer boundary at the opposite point. Four to seven sutures, according to the length of the canal, may be passed in this way, each per- forating all the structures that form its outer and inner walls, and leaving beneath INGUINAL HERNIA. 903 them a small space along the floor for the spermatic cord. If the neck of the sac has been tied or twisted, the first suture may be passed through it to hold it well up in the abdomen ; but, in any case, it must perforate the l)oundaries of the inner ring as high as possible. This one should be secured a.s soon as it is passed ; the others should all be inserted before one is tied, in order that the effect on the spermatic cord may be noted when they are all lifted up together. When the canal is shortened McEwen's plan is preferable; merely stitching the opposite walls together scarcely forms any protection. The finger is introduced into the canal, after the pad formed out of the sac has been placed in position, and the deep epigastric artery and the inner border of the ring carefully defined. A hernia needle with a sharp lateral curve at the end (right or left according to the side) is passed up the canal through the conjoined tendon (in and out) into the canal again, and threaded there, so that when it is withdrawn P'iG. 390. — McEwen's Sutures to draw the Conjoined Tendon down to Poupart's Ligament. a loop of catgut is left on the deep surface of the tendon with the two ends free in the canal (Fig. 390). These are dealt with separately. The upper is threaded on a needle and passed through the internal oblique muscle, and the aponeurosis of the external oblique from within the canal toward the surface, on a level corresponding to the upper end of the loop. The lower is treated in the same way, but is only passed through Poupart's ligament. By this a double suture is formed across the internal ring, drawing its inner margin outward toward the under surface of Poupart's ligament. The two free ends emerge on the surface of the external oblique, the loop lies on the abdominal side of the conjoined tendon ; when the ends are tied together this is drawn directly outward and downward until it lies beneath the margin of the outer pillar and closes the ring like a valve. 904 DISEASES AND INJURIES OF SPECIAL STRUCTURES. A second double suture may be passed in the same way lower down in the canal, or, now that the valve is restored, the walls may be sewn together as in the former plan. In some cases, oi)erating upon this plan, I have found very little difficulty in securing anything like a conjoined tendon. In one, at least, there was nothing of the kind attached to the ileo-pectineal line, and probably this was the cause of the hernia. The sutures should either be of chromicized catgut, tendon or silk ; their object is to secure the position of the sac and the walls of the canal until a sufficient amount of lymph has been thrown out to consolidate them and glue them all together, ^^'ire js unnecessary; it cannot hold fibrous tissues together if there is any strain, antl although, if the wound heals by the first intention, it becomes buried and disappears, it is always liable, years afterward, like any other foreign body embedded in soft parts, to set up a certain amount of irritation, and grad- ually ulcerate its way out. In a successful case the tissues become hard and dense after the operation, and not unfrequently after the stitches have been absorbed, or, at least, have lost all hold on the parts, the walls of the canal become more and more closely approximated by the gradual contraction of the lymph that has been poured out. The sutures should never be drawn too tight for fear of their cutting out too soon, and care should always be taken that a sufficient amount of space is left for the spermatic cord. Fig. 3QI. — The Pillars Open, the Cord Held Up. Fig. 392. — The Pillars Fig. 393. — The Deep Sutured, the Cord Fascia Closed over Held Up. the Cord. Radical Operation for Inguinal Hernia. {After Bassini.) The treatment of the wound is very simple. It is well sponged out with an antiseptic and dried ; the edges of the skin are brought together with a continuous catgut suture, and sprinkled over with iodoform ; and the groin is carefully and evenly packed with an absorbent dressing, so as to ensure eipiable pressure and perfect rest. If there has been much handling of the parts a drainage tube is inserted, and the dressing is removed the next day to make sure that it is not clogged ; afterward it is enough if it is placed just between the edges of the wound. At the end of a week or ten days healing is generally perfect, and the tube, with the portion of the sutures that has not been absorbed, is found lying upon the skin. A spring tru.ss should not be worn after the operation, as its pressure tends to cause premature absorption of the lymph ; but the abdominal wall requires a certain amount of support for some months. In infants this may be managed wTth a skein of Berlin wool as already described ; but for children and adults the form of appliance known as Harrison's truss answers best. It consists of a well- fitting pelvic band, and two short thigh pieces made of linen, like a pair of very short drawers, fitting tightly and fastened with lacers. A perineal band prevents its ascending, and it may in addition be furnished with a scrotal bag, and with braces passing over the shoulders. [The method introduced by Bassini, in 1888, modified according to the neces- FEMORAL HERNIA. 905 sities of the particular case, is at jiresent most in favor in the United States. 'I'his operation consists essentially in a reformation of the inguinal canal and transplanta- tion of the cord. Bassini asserted that his methotl was without danger, that the cure was speedy, and that no truss was required after the operation. Marcy thus describes Rassini's ojieration : " He lays open the canal to the internal ring. The sac is separated, drawn down, ligated, and resected. The closed peritoneum is returned, the si)ermatic cord pushed aside, and the posterior margin of Poupart's ligament exposed. The deeper layer is dissected in such a manner that it can be brought in close apposition to Poupart's ligament. From the ileo-pubic tubercle the canal is united jjosteriorly, from five to seven centimetres, to the entrance of the cord into the abdominal cavity. The cord is then replaced, and the aponeurosis of the external oblique sutured, only opening sufficient for the cord without com- pression being left. The wound is closed with drainage." In my hands this operation has been modified by freshening the edges of the pillars, and suturing with stout chromicised catgut, or whale tendon, or kangaroo tendon, the "purse-string" method most frequently used; the cord is then brought down, as in Bassini's operation, and the wound closed without drainage. I have seen no death follow the operation, and I haliitually employ it after release of the intestine in strangulated hernia. My youngest patient with strangulation was five months old (Presbyterian Hospital, Chicago, 1892), and my oldest seventy-four years.] Femoral Hernia. Hernia into the crural canal, the small conical space with base upward which is bounded in front by Poupart's ligament, the deep crural arch, and the falciform edge of the fascia lata ; on the inner side by Gimbernat's ligament ; on the outer by the femoral vein ; and behind by the bone (Fig. 394). In very rare instances the rupture protrudes externally to the vessels. Femoral hernia rarely occurs under puberty, and is more common among women than among men. The sac is always acquired, and the tissues that lie in the canal are pushed down by it and compressed so as to form a fascia propria. At the saphenous opening it comes into contact with the cribriform fascia, and as soon as this gives way the hernia curls upward upon itself until it projects over Poupart's and lies upon the abdomen. The size is rarely very large, although ones are not uncommon. The contents may be intestine only, but i proportion of instances there is as well a mass of irreducible and omentum. In one or two cases the caecum has been found inside. 5ii Fig. 394 ligament, moderate n a large adherent 9o6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Femoral hernia fither forms a small, tense, rounded tumor immediately below Poupart's ligament, or a larger, softer swelling, of irregular shape, traceable to a neck in the crural canal. So long as it is not strangulated there is an impulse on coughing ; and if the portion of intestine is not too small (Littre's hernia usually takes jjlace here) or too much covered in with omentum, it may be resonant on percussion. Diagnosis. — Itii^uitial Ilcniia. — Sometimes, especially in women, a fold which may be mistaken for the fold of the groin e.xtends across the thigh lower down ; but the spine of the pubes can always be felt, and the neck of a femoral hernia always lies below it and to the outer side. Psoas Abscess. — The swelling in this case lies beneath the vessels as well as to their inner side ; there is a fullness in the iliac fossa above ; fluctuation oin usually be detected, and gradual reduction takes place when pre.ssure is made upon the swelling. Varix of the fctnoral vein occ?i%\ox\a.\\y resembles femoral hernia ; there may be an impulse on coughing ; but if the finger is placed on Poupart's ligament after the swelling has been reduced the vein is filled from below. Enlarged lymphatic glands often present great difficulty, especially when there is only one and it is not elongated transversely ; but it never possesses a neck like that in hernia. Fattx growtlis in the canal, cysts, hydrocele of the sac, and a thickened empty sac often cannot be diagnosed. In such circumstances, if symptoms of strangula- tion are present, an exploratory operation should be performed. Treatment. — i. Reducible Hernia. — This should be .supported by a truss the pad of which presses a little upward as well as backward, hooking under Poupart's ligament, and is beveled off on the outer side so as not to compress the femoral vein. 2. Irreducible but not Strangulated.— \{ there is only a small amount of omentum (the common form) a pad may be moulded over the protrusion to prevent its increasing ; or an attempt may be made to effect reduction by taxis after the prolonged application of ice combined with scanty diet and iodide of ])otash ; but, especially in young women, it is advisable to have the sac opened, the omentum removed, and a radical cure performed. On the one hand there is the exceed- ingly slight risk of the operation ; on the other there is the existence of an omental band passing down from the stomach to the groin, exposing the patient to the danger of internal strangulation, and forming a kind of inclined plane which guides the intestine infallibly to the weakest spot in the wall. In most of the cases in which operation is required a small knuckle of intestine is caught and concealed behind irreducil)le omentum. If Gimbernat's ligament is too freely incised, the hernia that follows is either irreducible, or, if it can be reduced, cannot be retained in position. In such cases a firmly-made thigh belt, laced up, with a triangular pad to fit in Scarpa's triangle, affords more relief than anything else. It should either be attached to a truss or provided with a pelvic band of its own. 3. Strangulated. — In femoral hernia the symptoms are generally acute, and taxis has little chance of succeeding, owing to the unyielding character of the edges of the ring. If a portion of intestine has only just descended, an ice-bag may be tried for a short time in the hoi)e of reducing its bulk ; but if it is small and tense, and is down for the first time, or if there is an old epiplocele, it is better to give the i)atientan anesthetic, and if taxis does not succeed at once, operate. In the one case, if the least pressure is used, the edge of Gimbernat's ligament cuts into the congested bowel ; in the other, owing to the mass of omentum in front, the pressure is too diffused to act with any certainty. If the symptoms of strangulation have lasted acutely for more than two days, or if there is a history of many attempts at taxis, especially by the patient himself, the operation should be performed at once. In applying taxis the position of the patient is the same as for inguinal hernia. UMBILICAL HERNIA. 907 the thigh flexed, adducted, and rotated inward. The direction of the pressure is upward and backward, the tumor, if it has spread over Poupart's ligament, being drawn downward. The neck of the sac is steadied with one hand, the utmost gentleness being used, and softly squeezed from side to side, while the other draws the rupture down and then quietly presses it up again. The incision is vertical immediately over the neck, with its upper end on Poupart's ligament. The layers divided vary in each case, and often it is thought that the sac is exposed when the fascia propria is reached. The difference is plain at once if they are traced up to the neck ; the one comes from the abdomen, the other does not. Hey's ligament, the curled-in edge of the falciform process attached to the ilio-pectineal line, is the first tense band divided, and sometimes then the hernia can be reduced. More often the deep crural arch and the lower fibres of Gimbernat's ligament, where it is separating from Poupart's, must be cut as well. If there is no reason for opening the sac, the finger nail is slipped beneath them, and the end of a probe-pointed hernia knife gently insinuated and slowly turned round, so as to make a small incision upward and slightly inward. If this fail, or if it is not thought advisable to try it, the sac is opened with the usual pre- cautions and an incision made from the inside in the same direction. The incision should be made very slowly by the pressure of the knife, and should be as short as possible ; if more space is recjuired it is better to make a second than to divide Gimbernat's ligament more freely, as this is usually followed by a most intractable form of hernia. Moreover, in a small proportion of cases (about one per cent.), the obturator artery pursues an abnormal course, coming off from the deep epigastric and winding round the upper border and inner side of the crural ring. If, as it usually does, it runs down between the hernia and the vessels it is not likely to be hurt ; but if it loops round it may easily be divided, as it lies actually on the sac. For this reason the finger should be used in preference to a director, as the pulsation can sometimes be felt. Injury to the vessel may be avoided by using a blunt hernia knife ; the fibrous tissue is so tense that anything will divide it, while the artery is simply pushed away. If it should be hurt an attempt must be made to find the ends and ligature them or secure them with clamp forceps, but without dividing Poupart's ligament; an incision should be made above it, as for ligature of the external iliac, and a careful dissection carried down until the bleeding points are exposed. In one case the lower end of the artery was drawn right into the obturator foramen. Free hemorrhage may occur from the division of a small vein, but this stops of itself. The contents of the sac must be dealt with according to the ordinary rules, but especial care is required in femoral hernia, as the constriction may cause ulcer- ation, and even sloughing, of the mucous membrane without evidence of much congestion. Moreover, a small knuckle of intestine is sometimes concealed behind, and even in the interior of a mass of irreducible omentum. The sac, when it has been emptied, should be detached thoroughly from the tissues around, and sewn up into a pad after McEwen's plan. Afterwards a suture may be passed through the boundaries of the ring in a way devised by Wood for the radical cure ; a Liston needle is passed through the pubic portion of the fascia lata, entering about an inch below and emerging close to the pectineal line, and then through Poupart's ligament. Catgut, silk, or wire may be used, as in the inguinal operation, and two, or at the most three, sutures inserted between Gimber- nat's ligament and the femoral vein. Umbilical Herxia. Thismav be congenital, or it may occur during infancy, or later, during adult life. (a) The congenital form of umbilical hernia is due to the visceral plates fail- ing to meet in the middle line, and allowing some portion of the intestine, and, in 9o8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. rare cases, the greater part of the al)(h)niinal contents, to protrude. Owing to the method of its development tlie c;\icum is often found in it. A sac is j)resent in most instances, formed from the |)eritoneum, and extend- ing among the tissues of the cord. It may be so thin that the nature of the con- tents can be seen at once, or it may l)e thick. Occasionally it is wanting, even when the protrusion is small ; in cases of great deformity it is never developed. Strangulation may occur at the neck. Reduction and ligature of the sac at its neck should be performed imme- diately after V)irth ; if the protrusion is left the delicate tissues dry uj) and l:)ecome adherent to the bowel. In cases of strangulation, or where the contents have formed adhesions to the wall, or are irreducible for other reasons, the sac must be opened. If reduction is successful the edges of the ring .should be brought together with a catgut suture. {F) The umbilical hernia which is so common in infants is due to the stretch- ing of the cicatrix shortly after birth. It never appears to lead to strangulation, and it is usually cured rapidly by the contraction of the orifice, if the rupture is prevented from escaping. Tight abdominal belts with button-shaped projections to fit into the opening are most injurious ; the pad should either be flat (a penny sewn up in wash leather forms a very convenient one) or dispensed with altogether, the skin being merely rolled up into two folds, one on either side, and held together with strapping. In the case of a boy, four years of age, in whom the Intrusion still i)ersisted, I laid oi)en the sac (wiiich was very much thickened from the constant irritation of trusses), ligatured the neck and sewed up the opening with catgut. Wood has recommended lacing the orifice round with a suture. (f) The form that occurs in adult life protrudes through the linea alba close to the umbilicus, occasionally in more places than one, so that two herniae lie in the same tumor, separated at their necks by a tense band of fibrous tissue. It is usually met with in women who have had large families, and it may attain an enormous size, hanging down like a pendulous tumor filled with omentum, small intestine, or colon. This hernia is frequently irreducible, and when it attains any size is especially liable to become obstructed and inflamed. Strangulation, when it occurs, is usually a sequel of obstruction ; the tumor is allowed to hang down over the sharp edge of the ring, the veins are compressed, congestion sets in, the orifice becomes blocked with the swollen mass, and at length the circulation is stopped. When the hernia is reducible it must be retained in position by a suitable belt ; if this is impassible, it should be well supported, especially from beneath, and, as far as can be, prevented from increasing. Strangulation is often very insidious. The hemia has been irreducible for some time and is perhaps obstructed. At first there is only discomfort or uneasiness ; then vomiting begins, and soon the constitutional signs of strangulation set in definitely. Taxis may succeed, but, owing to the way in which the strangulated loop is shielded by the rest, it often fails. In this case an incision must be made over the upper i)art of the tumor (Wood prefers the lower), and the neighboring abdominal wall, in the middle line, and the skin carefully divided over the margin of the orifice. The sac is exces- sively thin, and the tissues are generally matted together from constant irritation ; but an attempt should always be made to relieve the constriction without opening the peritoneum. If it cannot be done, either a small incision must be made through the fibrous ring, from the inside of the sac at one or two points, and the strangulated loop reduced, the rest being left as it was before, or the sac may be laid freely open, the contents unraveled and released from the omentum, which is spread over and among them, and the operation completed as in abdominal sec- tion, excising the redundant ])ortion. Which of the two should be i)erformed must be determined by the circumstances of each case ; the latter requires the greatest care and may be exceedingly tedious and prolonged, but the results do not seem to be more unfavorable. VENTRAL AND OBTURATOR HERNIA. 909 In one case in which the walls of the abdomen were enormously thickened from the dei)Osit of fat, I made an incision in the linea alba below the umbilicus, where, owing to the pressure of the tumor, the tissues were not Cjuite so thick as in other parts, dilated the stricture from the inside, and withdrew the strangulated loop. The immediate result was successful, but the patient died some weeks later from bronchitis and prolonged sup|)uration in the abdominal wall. Ventral Hernia. Hernia through the linea alba (except at the umbilicus) the linea semilunaris, or some other part of the abdominal wall that is not usually weak. It may be the result of defective development, or it may be due to operations, injuries, extreme distention, rupture of muscles, abscesses leaving a yielding cicatrix, or, in short, anything that impairs the strength of the part. It must be treated in all respects like umbilical hernia. Strangulation is rare, although I have met with instances of it. Hernise of the subperitoneal fat may occur in the middle line, and have been known to cause symptoms of strangulation from dragging upon the peritoneum beneath. Obturator Hernia. Hernia through the obturator canal in the upper and outer part of the thyroid foramen is always acquired, is much more common in women than in men, and rarely occurs until middle age ; apparently it is connected with the emaciation and loss of fat which often follow the climacteric. It protrudes either between the obturator externus and pectineus, or through one or other, stretching the fibres over it, and causes an indefinite fullness in the groin, behind and to the inner side of the femoral vessels, between them and the adductor longus. The obturator artery and vein may lie either to the inner or outer side, the relation they bear to the neck of the sac being very inconstant. This form of hernia is rarely recognized unless it is strangulated. It is always small and deeply buried ; and, unless there is pain along the obturator nerve, there is little or nothing to direct attention to it. If strangulation sets in the symptoms are generally acute ; the inner side of the thigh is tender and painful ; sometimes, if the patient is thin, a certain amount of fullness may be made out, especially when the hips are slightly flexed and abducted ; the muscles of the abdominal wall are rigid, and the movements of the thigh are attended with pain. Vomiting and collapse usually come on at once and are very severe. In about half the cases there is a complaint of pain running down the inner side of the thigh to the knee- joint, or even into the leg, evidently due to the pre.ssure upon the nerve ; but in many instances this symptom has not been noted. Examination per vaginam is stated to have been of assistance in the diagnosis. Taxis has been successful in a fair number of cases. The thigh should be flexed, adducted, and rotated a little inward to relax the muscles around the hernia as much as possible ; and the pressure must be applied from below upward. If this fails to give relief, and the symptoms point to strangulation, an incision should be made to the inner side of the femoral vessels, parallel to them, commencing immediately below Poupart's ligament, and the pectineus muscle exposed. The fascia covering it is divided, the muscular fibres separated and held apart, and the finger passed down to explore the upper and outer part of the obturator canal. If the sac can be made out it must be separated from the tissues around and opened so that the condition of the intestine may be assured. The stricture is divided by cutting either directly downward, or a little downward and outward. In several instances the local symptoms have been so obscure that abdominal section has been performed for the relief of strangulation. Other varieties of hernia are very rare, and possess but slight surgical interest. Diaphrag7natic hernia may be either congenital or acquired. In the former 9IO DISEASES AND INJURIES OF SPECIAL STRUCTURES. case the protrusion takes place by the side of the ensiform cartihij^e, between the costal and xiphoid ])ortions of the diaphragm, or through some accidentally weak part, and it is usually covered with a sac. In the latter, which is much the more common, any part of the diaphragm may give way and allow the intestines to be forced through the rent into the pleura. The congenital form scarcely admits of diagnosis : in the actpn'red one, if the amount of the protrusion is very great (and, occasionally, the stomach, spleen, part of the liver, and a considerable i)roportion of the intestine are forced into the pleural cayity), death, generally speaking, occurs at once from the interference with the thoracic viscera; in other cases, if the patient survives, there is great distress, arising from the dispUicement of the organs and the adhesions that form between them : and strangulation may occur. Perineal Hernia. — In this the protrusion takes place either between the bladder and rectum, or the bladder and vagina, according to the sex. Usually it passes through the fibres of the levator ani and forms a soft, easily reducible swell- ing to one side of the middle line. Pudendal hernia may occur in women past middle life, the sac descending between the ramus of the ischium and the vagina into the posterior part of the labium. It might be mistaken for a labial cyst. Sciatie hernia has been described by Astley Cooper, the rupture lying between the pyriformis and the s[)ine of the ischium. Lumbar hernia occurs in Pott's triangle, the small space l)ounded by the ex- ternal oblique, the latissimus dorsi, and the crest of the ilium. It must either pass through the aponeurosis of the transversalis and the internal oblique, or stretch them gradually before it as coverings of the sac. [See plate opposite, illustrating case of lumbar hernia, back and front view, from photograph sent the editor by Dr. C. H. Mastin.] SECTION IV.— INTESTINAL OBSTRUCTION. Intestinal obstruction includes all cases of internal hernia, strangulation by bands, twisting, intussusception, stricture and impaction. For clinical purposes these are divided into two great classes. In the one the onset is instantaneous, and the chief symptoms are due to the effect upon the nervous system. The patient is in perfect health : suddenly and without warning, some part of the bowel is caught or twisted ; the circulation is stopi)ecl ; the great nerve-plexuses are thrown into a state of violent disorder ; vomiting, collapse, and pain come on at once; the vomit rapidly becomes faecal ; the prostration is complete ; and, if the patient does not sink from exhaustion, the intestine becomes gangrenous in the course of a few days. In the other the onset is gradual, and the symptoms for a time ill-defined ; the health often has been failing ; there have been previous slight attacks of a similar character, at first relieved easily, then with greater difficulty, until at length absolute obstruction and distention of the abdomen set in. Pain is present, but it comes on spasmodically and grows more and more intense. \'omiting, when it does occur, is due to the accumulation of food, not to the effect upon the nervous system ; but the case may run a course of weeks without its happening once. Collapse does not come on until the end is approaching. It must not be imagined, however, that every case can be included at once under one of these headings ; the diagnosis of the cause and of the seat of intestinal obstruction is one of the most difficult in surgery, and often an operation has to be performed with the double object of exploration and relief. Occasionally the aspect of a case changes suddenly : chronic obstruction be- O UJ CO < o CO z I- co $ < ACUTE INTESTINAL OBSTRUCTION. 911 conies acute, the symptoms become infinitely more severe, and the patient sinks from prostration, the more rapidly because of the exhaustion caused by the previous illness. Acute Intestinal Obstruction, or Internal Strangulation. The svmptoms acute and the strangulation sudden, as in external hernia. Causes. — The most useful classification is that adopted by Treves : — 1. Internal hernia and strangulation by bands of all kinds. 2. Volvulus. 3. Acute intussusception. 4. Sudden obstruction due to gall-stones, or impaction of fseces, with or with- out previous narrowing of the bowel. Stricture, in most instances, is gradual ; but, occasionally, the closure suddenly becomes complete, and the symptoms as.sume an intensely acute character. I. Internal Hernia and Strangulation by Batids. — Pouches, which may become hernial sacs, are occasionally developed from depressions on the posterior wall of the abdomen. One of these is the duodeno-jejunal fossa, caused by the fold of peritoneum covering the inferior mesenteric vein ; another is the subcecal, to the inner side of the caecum, bounded above by a fold passing from the pro- montory to the caecum ; and there may be a third, the i?itersigmoid, between the left ureter, the superior hemorrhoidal vein and the spermatic vessels. In other cases a pouch is formed by the yielding of the wall at one spot, the fascia covering the iliacus, for example, so that the peritoneum protrudes into the tissues beneath. Rings and loops are sometimes present in the peritoneal cavity. A hernia has been known in the foramen of Winslovv ; but, more frecjuently, the opening is abnormal, in the mesentery or the omentum, or in a sheet of lymph thrown out during an attack of inflammation. Bands and adhesions are more common. Pelvic peritonitis in women, and typhlitis in men, are the causes in most of the cases. In some the omentum is fixed to the pelvis, and rolled up into the shape of a fan ; this occurs more often in men, partly owing to the typhlitis, partly owing to the frequency of hernia. In others there is a tough fibrous band thrown across from one part to another at the back of the abdomen ; or two distant loops of intestine become connected together by an adhesion which, as they separate, is stretched out into a narrow cord ; or, again, a portion of intes- tine, the appendix vermi- formis for example, or the pedicle of an ovarian tumor, or even a Fallopian tube, is tied down in such a way that a- small space is left behind. No matter how it is produced, when a band of any kind is pres- ent, there is always the danger of strangulation. The intestine slips under it, sometimes in a great coil, and either becomes, congested or else twisted upon itself so that it can- not return ; in a very (ew hours it becomes loaded ; the veins are constricted, and the circulation stopped. IV r^ / A Fig. 395. — Strangulation of Small Intestine by Band. In rare instances the traction of a band upon one 912 DISEASES AND INJURIES OF SPECIAL STRUCTURES. side of the intestine has caused it to bend so acutely as to close the lumen ; and the same thing has occurred from the bowel being coni])ressed or held in a bent position, or even from its being tied down by adhesions, especially when it is doubled into a loop. Bands that are long and loose, or that are attached only at one end, are scarcely less dangerous ; in the former case they are sometimes thrown into a kind of spiral coil, through the centre of which a loop of intestine may descend. Probably, as Treves has pointed out, this is of little consecjuence so long as the intestine is healthy ; but if the sides of the loop are adherent to each other, or if the bowel is held by adhesions doubled upon itself, the neck is very likely to be narrower than the rest, and strangulation is highly j^robable. When one end is unattached, a knot, sometimes of a very complicated character, may be formed around the bowel, and lead to the same result. One end is free and slightly en- larged ; this slips inside a loop formed by the rest, the intestine pushing it on until at length the knot is drawn tight and the bowel strangulates itself. Meckel's diverticulum, the remains of the vitelline duct, is an especial source of danger. Springing from the ileum a short distance above the c?ecum, it is directed forward toward the umbilicus. Sometimes it is a tul)e resembling the small intestine, and opening on the exterior ; more often it jirojects two or three inches, and ends in a fibrous cord ; or the end is free and enlarged or club-shaped ; Fig. 3^6. — Prolapse of Intestine through Meckel's Diverticulum. or it may have secondary attachments elsewhere. It acts like a peritoneal band : if it is fixed at both ends a loop of intestine may slip beneath and be twisted on itself and strangulated ; it may coil itself into a loop, or if the end is enlarged and free it may knot itself into a snare ; in a few cases a loop of intestine has fallen over it and become acutely bent ; in one or two instances it has exerted such traction upon the intestine as to close the lumen completely ; and finally it may allow the intestine to become extruded through it ; the mucous membrane is prolapsed first, and this is followed by more and more of the bowel, until there is a huge, intensely congested protrusion, turned inside out, projecting through the umbilicus. In one case of this kind I was obliged to open the abdomen before the mass could be reduced (Fig. 396). Strangulation by bands or through apertures form, according to Treves, one- fourth of the total number of cases of intestinal obstruction from all causes. Of these more than one-third are due to false ligaments, about one-fifth to the omen- tum, and rather more than one-fifth to the presence of^ Meckel's diverticulum. 2. Volvulus. — Of this there are two forms. In the more common a loop of intestine, the ends of which lie close together, is tw-isted around its long axis ; in the other, two distinct loops are twisted around each other. A third, very rare form, twisting on its own axis, has been described in the colon. Owing to its anatomical relations the sigmoid flexure is the common seat of volvulus ; but it cannot occur even here unless the mesentery is elongated, and the ACUTE INTESTINAL OBSTRUCTION. 913 ends of the loop dragged close together by long-continued distention. For this reason it rarely occurs under middle life, is almost unknown in children, and is usually jjreceded by chronic constipation. It may hai)pen to the caecum, when, owing to the i)crsistence of a fcjetal condition, there is a long meso-ca;cum and mesocolon ; and to the small intestine, if a loop becomes tied together and fixed by atlhesions ; but these are very rare. The second form of volvulus may affect the same regions ; but it is very uncommon. The immediate cause is probably some sudden movement of the body ; the effect is a tight twisting of both ends, leaving the long and heavy loop hanging down without any power of recovering itself. In some instances the pressure of the anterior abdominal wall seems to retain it. Venous congestion sets in at once ; the loop becomes enormously distended with gases that are set free in it ; it may even reach the diaphragm, and by its pre.s.sure prevent the swelling of other portions of the intestine ; peritonitis is almost invariable, and .sets in exceedingly early ; and ulceration of the mucous membrane in the bowel above the seat of constriction, or gangrene of the loop, follows rapidly. At first the coil can be untwisted without much difficulty, but after a little while the walls become so dense that it rolls back as soon as the pressure is taken from it. Volvulus may prove fatal within forty-eight hours. Volvulus may occur after the reduction of a strangulated hernia, causing per- sistence of the symptoms ; and in the case of bands strangulation is often the re- sult of the combination, the band and the twist. 3. Intussusception is the prolapse of one part of the intestine into the interior of another immediately adjoining. It is a very common form of obstruction, making up very nearly one-third of the whole ; and, owing to the mobility of the intestines in children, is especially frequent among them. More than half the cases occur under ten years of age. If a section is made through an intussusception, three layers of intestine are divided, the innermost or entering layer ; the outermost, or sheath ; and the mid- dle or returning one, in which the mucous surface is outside, facing the mucous surface of the sheath, and the peritoneal inside, facing that of the entering layer. The two inner layers are known as the intussusceptum. In exceptional cases five and even seven layers are met with. The mesentery is carried in with the bowel, lying between the peritoneal surfaces of the inner layers, and dragging the intussusception into a cone, the apex of which lies at the point, the base at the neck. A certain amount of elonga- tion is necessary to allow this, but, owing to the direction taken by the bowel, not so much as might be expected : and as an ileo-csecal intus.susception can reach the rectum within a few hours, the increased length is not due merely to stretching. The effect of this traction is, in general, to throw the intestine into a curve, and to tilt up the orifice of the intus- susceptum, so that it has the aspect of a slit and looks toward the side of the bowel rather than the axis. Intussusception exists in two different forms. In the common one, the apex of the invagination never changes ; the part that entered first continues in front throughout, and the increase is entirely at the expense of the sheathing layer ; in the other (ileo-colic), Avhich only occurs at one part of the intestine and is rare there, the ileum slips further and further down the colon through the valve, without the caecum following it ; the increase is entirely at the expense of the small intestine, and the apex is constandy shifting. Not unfrequently after a time this variety changes into the other. .^ii- Fig. 397. — Double Intussusception. 914 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The ordinary form may be enteric, ileo-caical or colic. Of these the first and last are seldom met with, and are rarely of any length ; the second is the usual one, the ileo-caical valve forming the apex, and gradually passing through the colon and rectum until i)erhaps it protrudes at the anus. The frecjuency with which intussusception takes place at this spot, is due, to some extent, to the difference in size between the two parts, and to the fixed position of the caecum, but, as Leichtenstern and others have pointed out, there is a very close analogy between the sphincter-like ileo-ceecal valve and the sphincter of the rectum, and between the invagination that takes place at the one and the prolapse that occurs with equal frequency, especially in children, at the other. Ileo-caecal tenesmus probably sets in whenever there is any violent catarrh or abnormal irri- tability of the intestine, just as anal tenesmus occurs in similar conditions of the rectum ; and the repeated and forcible peristalsis, driving down on to the firmly closed ileo-ca2cal valve, causes intussusception in the one case, just as it causes pro- lapse of the rectum in the other. If the ccecum is freely movable, as it usually is in children, ileo-csecal intussusception occurs ; if, on the other hand, it is fixed, as in adults, ileo-colic. When once the invagination has commenced, the contact of the swollen and congested apex, stimulating the walls of the intestine below, tends to make it increase indefinitely. In upward of one-half the recorded cases of intussusce])tion no exciting cause can be found. It is undoubtedly more common in delicate patients than in those who are strong and robust ; and in most instances where there is a definite reason for its occurrence, it has followed diarrhoea, free purgation, or colic due to the presence of undigested food. Possibly slight degrees of it, undergoing sponta- neous reduction, occur more commonly than is usually imagined in severe colic attended with great prostration. In a few instances it has followed injury, blows upon the abdomen, or jumping a child up and down, and there is no doubt that the presence of fibrous polypi in the intestine predisposes to it. The relation that exists between intussusception and epithelioma is more doubtful. In several cases the apex has been found to be the seat of malignant disease, and in one the con- vexity of the curve was involved, but it is difficult to say whether this was the cause or the consequence, due to the prolonged irritation. The method of production, according to Nothnagel, is much the same whether the intussusception is due to paralysis or to spasmodic contraction (which is the more usual of the two), affecting one segment of the bowel. The intestines above scarcely take any share in the proceeding ; the longitudinal muscular fibres simply keep drawing the bowel from below, over the narrowed part, until an invagination is produced and the apex has become swollen and congested. True intussusception must be distinguished from the invagination which is not uncom- monly found in the bodies of children who have died from cerebral disease. Several of these may occur together, they are never of any size, and can always be reduced without difficulty. Probably they are due to the disorderly character of the peristalsis when the circulation is beginning to fail. Effect. — This chiefly concerns the invaginated part and its mesentery ; the sheath may escape altogether, although sometimes it becomes gangrenous, and the part above at first shows scarcely any change ; later it may be dilated and the walls hypertrophied, or ulceration may occur and end in perforation. It all depends upon the character of the constriction ; where this is very tight the bowel inside becomes intensely congested, blood pours out from the mucous membranes, the walls become thickened and almost solid, especially along the convexity and at the apex, and the intussuscepted part soon becomes gangrenous. The middle layer usually suffers the most severely ; in some instances the whole invagination is destroyed and comes away in a mass, the separation taking place at the neck ; more frequently it is detached in shreds, and occasionally the inner coat is gradually cut off from the rest, unfolded, and pas.sed with the middle layer, turned inside out. Where the constriction is less severe a low form of inflammation sets in, the ACUTE INTESTINAL OBSTRUCTION. 915 walls become thickened, adhesions form between the peritoneal surfaces, some- times at the neck only, but more frei[uently wherever they are in contact, and if the patient lives the whole of the intussuscepted part may at length slough off. Obstruction is not common, in spite of the thickening of the walls and the way in which the orifice at the apex is dragged to one side by the mesentery. Very often the intussuscei)tion is irreducible, even when there are no adhesions — the walls are so thickened, especially along the convexity, and the apex is swollen out to such an extent, that the tissues cannot be unfolded without being torn. The same result may follow from twisting of the bowel inside the sheath, from rigid contraction of the ileo-ca^cal valve, or from the presence of a fibrous polypus springing from the mucous membrane. Where the constriction is very lax there may be little alteration even after months, but not unfretpiently after some little time the symptoms suddenly change and become acute. Peritoneal adhesions are more common in chronic than in acute cases, and often render reduction impossible ; according to Treves they are present in no less than eighty per cent. Sometimes they are only at the neck, or they may be general, or limited to the part first invaginated, so that the whole can be reduced with the exception of the last i^w inches. The walls of the bowel above are hypertrophied ; sometimes there is considerable distention, owing to the narrowing of the passage by the swelling and bending of the intussuscepted part. Ulceration may occur, but when the bowel becomes gangrenous the process is usually more gradual than in acute cases ; it may involve the mucous membrane only, or it may begin at the apex of the invagination and extend slowly upward until in some extreme instances the greater part or even the whole of the large intestine has sloughed, leaving the ileum continuous with the rectum. 4. In stricture of the intestine the symptoms sometimes undergo a sudden change, become intensely acute and resemble those of strangulation. This may depend upon a variety of conditions : the narrowed part may have become blocked ; a fold of mucous membrane may have fallen over the orifice ; the bowel, especially in the case of the small intestine, may have suddenly become bent upon itself, and closed the passage ; or, if the obstruction is below the sigmoid flexure, and this becomes greatly distended, volvulus may suddenly set in and cause a fatal termination within a few hours. As a rule, the symptoms are hardly so abrupt or so violent as those of strangulation, and nearly always there is a history of previous trouble and of similar slighter attacks. If the onset is sudden and the symptoms acute, as occasionally happens, especially in stricture of the small intestine, there is no means of diagnosing one from the other. Gall-stones which have ulcerated through into the duodenum, faecal accumu- lations, and very rarely foreign bodies, may cause symptoms of strangulation, even when there is no stricture ; but, in this case again, it seldoms happens that they are so acute, or the collapse so extreme. A fatal result, however, has been known to occur from this cause within four days, and the average duration of acute ob- struction by impacted gall-stone is only seven. Symptoms. — These conditions are grouped together, because they are sud- den in their onset, and because, with certain exceptions, they present the charac- teristic features of intestinal strangulation, collapse, pain, vomiting, and constipa- tion. Of these the two first are always present, the others are not so constant ; vomiting, for example, does not always occur in volvulus, or only makes its appear- ance toward the end, while diarrhoea, with a discharge of blood and mucus from the anus, is the rule in acute intussusception. {a) The collapse is most striking in internal hernia, strangulation by bands, and acute intussusception. The patient is utterly prostrate ; the temperature falls ; the pulse is feeble and rapid ; the face is pinched, the eyes sunken, the extremities cold, and the secretion of urine diminished. The severity depends, to some ex- tent, upon the part involved ; it is more marked, for example, in the small than in the large intestine, and nearer the pylorus than at the lower end, but the amount caught and the tightness of the constriction are even more important. In volvulus 9i6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the prostration may prove fatal in two or three days, but, as a rule, it comes on more slowly, and reaches its maximum gradually. {If) Pain is never altogether absent, although it varies in character and severity. When strangulation is the prominent feature, and the ])critf)neum and the walls of the bowel are crushed together, it comes on at once and lasts through- out, varied only by attacks of colic, which, as in strangulated hernia, are espe- cially severe when the abdomen is examined. If, on the other hand, the symptoms are due to gradual narrowing of the bowel, as in chronic obstruction, the pain from the first is of a peculiar griping character, coming on at intervals, with jjeriods of repose and comjiarative comfort between. Later, as the obstruction becomes com- l)lete, the attacks grow more and more frequent, and the intervals shorter, until at length it is continuous, with, every few minutes, violent storms of colic, often visible on the abdomen as the coils of intestine move over and over. Tenderness is seldom present, unle.ss peritonitis has set in, or there has been severe cramp affecting the abdominal muscles. {c) Vomiting. — As in external hernia, this is reflex, caused by injury to the intestinal nerves. In acute strangulation it begins at once, and persists without ceasing ; first the contents of the stomach, then those of the duodenum, and, after a time, of the lower part of the intestine. Toward the end it ])ecomes faical, if the obstruction is low down in the ileum, or, if the contents of the bowel are retained sufficiently long for decomposition to set in. In volvulus, on the other hand, vomiting may not be present at all, or it may be very scanty, and even give a certain amount of relief. (^/) Constipation, in most cases, is absolute. Even when the sigmoid flexure is full of faeces, there is usually no evacuation, owing to the profound effect upon the nervous system. Acute intussusception, however, must be excepted ; in this absolute constipation is very rare ; diarrhcxa is the rule, and nearly always there is a discharge of blood and mucus, with violent tenesmus. These symptoms are common, more or less, to all forms of acute intestinal obstruction ; others are less general, and serve to distinguish one variety from the other. Ititernal strangulation, however produced, presents the closest resemblance to strangulated hernia. It usually occurs in young adults ; the onset is sudden, the collapse, pain, and vomiting (which soon become fjecal) are characteristic; constipation is absolute from the first ; there is no tenesmus or tenderness on pressure until i)eritonitis sets in) ; meteorism is absent ; the coils of intestine can- not be seen through the wall, and no tumor can be felt. As bands are the most common cause, there is a history of previous peritonitis or i)erityphlitis, or of the reduction of a strangulated (external) hernia, in a very large proportion of cases. Volvulus, as compared with this, very rarely occurs before forty, is far more common in the sigmoid flexure than elsewhere, and is usually preceded by chronic constipation. The on.set is sudden, and the pain .severe; but vomiting does not commence at once, and, unlike that of strangulation, it may give a certain amount of relief. Tenesmus is occasionally present. The immense distention of the affected bowel, the extreme prostration, and the rapid occurrence of peritonitis are the most important features. The abdomen becomes distended, until the diaphragm can scarcely act ; the muscles are tense and rigid, and the walls excpiisitely tender ; sometimes there is dullness on percussion at the back, but, as a rule, it is resonant all over; no coils of intestine can be seen, and no sign of any tumor. It is pos- sible that manual examination of the rectum and enemata may be of some use in the diagnosis of the ordinary form. Acute intussusception stands in great contrast to these ; more than half the cases occur under ten years of age, and a very large proportion in infants. Like the others, the onset is sudden, attended with pain, usually distinctly paroxysmal, and great prostration ; but the vomiting is not so constant, and does not occur so early as in internal strangulation, and absolute constipation is hardly ever present. Diarrhcea is the rule, and in more than eighty per cent, there is a discharge of ACUTE INTESTINAL OBSTRUCTION. 917 blood and nuicus from the anus, with well-marked tenesmus. A sausage-shaped tumor can be felt in a large proi)ortion, sometimes through the rectimi (in which case it bears a close resemblance to the os uteri), more often through the abdomi- nal wall, in the line of the colon ; it varies much in distinctness and becomes especially plain during an attack of colic. 'I'he region of the swelling is nearly always tender from the first ; no coils of intestine are visible, and meteorism and abdominal distention are not marked, until the peritonitis has spread from the region of the intussusception and becomes general. Intussusception in infants, if the parts are very tightly constricted, may prove fatal from collapse in forty-eight hours. Diagnosis. — Acute intestinal strangulation must be distinguished from peri- typhlitis and peritonitis (especially that form which is due to ulceration of the appendi.x), and from certain other conditions which, owing to the effect they pro- duce upon the great nerve ple.xuses, give rise to symptoms of a closely similar character (pseudo-strangulation.) Sudden obstruction, due to impacted gall-stones or the closure of a stricture, can only be distinguished from internal strangulation by the previous history. Perityphlitis seldom begins without some previous indication ; there may have been irregularity of the bowels, or an attack of indigestion ; local tenderness in the iliac fossa is an early symptom ; sometimes there is a distinct feeling of resistance in the same place, or even a certain amount of swelling ; very often there is a his- tory of previous attacks of a similar nature, and usually there is a slight but dis- tinct rise of temperature from the first. Peritonitis, again, of such a nature as to be mistaken for acute intestinal strangulation, is always severe, and attended from the first with fever, distention of the abdomen, and intense continued pain. Ascites very soon makes its appearance, the vomiting is of a different character, the skin over the whole surface is exceedingly tender, and, if it is due to perforation, gas very soon collects in the abdominal cavity, and causes a diminution in the hepatic dullness. If, however, the patient is not seen until the peritonitis is already gen- eral, or if, as frequently happens in such cases, the patient is too exhausted to give any account of his symptoms, the diagnosis of the cause is impossible. \\\ pseiido-straiigiilatio7i, on the other hand, or where a part of the bowel is paralyzed, and the symptoms are due, not to inflammation, but to the effect upon the nervous system, the diagnosis is often very difficult, and cases are not unknown in which all the characteristic signs of internal strangulation have been present, and have terminated fatally, without any evidence of mechanical obstruction being found after death. Paralysis of one segment of intestine may be the direct result of injury, or may be reflex. Instances of the former {ileus paralyticus^ are not uncommon after the reduction of strangulated hernia, and probably the cases in which fjecal vomit- ing and other signs of acute strangulation have occurred in the course of typhoid and other diseases that involve the coats of the bowel, or even after injury to the abdomen, are to be explained in the same way ; the bovvel is so much injured in one spot that it practically acts as a stricture which has suddenly become impassable. In other cases the paralysis is reflex, excited by some distant affection, inflam- mation of a retained testicle or of a hydrocele, or phlegmon of the anterior wall of the abdomen, and the symptoms subside as soon as the pain and irritation are relieved. In neither case does the paralysis of the intestine, however produced, account for more than vomiting and constipation ; the violence of the pain, the severity of the vomiting and the collapse, are the result of reflex disturbance, starting from the damaged nerves in the bowel, involving the great abdominal plexuses. Symptoms of a similar character occasionally arise from disease of the nervous system, hysteria, for example, although chronic obstruction is more common. Tubercular peritonitis, meningitis, hepatic and renal colic, dysentery and various other affections, have at times caused a certain amount of difficulty in diagnosis. 9iS DISEASES AND INJURIES OF SPECIAL STRUCTURES. Treatment. — In acute intestinal obstruction the first object is to release the bowel, whether it is strangulated by a l)and twisted on itself, invaginated into another segment, or blocked in such a way as to cause the same symptoms. Except possibly in this last mentioned case, it is of little avail merely to secure the dis- charge of the contents by opening the intestines above (in volvulus it is done with the hope of uncoiling and releasing the twist) ; the benefit obtained is only tran- sient, the cause is not removed, the nervous symptoms are not relieved, and gan- grene with fatal peritonitis is practically inevitable. It is true that a few cases of wonderful recovery without active treatment are recorded ; but the numl;er is exceedingly small, and if the j^atient is left the chances of spontaneous reduction or of recovery with an artificial anus are infinitely less than in external strangulated hernia. The more sudden the onset and the more marked the nervous symptoms, the more urgent is the need for active treatment. When the commencement is gradual, preceded, perhaps with other symptoms, the difficulty is greater ; but the possibility of an acute termination to a chronic affection must always be borne in mind, and if no diagnosis can be made, and the patient's condition admit of it, an operation should be performed for exploration before it is too late. I. Where all the characteristic signs of acute intestinal strangulation are pre- sent, with sudden onset and symjjtoms urgent from the first, as in strangulated external hernia. Such a condition may arise from internal hernia, strangulation by bands, omentum, or Meckel's diverticulum, sudden obstruction from kinking, looping, traction, or twisting (volvulus) of the small intestine, from ileus paralyti- cus or other affections attendant on taxis ; or exceptionally from stricture, impac- tion of foreign bodies or compression by some external tumor. There is no method at present by which it is possible to distinguish one of these from the others ; the symptoms are practically the same ; and if unrelieved they all end in the same way — gangrene and peritonitis, which prove fatal, as a rule, in the course of five or six days. The patient should be kept absolutely at rest and as warm as possible ; exposure to cold, especially during the operation, is exceptionally serious, owing to the collap.se ; no food may be allowed, only a fragment of ice to allay thirst, but an enema of brandy may be given with advantage, and if the patient has had no opium a small injection of morphia hypodermically. The effect of this is wonder- ful ; the pain is relieved, the severity of the vomiting diminishes, the skin becomes warmer, the collapse passes off to a certain extent, and the secretion of urine begins to increase. Care, however, must be taken not to mistake the nature of the improvement ; the opium relieves the collapse so that the patient ajjpears to rally ; it does not remove the cause. This, as in external hernia, can only be done by operation ; enemata, massage, and the other methods of treatment that have been advocated from time to time, are worse than useless ; they cause delay and inflict further injury. If the diagnosis is definite, the sooner the operation is performed the better ; if it is postponed until the condition of the patient is hopeless it is not to be blamed for the result. If the vomiting is severe or the stomach much distended, an oesophageal tube should be passed and the cavity washed out with hot water. An anaesthetic is only really necessary for the preliminary incision, and the patient should never be anaes- thetized to complete insensibility. The incision should always be made in the middle line l>elow the umbilicus, a catheter having first been passed to make sure that the bladder is empty. The whole of the abdomen may be explored from this point, there is very little bleed- ing, no important structures are divided, any part of the small intestine may be brought out through it (except the fixed part of the duodenum), a portion of the colon even has been excised (Treves), and it is practically impossible in the vast majority of cases to localize the seat of the strangulation. An incision two inches in length is sufficient ; the superficial structures are ACUTE INTESTINAL OBSTRUCTION. 919 divided, the i)eritoncuni and the wound extended sufficiently with scissors or with a scalpel, using the fingers as a director ; and the gap is filled at once with a loop of bowel more or less congested. In the easiest cases, where, for example, the strangulation is dependent upon an umbilical band or Meckel's diverticulum, the diagnosis can be made at once with the finger. More frequently nothing can be felt. In this difficulty the coils of small intestine lying near should be carefully inspected and the one that is most congested allowed to protrude into the wound, hot sponges renewed as soon as they become cool, being used to protect and control it. It is true that exjjosure of the intestine is, as a rule, to be most carefully avoided ; if the bowel is allowed to become cool, or even if it is exposed to the air for any length of time, the gravity of the operation is immensely increased, but it is a choice between evils, and probably the ])rotrusion is the least. It need not be a great coil ; nearly always by gently moving it about it can be seen which of the ends is the more congested and dilated, and this guides infallibly to the seat of strangulation. Usually it is not far off, for as Greig Smith has pointed out, the greater amount of bowel is within three inches of the umbilicus, and the most dilated coils rise to the surface. Sometimes, as was first pointed out by Rand, of Liverpool, it is possible to make out which is the upper end of the loop, and even whether it belongs to the nearer or more distant part of the small intestine, by passing the finger down to the root of the mesentery against the spinal column. If the distention is too great to allow exploration, either the intestine must be punctured with a capillary trocar in many places, to let out the air, or an incision made in the protruding loop in order to empty the neighboring segments. Of these methods the former is scarcely safe ; leakage is very likely to occur from paralysis of the walls of the intestine. It has been done through the wound, and guided by the hand, through the abdominal wall at some distant spot ; but to afford effectual relief it must be practiced at many points. The other method is strongly advocated by Greig Smith, not only to allow of exploration, but as a means of relief; he points out that in such cases as these the mere distention of the intestine is sufficient to perpetuate the obstruction ; the bowel no longer lies in gentle curves, but forms acute flexures which act as valves and prevent its being emptied even after death, and he compares this with the benefit which often follows the use of Kussmaul's esophageal tube. In short, he regards evacuation of the intestinal contents as an essential part of the operation. The loop of the bowel is secured to some strapping fixed on the front wall of the abdomen by means of four quill sutures passing through the serous and muscular coats, and an aspirator trocar and cannula introduced into the centre of the square marked out. Evacuation may take an hour or more, the abdomen being gently kneaded the whole time, but as soon as the skin incision is made and the sutures passed the auc-esthetic should be discontinued. As a last resource, when nothing can be found, even after the distention is relieved, the opening may be enlarged (if the patient's condition will admit of further exploration), the hand introduced, and the hernial openings, the csecum, and then, according to its condition, the colon or the small intestine carefully traced back, beginning with a part that is empty and collapsed, until the seat of strangulation is found. The actual constriction rarely presents any difficulty ; small bands can usually be broken down with the finger; longer ones may require division, and in such cases it is as well to ligature them near their attachments and remove them ; omentum may be treated in the same way. Meckel's diverticulum, if it has to be divided, should be treated like a portion of intestine, the end invaginated, and the serous and muscular coats sewn together over it. When stricture, or the impaction of a gall-stone or other foreign body, is sufficiently acute to cause symptoms of strangulation, the bowel may be opened and the obstruction removed, or the stricture resected, as the case may be. In one or two instances an impacted gall- 920 DISEASES AND INJURIES OF SPECIAL STRUCTURES. stone has been <:;ently passed on throutih the ileo-ca^cal valve, and Tait has sul(- gested that, as they are very brittle, it might be possible to crush them or split them with a needle. It seldom happens, however, that the condition of the walls is sufificiently good to allow this to be done. In many cases it is wiser to be content with the formation of an artificial anus, which may be dealt with later, when the patient has recovered. The same thing should be done when the state of the bowel is such that its recovery is a matter of question. Treves has pointed out that, even when one constricting band has been divided and a definite strangulation relieved, it is always as well to make sure that there is no second. Instances of twofold strangulation by bands have occurred on more than one occasion. The subsequent steps in the operation present no special feature. If the constriction has been found, and there has been no hemorrhage or escape into the peritoneal cavity, the less the parts are disturbed the better ; the wound must be closed as in other operations. If, on the other hand, there has been much bleed- ing, the cavity may require to be sponged out, and if any of the intestinal contents have escaped, it must be thoroughly irrigated with hot water. Drainage must be provided for if peritonitis is present at the time or is expected to follow. In many cases the condition of the patient is much too critical to stand any prolonged or systematic exploration ; the face is drawn and jiinched ; the pulse very rapid and scarcely perceptible ; there is dullness in the flanks, the coils of intestine being filled with fluid ; the stomach is distended with fluid and gas with- out the patient having strength to vomit it up ; and there is complete apathy and almost insensibility to pain. In such as these (ireig Smith recommends an injec- tion of cocaine, a small incision, and if the seat of strangulation is not api)arent at once, suturing the intestine as already described, so that it may be emptied of its contents. It may give relief for a time until the patient rallies, and it is not possible to do more. The after treatment must be conducted on the same principles as in external herniotomy. The blankets must be warmed, and hot bottles kept round the patient ; the temperature, which is not unfrequently subnormal before the opera- tion, is often still further reduced by shock and exposure, and by the anaesthetic ; moreover, life has to be sustained on a mininum of food. Nothing may be given by the mouth for at least forty-eight hours ; only small fragments of ice at long intervals to allay the thirst ; and even at the end of that time food should only be given by the spoonful. The strength must be maintained by small enemata of peptonized food with brandy every three or four hours, so as to allow the intestine ample time for recovery, and the patient must be kept under opium. Hypodermic injections of morphia are the most useful, as there is never any question how much has been lost if the patient should be sick ; but the tincture, with an ecpial quantity of water, is sometimes preferred; and this must be continued until there is no longer any fear of the intestine giving way, or of peritonitis. The prognosis depends, as in strangulated hernia, upon the condition of the bowel ; but there is not as yet a sufficient series of cases to form any estimate as to the probable mortality. It is manifestly unfair to include those (and they form by far the majority) in which the o])eration has been done as a last resource, when everything else has been tried, when the patient is in a state of collapse, and general peritonitis has set in ; sometimes even under these circumstances it has proved successful, and there is no reason why, if it were done before the bowel is too much injured and the patient's strength exhausted, the mortality should be much higher than after external herniotomy. 2. Volvulus, when it affects the small intestine or the caecum, cannot be diagnosed from the preceding ; if such a condition is found after laparotomy, an attempt must be made to uncoil the bowel, or, failing this, the loop must be emptied through an incision and an artificial anus formed. Volvulus of the sigmoid flexure has never been known to recover without operation, though in one case (quoted by Treves), which terminated fatally at last, ACUTE INTESTINAL OBSTRUCTION. 921 .the patient had suffered from many previous attacks of colic, but iiad always been able to obtain relief by lying in one si>ecial position. If the case is left to itself peritonitis is invariable ; the distention becomes immense; the serous coat gives way ; and gangrene ensues, unless the patient dies first from asphyxia or collapse. In the very early stages it is possible that, if the coil is exposed through an abdominal wound, it may be untwisted and gradually emptied ; but if there is much distention, and the walls are thickened and congested, either this cannot be done, or, if it is accomplished, the bowel at once resumes its former position. In such a case the coil of intestine must be laid open and secured to the wall of the abdomen, so that it may empty itself thoroughly. Possibly after this has been done the circulation will recover, and the passage from above be restored ; if not, an artificial anus must be formed. If the patient recovers, the greatest care must be taken not to allow the bowels to become confined or the colon loaded. 3. Acute intussusception differs from the other forms of intestinal strangulation in the fact that a certain proportion of cases recover spontaneously, the bowel either releasing itself or becoming gangrenous and sloughing off. How often the former of these occurs it is impossible to say ; probably it takes place in many of the cases of severe intestinal colic, in which opium gives such complete relief, but there is no means of proving it. The latter, as Treves has pointed out, is too exceptional an occurrence, especially in the young, to deserve any reliance ; and it is probable that it is much more rare than statistics show. Besides, even when it does happen, over forty per cent, of the patients die from effects directly con- nected with the process ; the separation is premature ; or the ulceration continues and leads to perforation ; or hemorrhage occurs ; or the patient dies from prolonged exhaustion ; stricture, sufficient to cause symptoms of obstruction, apparently is not proved. In these cases opium is invaluable. In other forms of acute intestinal stran- gulation it relieves the collapse and places the patient in a more favorable condition for further treatment ; but in acute intussusception it does much more : it stops the violent peristalsis ; prevents the invagination increasing; diminishes the risk of congestion and strangulation ; and occasionally relieves the spasm so completely that the symptoms subside of themselves and the bowel quietly regains its place. Unfortunately this result is only occasional, and great care must be taken that the symptoms are not merely concealed without the cause being removed. Unless every sign disappears and relief is complete, no reliance can be placed upon it. Enemata are often successful in the early stages, especially when the large intestine only is concerned, and when the symptoms point rather to incarceration than strangulation. When the tumor is to be felt on the right side, or even in the middle line, the chances are much less; and if inflammation has set in and caused the formation of adhesions, or if the intussuscepted part has become thickened from long-standing congestion, success is out of the question : the bowel will give way sooner than unfold. They should not be tried ii" collapse and prostration are prominent features. Insufflation with air has been recommended on the ground that the bowel is not so likely to be ruptured ; on the other hand, water has succeeded (Waren Tay) after air has been tried and failed. Moreover, the quantity used can be measured more easily. The position of the patient is not material so long as the knees are well flexed; there is no advantage, that is to say, in inversion. An anaesthetic is generally advisable ; in one case under my care reduction was effected easily when the muscles became relaxed, although the same injection had failed before. Siphon action is preferable to a syringe, the flow is uniform and the pressure can be gradually increased to any required extent. It is essential that the fluid should enter very slowly and quietly, so that the bowel may have time to unfold itself, and it should not be allowed to escape again too soon. Regurgitation may be entirely prevented by means of Lund's insufflator, the ring of which stretches the margins of the anus and effectually blocks it. Gently kneading the abdomen at the same time, drawing the bowel down toward the anus from below the intussusception, is 59 92 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. sometimes of assistance when the walls of the abdomen are thin and flaccid, as in. a child, and when the swelling can be distinctly felt. By itself it is probably of little value. How much fluid should be used varies necessarily with every case, and no guide can be laid down. When reduction is successful the tumor can be felt to slipaway suddenly from under the hand, sometimes, but not often, with a gurgling noise ; the abdomen becomes evenly and slowly distended, and the severity of the symptoms disappears at once ; but of these signs the last is the only one upon which any reliance can be placed. The intussusception ma\- apparently be reduced, but in reality be only concealed by the distention of the rest ; or the apex may remain caught, owing to the way in which it is swollen ; or the bowel itself may give way, and the contents suddenly discharge themselves into the peritoneal cavity. If enemata fail, or if the intussusception persistently returns, the choice lies between leaving the bowel to itself while the patient is kept under the influence of opium, or performing laparotomy at once. The duration of these cases varies very much : acute ones, esjjecially in young infants and in the small intestine, may prove fatal within forty-eight hours; the majority last from four to seven days ; some survive for longer periods still. The chances of spontaneous recovery, however, are exceedingly slight : in infants, according to Treves, elimination occurs in only 2 percent. ; and, between the ages of two and five, in no more than six ; and even when this does take place the result is fatal in the majority Between eleven and twenty years of age, on the other hand, the results of the expectant method are more successful ; the deaths after spontaneous separation are only twenty-eight per cent. ; but after that time, again, the chance of recovery becomes more remote. Clearly, therefore, so far as infants are concerned, spontaneous recovery is very doubtful ; and though the prospect may be better in youth and young adult life, it must be remembered that elimina- tion, to commence with, does not occur in more than half. There are no statistics showing the results of early laparotomy ; in acute intus- susception, if enemata fail, it should be done at once, within twenty-four hours, in the same way that herniotomy is done at once if taxis fails ; it is of no use wait- ing until collapse or peritonitis has set in, or the patient's strength is exhausted ; and the chances of an acute case becoming chronic, or, if it does become chronic, of the patient's surviving, are much too remote to deserve the least reliance. The operation must be performed in the same way and with the same precau- tions as laparotomy for intestinal strangulation, the incision being in the middle line. When the intussusception is exposed an attempt must be made to draw down the sheathing layer from off it, using the utmost gentleness for fear of tearing the bowel, which is often much softened already ; it is of no use, in most instances, trying to draw the intussusception out. Sometimes this succeeds at once ; but, even after three days, it may be impossible, either from adhesions, from swelling and congestion of the invaginated part, from the way in which it is twisted and curved inside the other, or from the presence of a polypus. In such a case, or if the bowel is torn or gangrenous, the only choice left is primary resection, suturing the ends together; short-circuiting the intestine by means of Senn's approximation plates ; or forming an artificial anus, leaving the intussuscepted part to take care of itself. The first, no doubt, is the ideal one, but in most cases that proceeding is advisable which can be accomplished most quickly and with the least disturbance. Chronic Intestinal Obstruction. The onset gradual and the symptoms due not so much to the reflex action of the nervous system as to the i)rogre.ssive narrowing of one portion of the bowel. In many instances the final attack has been ])receded by slighter ones. At first they attract but little attention : the narrowed part is blocked by some undi- gested food or faecal mass which soon gives way ; constipation and colic last for a time, and then there is a certain amount of diarrh(jea. Later, as the constriction CHRONIC INTESTINAL OBSTRUCTION. 923 grows tighter, these attacks become more frecjiient and last longer ; and, at length, in one of them the closure is final, and the oI)striiction complete. The pain is intermittent at the first, with long pauses between. As the passage becomes narrower the paroxysms grow more severe and the intervals shorter, until at last there is a continuous griping all over the abdomen, with every now and then violent storms of colic. There is no collapse until near the end. It is due to peri- tonitis or exhaustion, not to the injury inflicted upon the bowel. Vomiting, in the same way, is caused by the accumulation of food, or the action of purgatives, and may not appear for weeks ; the time when it does occur depends chiefly upon the distance of the obstruction from the pylorus. Constipation is absolute, although the rectum may be emptied. Meteorism is very marked, especially if the obstruc- tion is low down ; the walls of the abdomen gradually become thin and stretch before the increasing pressure, and the coils of intestine, enlarged and hypertrophied from the increased amount of work, are visible in many cases, on the surface of the abdomen, especially (.luring the attacks of colic. In spite of this difference it is impossible, in many cases, to draw a definite line between obstruction and strangulation. Sometimes, as in impacted gall-stones, the first closure is final and the symptoms intensely acute ; or in true intestinal strangulation, slight attacks of a similar character have occurred previously and been mistaken for colic ; or, again, intestinal strangulation suddenly happens to a patient who is already suffering from chronic constipation. The distinction that is wanted is a clinical one ; the pathological data are fairly clear, but as yet it does not seem possible to place them in definite association with the symptoms. Causes. — (i) Narrowing of the lumen of the bowel, whether due to stricture, compression from the outside, or to looping, bending or twisting of the bowel itself. (2) Loss of muscular power and accumulation of faeces. (3) Chronic intussusception. I. Of these by far the most common \^ stricture, originating in the mucous or submucous layers of the bowel, and caused usually by cicatricial tissue or by carcinoma. Simple stricture is occasionally met with in the small intestine, and then it may be multiple; in the large, in which it is nearly always single, it is infinitely more common. Upward of one-half occur in the region of the sigmoid flexure ; from this they graclually become more rare as the caecum is reached, although stricture of the hepatic flexure is slightly more common than that of the transverse colon. In the small intestine it is most frequent toward the lower end ; occasion- ally it involves the ileo-csecal valve. In most cases the cause of the ulceration has disappeared ; there is nothing either in the shape or character of the cicatrix to lead to any conclusion. Of the rest a large proportion is due either to dysentery or tubercle. The former leaves behind it exceedingly irregular cicatrices, very often involving a large extent of bowel, and so hard and dense, and associated Avith so much contraction that, accord- ing to Treves, not improbably some of the cases of reputed scirrhus are really due to this. The latter is more common in the ileum, where it may either spread in a longitudinal direction producing little effect, or around the bowel transversely, in which case, if it cicatrizes, it leaves an annular stricture, rarely very tight. Ulceration following catarrh, or due to the irritation of long-retained faeces (ster- coral), is not uncommon in the large intestine, especially in the c;^cum. Syphilis, in all probability, accounts for a few ; and stricture is said to have been caused by the peptic ulcers that are occasionally found in the first part of the duodenum, and even by those that occur in typhoid fever. Stricture of the small intestine sometimes follows blows and severe contusions of the wall of the abdomen, and may occur after the reduction of strangulated hernia, owing to the injury sustained by the mucous membrane. Malignant stricture may be either primary or secondary ; the former is prob- ably always due to columnar epithelioma; the latter naturally depends upon the character of the original growth. 924 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Columnar ei)ithelioma generally occurs as an annular constriction, the growth following the course of the vessels ; much more rarely in the form of nodules or flattened plaques. The stricture is always short and narrow ; from the outside it seems almost as if a piece of string had been tied around the gut. The peritoneum is usually thickened and sometimes is adherent ; the rest of the structures disap- l)ear ; there is merely an irregular ulcer extending transversely around the interior of the l)Owel. with its base and sides hardened and infiltrated by the new deposit. Very often the diameter is so small that it scarcely admits a goose-quill. Non-malignant tumors oi\k\t^ bowels, adenomata, fibromata, and fibro-myomata, have a tendency to assume a polypoid shape, and may lead to intu.ssusception, but they rarely of themselves obstruct the interior. Lympho-sarcoma sometimes causes immense thickening of the wall, but seldom gives rise to any symptoms. Compression. — The rectum, the sigmoid flexure, and the lower part of the ileum (especially those coils which hang down into the cavity of the pelvis) may be compressed by tumors growing from the walls of the abdomen or connected X, Fig. 398. — MaUgnant Disease of Large Intestine. Fig. 399.— Annular Stricture due to Epithelioma. with the other viscera. In some cases the symptoms are acute ; in twelve out of twentv-two collected by Treves the patient died before the ninth day (in one on the second) : the bowel was suddenly caught in some way, or bent upon itself, and though the pain and collapse were scarcely so marked or .so severe as in strangulation by bands, the points of difference were not sufficient to make the diagnosis certain. In the others the course was chronic, sometimes resembling that of stricture with intermittent colic, sometimes presenting nothing but increas- ing constipation. In most cases this compression is affected by a tumor growing from the pelvis, or connected with the ])elvic organs, the retroverted uterus, for example, and uter- rine or ovarian tumors : but it has been caused by vesical calculus, al^scesses con- nected with the bones or the viscera, extra-uterine foitation, tumors of the kidney or pancreas, floating kidney, hydatid cysts, and even by an enlarged and displaced spleen. Compression may also be caused by peritoneal adhesions, especially at the hepatic and splenic flexures of the colon. In some cases the peritonitis may be CHRONIC INTESTINAL OBSTRUCTION. 925 due to fcecal accimiulatioii ; in others it s])reads from the liver, gall-bladder, or other neighboring structures; in others, again, it follows ulceration of the mucous membrane, and the cicatricial stricture inside the bowel is made worse by the peritoneal thickening around it. Whatever may be the cause, the l)owel becomes narrowed ; the walls become hard and dense, and a stricture is formed which can- not be distinguished by any of its symj)toms from that which is due to dysentery or malignant disease. Matting together of the intestine after operations for strangulated hernia, or ovarian tumors, pelvic or tubercular peritonitis, bending of the bowel, forming a valve in the interior, or limited adhesions imj^eding the peristaltic action of one segment, may all, according to Treves, give rise to the symptoms of chronic ob- struction. Volvulus is nearly always acute ; in one or two of the cases, however, in which the caecum has been concerned, it has lasted some length of time, and the symptoms have resembled those of obstruction rather than strangulation. Obstruction by gall-stones and foreign bodies resembles compression of the bowel in this, that while many of the cases are exceedingly acute others are chronic, the masses lying latent for years, and then, perhaps, causing symptoms of slow obstruction. Gall-stones find their way in by gradual ulceration, so that sometimes there is a history of previous peritonitis. Foreign bodies for the most part consist of materials swallowed in small quantities from time to time and worked up into solid masses- with mucous or vegetable fibre. Pins, cherry-stones, cocanut-fibre, yarn, and many other substances have been met with on various oc- casions, rolled up into enormous masses. Concretions, composed of carbonate of magnesia (taken as medicine), phosphate of lime and magnesia, and other indigestible substances mixed together are more rare, but occasionally attain an enormous size. 2. Loss of Power in the Muscular Fibre of the Intestine and Accumulation of Fceces. — This rarely happens in the small intestine, but is not uncommon in the large, especially in the caecum, transverse colon, and sigmoid flexure. The causes are very various — want of exercise, hysteria, chronic catarrh of the mucous mem- brane, hereditary influence, in short, anything that tends to impair the activity of the peristalsis. As a result the faeces collect and become hard and solid, the bowel below contracts, that above becomes distended ; at length, the muscular fibres, al- ready too weak for their work, are stretched until they are not able to contract at all, and the passage is completely obstructed {ileus paralyticus). In many of the cases, as mentioned already, chronic peritonitis sets in and increases the difiiculty by the thickening of the serous coat that it causes; in others ulceration of the mucous membrane occurs in the bowel above, and even if the obstruction is re- moved in time to prevent perforation, the subsequent cicatrization may lead to the formation of a true stricture. 3. Chronic intussusception is a term applied somewhat arbitrarily to cases that have lasted longer than a month. It is classed with chronic obstruction more as a matter of convenience than because of the symptoms, for these are of the most indefinite and irregular character. Pathological Effects. — The consequences of obstruction are, speaking gen- erally, the same as those that occur elsewhere in the body under similar conditions — dilatation and hypertrophy ; but, from anatomical reasons, and because of the nature of the contents, they differ considerably in their importance. Where the difificulty has arisen slowly, the coils of bowel, especially in the case of the small intestine, sometimes become of immense thickness, so that during the attacks of colic, when they are seen through the abdominal wall, they may be mistaken for the transverse colon. The distention is greatest immediately above the obstruction ; the splenic flexure, for example, may be as large as the stomach, and the sigmoid one may stretch right over the other side of the abdomen ; the mucous membrane becomes exceedingly thin ; stercoral ulcers make their appear- ance, and sometimes, partly from the compression of the blood-vessels, partly from the irritation of the retained faeces, extensive tracts become gangrenous. In the 926 DISEASES AND INJURIES OF SPECIAL STRUCTURES. case of the large intestine the ulceration is most marked immediately above the obstruction, and in the c?ecum, where, if the ileo-caecal valve is competent, the ])ressure is greatest, the intermediate portions may be quite intact, or the whole surface may be more or less involved. Perforation is not uncommon, leading to i'ajcal extravasation and general peritonitis ; in some exceptional cases the extra- l)eritoneal portion of the bowel gives way, or adhesions form between two neigh- l)oring coils, so that a fistula is established and this result avoided. Causes of Death. — Death may ensue in various ways in the course of chronic intestinal obstruction. Perforation, for examjjle, may take jjlace suddenly, and lead to faecal extravasation ; the stricture may become blocked by a mass ot faeces, or some foreign body, or it may be covered in by a fold of mucous mem- brane ; volvulus or acute bending may occur \ or the bowel above may gradually become so dilated that the pressure alone is sufficient to close the opening, and the symptoms suddenly, from one hour to another, become acute, resembling, but rarely quite so severe as. those of strangulation. In other cases, especially where there is malignant disease, the stricture gradually grows so narrow that at last the patient dies, worn out and emaciated by the long-continued trouble. Very narrow strictures may exist for a long time in the small intestines without causing any symptoms, owing to the liquid character of the contents, and occasionally, but much more rarely, when there is persistent diarrhcea, this happens in the large. Symptoms. — i. In stricture, peritoneal adhesions, and compression, the symptoms, so far as the obstruction is concerned, are essentially the same ; the differential diagnosis is often impossible, except from the history and age of the patient, from the ])resence of a tumor or some other additional evidence, and the locality is in many cases equally uncertain. Co/ic, constipation, and distention of the abdomen are generally present. In a typical case the attacks at first are intermittent, with intervals of comparative comfort ; but as the constriction becomes narrower, they grow more and more frequent until at length, when the obstruction is complete, they never really cease, although they are worse every now and then. Sometimes they occur suddenly in patients who are perfectly well to all appearance ; more often they are preceded by dyspepsia, diarrh(jea or constipation. In a few rare cases there is only one, the bowel becomes kinked, or the narrowed portion is blocked for the first and last time, and the symptoms are those of strangulation. In most cases the onset is insidious, and the first attacks slight, merely regarded as indigestion ; only as the case progresses do they become definitely associated with vomiting and consti- pation. Pain. — As a rule nothing can be gathered from the locality of the pain ; as often as not it is referred at first to the umbilicus, but it soon becomes general, and it rarely happens that the patient is able to describe it as beginning and ending at any definite spot. It is due to violent peristalsis, and is always griping, even when it is continuous ; the coils, which are nearly always visible through the wall of the abdomen, working over and over each other. Food, enemata, and even digital examination of the rectum, may bring on an attack. Sometimes toward the end it becomes less severe, probably from the muscular and nervous mechanism of the bowel becoming exhausted. The pain is generally more acute when the seat of obstruction is in the small intestine ; in this case it is often traceable to the food, coming on at regular inter- vals after meals, and it may be relieved by aperients, which when the colon is con- cerned merely aggravate it. Constipation is the rule. During the attacks of colic it is always present, and as they pass off is often followed by diarrhoea. In the small intestine, where the contents are liquid, it may not ai^pear until comparatively late ; and until the con- striction is very tight, it may generally be relieved by aperients. . When the colon or the sigmoid flexure, on the other hand, is involved, there may be a certain amount of spurious diarrhoea for a time, similar to that which is often present in faecal accumulation, kept up by the irritation of the mucous membrane ; but always CHRONIC INTESTINAL OBSTRUCTION. 927 at length the ol)struction becomes complete, and sometimes no motion is passed for weeks before death. A single copious motion after prolonged obstruction is, according to Treves, often significant of perforation. Metcorism. — The distention of the abdomen dejicnds upon tiie seat of obstruc- tion and the amount of diarrhuia ; when the constriction is high up it may be altogether wanting, except, perhaps, during the attacks of colic, and in some cases there is retraction instead, owing to the emaciation. On the other hand, in stricture of the sigmoid flexure, the enlargement may be immense, the diaphragm being pushed up into the thorax, displacing the heart, and seriously impeding respiration. During the attacks of colic, and if peritonitis sets in, the walls become tense and tender ; at other times they are soft, so' that when the coils of bowel are distended with fasces and flatus they may be felt as well as seen through them. Vomiting, unless the obstruction suddenly becomes acute, is not a prominent symptom. Its occurrence and severity depend upon the seat of obstruction and the amount of food ; when the stricture is near the pylorus it rarely fails to make its appearance early in the attacks of colic, and may be very profuse; when it is in the large intestine and the food is carefully selected, it may not occur for weeks, and it rarely becomes faical until complete obstruction has lasted for some time. Other symi)toms, which may be of help in diagnosis, are occasionally present. Tenesmus only occurs in stricture of the large intestine, and is rare even then. In carcinoma of the sigmoid flexure there is not unfrequently a thin blood-stained discharge from the anus, especially in the intervals between the attacks of obstruc- tion. Sometimes a tumor can be felt, Qxther per rectum or through the abdominal wall, but rarely when the small intestine is concerned. Masses of faeces can occa- sionally be felt in the caecum or the transverse colon, and this may be stretched and displaced so far as to reach the symphysis. The outline of the colon may be seen, or there maybe dullne.ss or percu.ssion along some part of its course — in one flank, for example, and not in the other — and in some few cases valuable infor- mation may be obtained by means of eneraata, or by the introduction of the hand into the rectum. 2. Obstruction due to /cecal accumulation rarely occurs until comparatively late in adult life, and is more common in women than in men. Not unfrequently it is associated with hysteria or hypochondriasis, and nearly always there is a history of chronic constipation for years past ; the bowels have only acted at long inter- vals and after aperients or enemata, and the motions have become copious and exceedingly hard. In other cases the patient complains of persistent diarrhoea with thin watery stools ; the mucous membrane of the bowel is irritated by hard scybalous masses, and the secretion mixed with the liquid portion of the faeces is constantly flowing down into the rectum. The symptoms are essentially the same as those of stricture of the large intes- tine, only they are as a rule more chronic ; in rare instances there is a sudden acute attack with prostration and vomiting, probably due to the bowel becoming bent or twisted upon itself in some way, or to atony of the muscular wall. The patient is a martyr to dyspepsia ; the tongue is foul ; the appetite poor ; the breath exceedingly offensive, and there are constant attacks of flatulence with dis- tention and severe griping pain and nausea. The abdomen is large and resistant; faecal masses may often be felt through its walls, sometimes in the c^cum, lying in the right iliac fossa, more often in the transverse colon or the sigmoid flexure. Tumors of considerable size are occasionally formed in this way, but their nature may almost always be made out from their mobility, variable shape, and doughy consistence. The diaphragm is pushed up, causing palpitation and interfering with respiration ; the portal circulation is obstructed so that hemorrhoids result ; sometimes the uterine, spermatic, or iliac veins are affected as well ; and the patient loses flesh and strength and not unfrequently becomes hypochondriacal. In many instances this condition persists for years, relieved from time to time with aperi- ents and enemata, but there is always the danger that sooner or later the muscular 928 DISEASES AND INJURIES OF SPECIAL STRUCTURES. power of the bowel may fail, or the distention above increase, until at length ulceration and perforation occur. 3. Chronic intussusception is exceedingly variable in its course. It is rare in children, and is nearly confined to the large intestine. The onset is usually sud- den ; in most instances a tumor can be felt through the abdominal wall, ox per rectum, and the coils of small intestine can often be seen, especially during the attacks of colic. Vomiting may occur, but it is not urgent like that of strangula- tion ; tenesmus and a discharge of l)lood-stained mucus are rarely absent ; some- times there is constipation, but more freciuentlya kind of spurious diarrh(ca. The pain is seldom severe^ except during the attacks of colic, when all the symptoms become intensified. This condition has been known to continue with fluctuations for months; as a rule, after it has lasted some length of time, either the bowel becomes strangulated or the patient becomes exhausted from the prolonged suf- fering and want of food, grows thinner and thinner, and succumbs at last rather suddenly. Diagnosis. — The diagnosis of intestinal obstruction is always a matter of the greatest difficulty, and in most instances the examination of the abdomen has to be repeated time after time, during the attacks of colic as well as during the intervals, with an anaesthetic as well as without, before a definite opinion can be given. 1. The Previous History of the Patient. — In stricture and faecal obstruction there is generally a record of previous slight attacks of a similar character, yield- ing at first easily to remedies and gradually becoming more severe ; constipation has often continued for a time, and then given way to diarrhoea ; and the patient has been distressed, and the action of the bowels and the digestion disordered, for some considerable period. Scybalous masses passed from time to time, and habitual constipation for years before, point rather to the latter, though it must not be forgotten that this may be merely a complication ; a blood-stained discharge from the anus is suggestive either of malignant stricture low down or of chronic intussusception. Antecedent attacks of local peritonitis or typhlitis ; strangulation of a hernia some months before ; injuries to or operations on the abdomen ; hepatic colic, dysentery, gastric ulcer, or any other intestinal trouble ; or the history of an abdominal tumor, may be of very great significance. Rapid wasting, without suffi- cient apparent cau.se, is suggestive either of tuberculosis or of malignant disease ; but a certain degree of emaciation is always present in chronic obstructions, and if the case lasted any time it may be very distinct. 2 . The Mode of Onset of the Present Attack and the Order of Appearance and Severity of each of the Symptoms. — If it commences suddenly and the vomiting and prostration are serious from the first, it must be regarded as a case of intestinal strangulation. Pathologically the actual cause may be a gall-stone or some other obstructing agent; the symptoms are those of strangulation and must be met in the same way before it is too late. If it is gradual, each symptom mu.st be taken in order. First the pain, whether it is gri[)ing, as in colic, and whether the i)aroxysms are becoming more frequent, showing that the obstruction is growing tighter. If it occurs a short time after taking food and is relieved by aperients it is probably due to stricture of the small intestine ; if it is continuous, the obstruction is com])lete ; if it is made worse by digital examination of the rectum or by enemata, it is most likely in the large intestine ; and if it is distinctly localized, or if it always ends at one spot, it may point to the seat of obstruction, but this is exceptional. The state of the bowels is of equal importance ; constipation may be complete, both as regards faeces and flatus ; or there may be a certain amount of diarrhcea, as in faecal accumulation ; and blood and mucus may be passed at fre(]uent intervals with tenesmus, as in chronic intussusception. Vomiting is rarely of much help; unle.ss the attack is acute, so that it is excited by the injuries to the nerves of the bowel, it does not come on until late, and it depends chiefly upon the amount and kind CHRONIC INTESTINAL OBSTRUCTION. 929 ^{ food. Stricture of the small intestine high up is an exception, as in this vomit- ing is one of the earliest symi)toms.' It seldom becomes stercoraceous until the obstruction is of some standing. The amount of urine may be diminished, but this as a rule depends ui)on the small (piantity of fluid taken, not, as in strangula- tion, upon the presence of collapse. 3. Physical Examination. — Inspection. — 'I'he attitude of the patient is generally such as to relieve the abdominal muscles as much as possible. The abdomen may be immensely and unevenly distended or retracted, according to the seat of obstruction and the degree of emaciation. The walls are always thin, sometimes tense and stretched, and in nearly every case the coils of intestine can be seen working through them, es|)ecially during the paroxysms of colic. Respiration is usually shallow and thoracic. There may be hiccough, especially in advanced cases, and under the same circumstances, when collapse is approaching, there may be vomiting without effort, coming up in gushes, as in strangulation. Everything that is brought up or that is passed/^/- anuni must be carefully examined. Palpation. — The first thing is to exclude all forms of hernia: every aperture through which one could take place must be carefully examined. Then the state of the walls and the presence of any tenderness must be noted. During the attacks of colic the muscles become rigid and the skin is very tender to the touch ; in the intervals this disappears to a great extent unless there is some inflammation, such as perityphlitis or peritonitis, or a tumor of rapid formation, as in intussusception. Finally, if the condition of the abdomen and of the patient allows it, the surface must be gently kneaded to ascertain if there is any sense of resistance in one part more than in another, or if any sign of a tumor can be found. Faecal masses are usually nodular in shape, moderately hard and uneven ; generally speaking they are movable, but this depends, of course, upon the portion of intestine in which they are contained ; sometimes the transverse colon reaches down as low as the pubic symphysis, and the masses can be pushed up nearly to the ensiform cartilage. Examination of the patient in various positions — the knee and elbow, for example, — is often of service in diagnosis. Percussion, although digital examination of the rectum should be regarded as part of palpation, follows next. It is rarely of much service, although one flank or one iliac fossa is occasionally much less resonant than the other. Examination of the rectum should never be omitted ; in young subjects in whom the perineum is soft and yielding the anus should be pushed so far in, especially under an anaesthetic, that the finger can touch the promontory of the sacrum, and faecal masses, stricture of the rectum, intussuscei)tion, and other conditions diagnosed. In the case of adults a moderately small hand can be introduced. I have on several occasions diagnosed new growths al)ove the reach of the finger, and in one instance a mass of scybala in a loop of intestine ; but probably the chief use of this method is as an aid to the long enema tube. By itself this is almost worthless for diagnosis ; but if it is guided in over the hand, so that it can be freed from the folds of the bowel, and its entrance into the sig- moid flexure assured, it can be passed without difficulty into the descending colon, beyond the point at which the bowel can be exposed in the loin. The rectum and the lower part of the large intestine vary to such an extent in size that the amount of fluid which can be introduced gives no idea. If, however, the long tube is passed, the position of the end of it in the bowel can be made out with tolerable accuracy by means of auscultation. There is no means of diagnosing cancerous stricture of the small or large intestine from chronic obstruction due to cicatrices, peritoneal adhesions, or com- pression. Carcinoma may occur in the intestine at twenty years of age, though it is much more common later in life, and the symptoms are practically the same ; the emaciation is a little more rapid, diarrhoea is rather more common, especially at the beginning of the case, and in epithelioma of the large intestine a discharge of blood and mucus may occur; but there is nothing more definite on which a 930 DISEASES AND INJURIES OF SPECIAL STRUCTURES. cliai,niosis can be based. The prognosis in cancerous stricture is rather longer than in the cicatricial form, so far as life is concerned, probably because, as Treves has pointed out, obstruction does not make its appearance so early. Treatment. — i. Chronic Obstmction due to Stricture, Peritoneal Adhesions, Volvulus of the Cctcuin, Compression, etc. — So long as the closure is incomplete, relief may be obtained for a time by dieting and by laxatives and enemata. Vigorous purgatives do more harm than good by disturbing the orderly action of the intestine and hurrying down a mass of semi-digested material on to the face of the stricture. The object is to nourish the patient as well as possible without increasing the amount of indigestible material or rendering the fceces hard. In the small intestine this is tolerably easy for a time, and partly by restricting the diet to small quantities of liquid food given at long intervals, partly by nutrient ene- mata, the strength may be maintained for a considerable period, especially if it is economized by warmth and avoidance of exertion. When the large intestine is involved, this is not so easy, but a great deal may be done at first by means of enemata of hot water with some alkali to soften the fceces and stimulate the walls of the bowel. Not unfrecpiently a stricture that has been impermeable by the impaction of a mass of foeces in its orifice, may be entered without difficulty from below, and the intruding substance displaced, and perhaps softened sufficiently to relieve the obstruction for the time. Opium is invaluable for the relief of pain, as in acute cases, and prevents to a certain extent the severity of collapse, but it has little or no influence on any of the causes of obstruction mentioned above, and obscures the symptoms to such an extent that, when it has been given, full allowance must be made for it. If the obstruction is complete, or if, in spite of all precautions, the abdomen is becoming more distended, and the attacks of colic more frequent and more severe, it is of no use delaying further; if any operation is required, it should be done before the patient is exhausted. {a) Where the Seat of Obstruction can be Diagnosed. — If it is in the small intestine, the abdomen must be opened in the middle line, and the cause dealt with, according to its nature and the condition of the patient. In some cases, relief may be obtained by dividing adhesions and so releasing the bowel, but in the majority the choice lies between enterostomy, short-circuiting with Senn's plates, and resection. Of these, the former is more simple, and, if a large extent of bowel is involved, is the only one admissible: but it can, of course, only be regarded as a palliative, and is useless, unless the seat of obstruction is low down in the ileum. Resection alone can give permanent relief, and the condition of the bowel and the strength of the patient must decide whether it should be per- formed at once or postponed until an artificial anus has been formed. The rule is the same in the case of the large intestine ; if the seat of obstruc- tion is known, the bowel should be opened at the most convenient spot above ; or, if it is a malignant stricture, an attempt may be made to excise it, and either form an artificial anus, or suture the two ends together, according to circumstances. Compression by external tumors is an exception ; in these cases, special treatment is required. (J)) Where an Exact Diagnosis Cannot be Made. — If the situation is entirely unknown, median lajjarotomy must be performed as an exploratory measure, and the obstruction dealt with according to what is found. The colon or ctecum may be opened and stitched to the skin, or the wound closed and colotomy performed later on. When, however, the balance of evidence points distinctly to the large intestine, without the exact site being indicated, the colon should be opened in the right loin or in the right iliac region. If the bowel is found not to be distended, temporary relief may be obtained by opening the nearest and most prominent loop of small intestine. 2. Fcecal Accumulation, 7iiith Loss of Power of the Wall of the Intestine— Unless acute symptoms, such as vomiting and prostration, indicative of ileus, set PERITYPHLITIS. 931 in, this should be treated with laxatives and eneniata. Lumbar colotomy must be regarded, according to Treves, rather as a surgical misfortune than as a recog- nized method of treatment. A siphon apparatus is better than a syringe, as the pressure is more uniform. The patient should be placed so that the abdominal muscles are relaxed as far as possible, and warm water, with soap or oil, allowed to flow in gently until by degrees the whole of the colon has been washed out. It may be cleared thoroughly aslilir as the coicum ; there is no fear during life of any quantity of fluid passing beyond. A little turpentine may be used, if a more stimulating injection is re- quired.* Massage, kneading the abdomen in the course of the colon, and elec- tricity are sometimes of benefit in these cases. The faradic current is used, and one pole is placed on the abdomen or the dorsal spine ; the other, properly insu- lated, in the rectum. 3. Chronic Intussusception. — Here, as in the acute form, opium should be given at once to check the increase of the invagination, and to delay the onset of strangulation and inflammation. Then an attempt must be made to reduce the bowel by means of enemata given with great care, and combined with massage under an anesthetic. Reduction has taken place even at the end of a month, but, as Treves has shown, adhesions, as a rule, very soon make their appearance in cases that are left to themselves. If enemata fail, the only course left is laparotomy, and, if reduction cannot be eff'ected then, either resection, short-circuiting, or the formation of an artificial anus. SECTION v.— PERITYPHLITIS; PERITONITIS. Perityphlitis. Inflammation of the ceecum and appendix is common in young adults, espe- cially males. It may be simple or suppurative. The former merely leads to thickening and condensation of the tissues around ; the latter ends either in a perityphlitic abscess, or in general peritonitis. Suppuration may begin outside the bowel, in the inflammatory exudation (forming sometimes a secondary com- munication with the intestine) ; but, probably, in most cases, it is the result of perforation (nearly always of the appendix), especially when its onset is instanta- neous, without any warning. Causes. — The simple form, like colitis, usually arises from the accumulation of scybala, and remains limited to the mucous surface. Occasionally, the inflam- mation is more severe, involving the whole thickness of the wall, and then the serous covering becomes affected. The perforative form may be due to ulceration (the stercoral ulcers of old intestinal obstruction, or those resulting from tubercle, syphilis, or dysentery, for example) ; to the presence of foreign bodies, such as fish bones ; or to the appen- dix becoming blocked. When this occurs, whether it is due to cherry stones, dried feeces, the presence of adhesions, or any other cause, the secretion accumu- lates, the tension grows higher and higher, inflammation sets in, and, unless the obstruction gives way, ulceration follows, and ends in perforation. * Hutchinson's description of massage of the abdomen, in cases of intestinal obstruction, is as follows : " The first point in abdominal taxis is the full use of an ansesthetic, so as to obliterate all muscular resistance. Next (the rectum and bladder being supposed to be empty), the surgeon wdl forcibly and repeatedly knead the abdomen, pressing its contents vigorously upward, downward, and from side to side. The patient is now to be turned on to his abdomen, and in this position held up by four strong men, and shaken backward and forward. This done, the trunk is to be held, feet upper- most, and shaking again pmcticed directly upward and downward. WhiKt in this position, copious enemata are to "be given. The whole proceedings are to be carried out in a bond fide manner. Half an hour or more is to be spent in the process." 932 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Cases in which the appendix is blocked and the obstruction yields from time to time without actual perforation taking place, are sometimes distinguished as relapsing typhlitis. {a) Simple Perityphlitis. — This usually occurs in young adults who are sub- ject to chronic constipation. They may even have pas.sed scybalous masses or have suffered from attacks of diarrhtea (colitis) e.xcited by them. It commences quietly wMthout a rigor, and generally with little fever. Almost from the first there is a hard, doughy tumor in the groin. The abdominal muscles are rigid and tense, and jjressure causes such ])ain that it is rarely possible to make out the outline without an anoesthetic. Vomiting is not severe or continuous, and examination /) Organic irritants may be either specific or non-specific. The tubercle bacillus is by far the best known example of the former, and tubercular peritonitis will be dealt with separately. Syphilitic peritonitis rarely occurs, except as a result of extension from neighboring organs, such as the liver, and presents no special features. The non-specific organisms may be pyogenic or not. Of these the latter are not capable of causing peritonitis so long as the surface of the membrane is unin- jured ; if, for example, putrid fluid, containing only the organisms of putrefaction, is injected into the uninjured peritoneal cavity, death will ensue from septicaemia if the quantity is large enough, but if it is small the whole may disappear without exciting any local irritation. The constitutional effect dei^ends entirely upon the dose, and it is practically the same whether the fluid is injected into the blood- stream at once, or allowed to find its way in through the peritoneal cavity, and it follows nearly as quickly in the one case as in the other. Even the pyogenic organisms, according to Grawitz, can only cause peritonitis under special conditions: when, that is to say, the amount of fluid injected with them or poured out by the injured surface is so great that the germs are produced more rapidly than the tissues can deal with them ; or when the surface of the peri- toneum is injured and the subepithelioid layer exposed. In many instances the inflammation was found to have spread from the i)rick of the needle that had been used for the injection. Unhappily, these conditions are of common occurrence. Infected wounds, rupture of the viscera, perforation of the intestine, bursting of a hydatid cyst or of an abscess, and communication with a neighboring cavity, such as the Fallopian tube in a case of metritis, present in abundance everything that is required for the development of acute suppurative peritonitis. There is a sufficient amount of nutrient fluid for the growth of the germs, or if there is not it is poured out at once by the irritated peritoneum ; the epithelioid surface is injured over a wider or smaller area by the fluid that bathes it ; absorption is checked, and myriads of pyogenic organisms can make their way in from the intestine, through the wound, or even through the blood stream. (<:) Peritonitis due to extension from the parts around varies naturally with the primary cause ; as a rule it is protective in character, and leads to the formation of adhesions. Whether cold can be regarded as a cause is uncertain ; there can be no doubt, however, that it predisposes to it by lowering the vitality of the tissues and render- ing them more susceptible. Symptoms. — Clinically, peritonitis may be sthenic or asthenic in character. The latter occurs when the strength of the patient is overcome by septicaemia, typhoid fever, or Rright's disease. In the sthenic form the symptoms are very striking. They may be a succes- sion of chills or a rigor ; the temperature rises at once ; the pulse becomes peculi- arly hard and rapid, and the respiration hurried and very shallow. The abdomen may be retracted at first, but very soon it begins to swell over the affected spot, and, in a short time, the whole becomes tense and hard, the muscles are abso- lutely rigid, the diaphragm is pushed up as far as it can go, and the least touch causes the most fearful pain. The patient lies on the back with the knees drawn up ; the face becomes pinched and anxious, the eyes sunken, and the tongue dry and brown ; vomiting with hiccough is very common, and usually the fluid is poured up in gushes almost without effort. Constipation is almost invariable, PERITONITIS. 935 and the amount of urine secreted is very small. Toward the end the temperature may fall, and the i)atient sink into a state of collapse ; sometimes this occurs almost w ith the fust onset of the disease. In the asthenic form the constitutional symptoms are more i)rominent. The abdomen may or may not be distended, sometimes it moves with respiration ; pain is felt on j)ressure ; but there is not the intense tenderness characteristic of the sthenic variety. The pulse is very small and weak, the temperature subnormal, and the collapse profound from the first. Fost-mortetn there are no adhesions between the coils of intestine and no lymi)h on the serous surface, merely a small (luantity of a turbid, intensely poisonous li(juid. Treatment. — It used to be the rule in every abdominal operation to give opium in order to keep the intestines quiet and prevent peritonitis. Now it is rec- ognized that while ojjium is es.sential when the walls of the intestine have been in- jured, and is of great value in localizing inflammation, it can do nothing to pre- vent it; indeed, by assisting the distention of the intestine, and still further impairing the muscular tone of its wall, it may actually intensify the evil it is in- tended to check. For this reason, Wylie, Tait, Greig Smith, and others recommend a saline purge after abdominal operations if fluid is collecting in the pelvis, or if there is a rapidly increasing distention of the abdomen, with restlessness and vomit- ing. The tympanites is an additional cause of obstruction and vomiting; opium only encourages it ; a purge, on the other hand, followed by a turpentine or hot- water enema, will carry off immense quantities of gas and fluid, and relieve the congestion of the abdominal vessels. Afterward the beneficial effect may be con- tinued by the frequent use of the rectum tube. The vomiting that is consequent upon an anaesthetic may be checked by allowing the patient to suck one or two small fragments of ice (not more) ; if it continues, particularly if there are other signs of peritonitis and the straining is very severe, a cupful of hot water is much more serviceable, and occasionally the stomach may be washed out with advantage. If in spite of this the symptoms grow worse, or if it is clear from the first that it is a case of perforated peritonitis, the only hope lies in giving free exit to the l)oisonous fluid. It is true that the condition of the patient is almost desperate, and that shock is much more severe when the peritoneum is inflamed ; but if the serous cavity is unable to deal with the poison that bathes its surfaces, steps must be taken first to prevent any more entering, and then to get rid of that which is already there. Greig Smith recommends the injection among the intestines of boroglyceride solution, an ounce to the pint, at a temperature of 102° F. It should be slowly forced into the cavity among the intestines through a drainage tube, and compelled to remain there for a time by temporarily plugging the orifice ; and this may be repeated several times a day. Mikulicz distinguishes between diffuse peritonitis, due to a large amount of the contents of the intestine being poured suddenly into the cavity, and a progres- sive form which is localized at first. The former can only be treated by a free opening and washing out the cavity with hot salt and water, or hot boracic solu- tion, until it is thoroughly cleansed. The latter, on the other hand, may remain localized for a time, and if the situation of the successive foci can be made out, they may be opened and drained separately, taking great care not to disturb any of the adhesions. Thorough drainage of the peritoneal cavity is almost impossible, but the attempt has been tried by making numerous openings in the middle line and in the flanks, and by passing across as many as eight large perforated tubes through which a current of hot salt solution could be sent. When the suppuration is localized already, the prospect is much more hope- ful ; there are already many instances on record in which purulent collections, consequent on intestinal perforation, gonorrhceal inflammation, and other causes have been successfully drained. 936 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Tubercular Peritonitis. A large number of cases of encysted tubercular peritonitis have been relieved and not a few cured by free incision. PLven when the disease is part of a general tuberculosis a certain amount of benefit may be obtained without in any way has- tening its progress. In the earlier cases the diagnosis was not made until the cavity had been incised, and from the extreme difficulty of distinguishing between some of these forms of encysted ascites and ovarian and other cysts, the same mistake is not unlikely to occur again. In a fair projjortion of cases the diag- nosis has l)een verified by the microscopic examination of the miliary growths and the discovery of bacilli. Primary peritoneal tuberculosis (the class of disease for which oj^eration is most suitable), is probably not common ; nearly always it is secondary, but as there is evidence to show that the partial removal of tubercular foci in other parts of the body is sometimes beneficial, the patient appearing to make better headway against the rest, and as considerable relief may not unreasonably be expected to follow the removal of a mass of this character from the abdominal cavity, opera- tion is not negatived by this, provided the disease is not too far advanced. Whether anything more than simple drainage is advisable is uncertain ; probably it would depend to a large extent upon the size of the cavity and the character of its walls. SECTION VI.— OPERATIONS UPON THE INTESTINES. Enterostomy. This is sometimes known as Nelaton's operation. A small incision is made in the abdominal wall, an inch and a half or two inches in length according to the thickness; the peritoneum is incised, and the most distended loop of small Fn;. 400. — Inguinal Wound Made in Nelaton's " Operation of Enterostomy." intestine that lies near is drawn into the wound and fixed with sutures. If the case is urgent and the bowel must be opened at once, very accurate and very firm adaptation is necessary, as in such cases there may be a considerable amount of movement as soon as the pressure is relieved. The parietal peritoneum may be drawn outward and fixed to the skin by two or three sutures ; and then four, or better six, silk threads must be passed through the united layers, the visceral peri- toneum, and the outer coats of the bowel. One or two catgut sutures may be used between the others for greater accuracy. The opening in the intestine should LUMBAR COLO TO MY. 937 be merely a puncture. Escape of the contents may be best prevented by covering the edges of the wound with an antiseptic ointment and using the aspirator. Where it is possible, it is advisable to divide the oi)eration into two stages, stitching the l)owel into position first ; and two or three days later, when adhesions have formed between the i)eritoneal surfaces, making the opening into it, and if necessary securing it by further sutures. As originally performed by Nelaton, the operation was in the right iliac fo.ssa, between the deep epigastric artery and the anterior superior spine of the ilium ; and the portion of bowel opened was the small intestine immediately above the caecum. It may be done, however, in the middle line or in the right lumbar region, if it is found when the colon is exposed that the seat of obstruction is higher up. As a primary operation enterostomy meets with but little favor. The cases of obstruction in which distention of the bowel is the only cause are very few in number ; these may be cured by such an operation, and the opening closed. It is, however, as yet impossible to diagnose them from other forms of intestinal stran- gulation in which the operation, if it were performed, would merely give momen- tary relief, leaving the real source of the mischief untouched. On the other hand, when the colon has been exposed and found empty, or when laparotomy has been performed and some hopeless condition discovered — an irreducible and extensive intussusception, for example — or widely spread carcinoma in a patient who is com- pletely exhausted, enterostomy may prove of the greatest service by relieving dis- tention and pain and prolonging life. Greig Smith recommends that in cases of intestinal obstruction in which the patient is much collapsed, this operation should be performed under local anaes- thesia by the subcutaneous injection of cocaine, merely to give time to rally. P2ven if nothing is given the pain of the incision is scarcely felt, and any other anaes- thetic, increasing the depression or causing vomiting, would almost certainly ex- tinguish the little chance that is left. COLOTOMY. The colon may be opened either in the lumbar region on the right or left side, or in the left inguinal. In the former operation, which was first performed by Amussat on the right side, the posterior surface of the bowel where it is un- covered by peritoneum is, generally speaking, exposed ; in the latter (Littre's) the peritoneal cavity is always opened. Lumbar Colotomy. The colon is placed half an inch behind the middle of the crest of the ilium, as measured between the anterior and posterior superior spines, lying upon the quadratus lumborum, immediately below the kidney. If it is distended there is usually a considerable surface uncovered by peritoneum ; when it is collapsed this contracts ; but the sides may generally be separated from each other, and the bowel reached without interfering with the serous surface. In a certain propor- tion of cases, however, a meso-colon is present, especially on the left side (Treves), and then it is impossible. The patient is placed on the opposite side, almost semi-prone, with a hard, round pillow under the loin to separate the last rib from the ilium. The margin of the erector spinae is defined, and an incision, two and a half to three inches in length, is made obliquely upward and backward toward the angle enclosed by the last rib and the spine. The middle of it should correspond to the spot at which it is expected the bowel will be found. Practically, unless the last rib is much depressed, the incision is parallel to it and the arteries, and lies in one of the natural folds ; but care must be taken not to bring it too near the crest, or one margin will sink below the other. 60 938 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The latissimus dorsi, with a few fibres of the external obliciue, and the internal oblique are divided first and all hemorrhage stopped. The fascia lumbonnii is slit uj) on a director for the whole length of the wound and the outer border of the quadratus ex})Osed. A quantity of loose fat, in which the kidney is embedded, and the transversalis fascia at once come into view, the latter in some cases closely resembling the peritoneum in appearance. This must be teased through gently with forceps, the bleeding stopped, and the finger introduced to ascertain the position of the kidney. If the bowel is distended, the non-peritoneal surface generally rises into the wound at once, so that there is no difficulty. If it does not, the bowel may be filled with air from the anus by means of Lund's insufflator, but this is rarely required. As a rule, it is sufficient to pass the finger down into the angle between the quadratus and psoas, dividing the edge of the former a little if it is necessary, and by rolling the patient over to the left side allow the bowel to fall against the digit. The intestine should now be hooked well forward into the wound, the sides of which are held ai)art by retractors, in order to make cer- tain that the portion exposed is really the colon. This is especially necessary on the right side ; it has happened to several of the best operators to open the loop of the duodenum by mistake. If it is full of hard scybalous faeces, or if one of the appendices epiploicae can be recognized, it is usually sufficient ; but the only absolutely sure test is the presence of a band of longitudinal fibres, and when the non-peritoneal surface is exposed these are remarkably inconsjjicuous. Allingham, junior, who found an ascending and a descending meso-colon in five-sixths of the cases he examined, considers it advisable, unless the intestine presents itself in the wound, or can be recognized beyond all doubt at once, to open the peritoneal cavity, and by introducing the finger, or if the colon is much displaced, the hand, to find the portion of bowel required and bring it up to the surface. The cut edge of the peritoneum is then to be stitched to the skin so as to shut out the abdominal muscles from the wound, and the bowel secured in position. When the intestine must be opened at once, a large curved needle is passed through the skin on one side of the wound, across the bowel, and then through the skin from within outward upon the opposite side again. The same thing is done with another needle about an inch lower down. The ends of these sutures are to be held by an assistant. A small puncture is then made with a tenotomy knife in the centre of the square so marked out, and the two threads, as they traverse the interior of the bowel, are caught up and pulled out in loops by means of an aneurysm needle. As soon as the loojjs are cut, the bowel is held up against the skin, slightly overlapping it, by four silk su- tures passing through its whole thickness. Ad- ditional security may be obtained by passing other sutures where required, either to hold the bowel to the skin, or to bring the angles of the skin wound together ; and often it is advisable Fig. 4oi.-Method of Securing Boweiin Lum- to place a serics of buricd catgut sutures in the bar Incision. wouud to close, as far as possible, the planes of cellular tissue between the muscular strata. Whenever it is possible the opening of the bowel itself should be postponed ; union by the first intention may make everything secure within three days, and prevent all fear of faecal extravasation and suppuration, and an interval of only a few hours can appreciably diminish the risk. The intestine may be secured in position by sutures passing through its muscular wall only, the mucous membrane being carefully avoided, or by means of Howse's forceps, which are made to grasp small folds of the muscular coat at intervals of about half an inch, and are then laid flat upon the skin and kept in position by broad strips of plaster. INGUINAL COLOTOMY OR LAPARO-COLOTOMY. 939 In any case, it is absolutely essential to draw the bowel well up into the wound, so as to form a spur on its deep surface and prevent the fasces passing beyond ; unless this is done the relief is exceedingly imj)erfect, and faeces may collect in the part below, and give rise to serious inconvenience Madelung, to obviate this, and to prevent the irritation of faeces passing over a cancerous surface, has divided the bowel comi)letely, sutured the upper end to the lumbar wall, and completely closed the other ; but. as (ireig Smith points out, this is open to the objection that, if the stricture becomes closed, there can be no escape for the foul and decomposing dis- charges in the lower segment. When the opening is a considerable distance above the seat of stricture, and the bowel is much distended, it is of advantage, as soon as the parts are fairly firm, to introduce the tube and gently wash out the accumu- lation from below. Afterwards the spur ought to be sufficient to prevent anything more passing on. Fig. 402. — Artificial Anus after Colotomy with the Oblique Incision. The discharge of faeces is generally easy ; exceptionally, when there are scybala, it may be necessary to wash them out, or even to extract them with forceps. The only dressings required are wood-wool, or some other absorbent an- tiseptic material in large pads, changed as frequently as necessary, and some zinc or boracic ointment around the margins of the wound. Afterwards an apparatus must be worn to support the opening and collect any faeces that may escape. Ivory or india-rubber rings may be used, fixed to an abdominal belt so that there is a certain amount of pressure, as well as tension, around the opening ; but in many cases patients find the greatest amount of convenience from absorbent pads covered on the outer surface with oiled silk, and secured by a linen binder. Inguinal Colotomy or Laparo-Colotomy. This is performed in the left inguinal region, but when it is desired to open the caecum or ascending colon, a similar operation may be carried out on the right side. Various incisions are recommended, but in the majority of instances one two inches in length, parallel to Poupart's ligament, and about one inch inside the anterior superior spine, fulfills all requirements. Ball prefers the linea semilunaris, as there is no muscular substance divided. All bleeding must be stopped before the peritoneum is opened. As soon as this is done the finger is introduced and passed along the lower margin of the iliac crest until the mesentery guides it to the sigmoid flexure, and its condition, with regard to distention and the situation of the stricture, is ascertained. The parietal peritoneum is then sutured to the skin, so as to exclude the muscles of the abdominal wall, and a loop of intestine, with a sufficient length of mesentery, is pulled out and secured. The simplest way of forming a spur is that devi.sed by Allingham, junior. A needle, threaded with carbolized silk, is passed through the meso-colon behind the bowel, and 940 DISEASES AND INJURIES OF SPECIAL STRUCTURES. through the whole thickness of the abdominal wall on either side of the opening, so as to sling the intestine up and bring its posterior wall forward. The sides of the intestine are then fixed all round to the margins of the skin by silk sutures jnssing through the muscular and serous coats only, and leaving at least two-thirds of the circumference of the bowel protruding between the rows. A few hours' delay in opening the intestine is even more essential here than in the lumbar operation. Ball recommends that a loop of intestine should be pulled out through the wound, emptied as far as possible, by gentle pressure, and secured for the time by clamps placed above and below, so that no fceces can escape when it is opened. A series of sutures is then passed through the whole thickness of the abdominal wall on either side, and across the bowel between the clamps. One should pass through the meso-colon in the angle of the loop, and three or four through the bowel above and below. When these are placed in position the convexity of the bowel is opened, the mucous surface carefully cleansed, and the threads fished out, divided, and secured, with the exception of the outermost one at either end. The mucous membrane is adjusted all round, the angles of the wound brought together, leaving the handles of the clamps still pro- truding, and then at last, when everything is secured, the clamps are withdrawn, one at a time, and the opening closed instantly by tightening up the sutures that have been left. In this way the upper and the lower ends of the loop are fixed securely side by side, and no escape of faces is allowed until the clamps are unscrewed, ^^'hen the bowel Fig. 407. — Method of Securing Bowel in Inguinal ^ •, , . 4.\.- ^ ^ ^ ^ Incision. iiiust be Opened at once this plan presents considerable advantages over the other ; but great care is necessary to secure it sufficiently firmly without bruising it, especially as the walls are not unfrequently much softened and congested. Redundant por- tions of the bowel can be removed with scissors afterward, as far as maybe neces- sary, without its being felt. [In Maydl's operation, incision is made parallel with the fibres of the external oblique muscle. The colon is drawn into the wound, and a glass rod wrapped with iodoform gauze, thrust through the mesentery underneath the loop ; the gut is then stitched under the rod on each side. If considered necessary to open the colon immediately, the peritoneum of the abdominal incision is stitched to it, and the incision covered with iodoform collodion. If it is intended to open the colon in four or five days the wound is well packed with iodoform gauze. When ready the colon is opened by the Pac(iuelin cautery and drainage tubes inserted into each bowel opening. Through these tubes irrigation can be effectively carried on, and the action of the external oblicjue muscle takes the place of a sphincter. The accompanying figures from Esmarch (" Chirurgische Technik ") will render further de.scription unnecessary.] Inguinal v. LuMn.\R Colotomv. Little reliance can be placed upon the older statistics, which give the former of these operations a much higher rate of mortality than the latter. More recent experience tends to show that, so far as this is concerned, if there is any material difference, the balance is rather on the other side. In a certain number of cases lumbar colotomy is almost im])ossible: a faecal fistula may be formed in the loin, sufficient so long as the bowel is immensely dis- tended ; but when there is no meso-colon, and the walls are perhaps four or even five inches in thickness, it is not possible to draw out the bowel sufficiently. The peritoneal cavity, it is true, is always opened in the one, but it very. often is in the other, and sometimes without its being known. The inguinal operation is shorter. ENTERECTOMY. 94' and the wound much smaller ; the large intestine can be found more easily, and can rarely be mistaken ; the seat of stricture can often be ascertained, and it is always possible to make sure that it lies below the wound. So far as the after treatment of the case is concerned, there is no (juestion as to the side upon which the advantage lies : the tendency to prolapse may t)e slightly greater in the inguinal region, but it is easily controlled, and the i)atient can attend to himself much better. The only exception is where the bowel is very greatly distended and the walls much thinned ; then it is probable that the immediate risk is less in the case of the lumbar than the inguinal. The actual distance between the two openings is not more than four inches, so that very little is gained in this respect by the lumbar incision. ^k Fig. 404. — First Stage of Maydl's Operation for Artificial Anus. (AJier Esmarck) Fig. 405 -I. The Intestinal Loop drawn forward. 2. Completely severed. (a) Conveying; (<5) Discharging End. Prolapse of the mucous membrane of the bowel is more frequent after the in- guinal than the lumbar operation, but this may be prevented to some extent by drawing down the sigmoid flexure as far as possible and fastening in the wound the highest part that can be reached. It must not be forgotten that patients who are suffering from abdominal dis- tention and are worn out from intestinal obstruction, frequently take anaesthetics badly, and that the position necessary for the lumbar operation still further impedes their respiration. Enterectomy. Resection of the small intestine may be performed when the condition of the bowel is hopeless from gangrene, irreducible intussusception, or matting together and bending; for stricture, simple and malignant; for perforating wounds, or as a plastic operation for the cure of artificial anus. If the condition of the patient and of the wall of the intestine is such as to admit of it, the two ends may be sutured together and returned into the abdominal cavity at once. In other cir- cumstances an artificial anus must be formed, and left to be dealt with later on. The operation, following Greig Smith, is conveniently divided into three steps : (i) the isolation of the bowel, so that it can be drawn out of the abdominal wound and emptied ; (2) the resection ; and (3) the suturing of the ends, either to each other (enterorrhaphy) or to the wall of the abdomen. I. Isolation. — In most instances there is but little difficulty: a part that is gangrenous or has been wounded can generally be drawn outside and thoroughly 942 DISEASES AND INJURIES OF SPECIAL STRUCTURES. examined. More preparation, however, is required when there is an artificial anus: the abdomen must be opened above and below, the orifice of the bowel closed, and the adhesions carefully dissected off; and in the case of malignant stricture very strict examination is necessary to make sure that the whole of the growth can be taken away. One or two glands may be removed, but if there is any extensive infiltration, or if the intestine is adherent, the attempt is not likely to succeed. As soon as the bowel is drawn out, it is laid upon a flat carbolized sponge, and the opening into the abdomen packed with more sponges to prevent the intrusion of faecal matter and the escape of more of the intestine. 2. Resection. — As soon as the bowel is safely held away from the margin of the wound, it should be opened and encouraged to empty itself as far as possible. Whether it should be secured above and below with clamps, or merely held with the fingers, depends, to a large extent, upon the condition of the bowel itself and upon the character of the assistance at hand. The more instrumental compression can be dispensed with the better, but it must be allowed that nothing can prevent the escape of the contents more effectually or maintain the cut edges in better apposition for the application of the sutures. Many forms have been devised, and something may be said in favor of nearly all, but perhaps the simplest is that adopted by INIakins. It merely consists of a pair of spring-catch forceps with longer blades than usual, and a screw so that they can be tightened to any required extent. The blades are covered with rubber tubing to avoid injury to the coats of the bowel. If the portion of the bowel to be removed is of any length (in Koeberle's case the amount was over two yards) a triangular segment of mesentery to correspond must be taken away to prevent kinking afterward. The base of the triangle should be rather smaller than the interval between the ends of the intestine, so as not to interfere with their blood-supply, and the raw edges must be adjusted to each other by means of a continuous catgut suture carried over and over the margins. In most cases, however, this is scarcely necessary ; the folds may be drawn together and the base so formed stitched to the intestinal walls. The line of section through the mesentery should always be carried as close to the attached margin as possible, to preserve intact the row of anastomotic loops from which spring the vessels supplying the wall itself. Any part of the intes- tine separated from this is sure to slough. Mac- Cormac recommends that the section through the bowel should not be exactly transverse, but that rather more should be removed on the convex side, as by this, after the suturing is complete, the tube remains somewhat straighter. 3. The Sufurhig. — A great variety of intestinal sutures have been described, but the essential features are : (i) that the peritoneum should be in contact over a sufficiently broad surface ; (2) that no suture traversing the mucous membrane should pass at once through the serous coat as well, or it will inevitably act as a seton, carrying the contents into the peritoneal cavity ; if sutures are used to bring the mucous edges together, they should be independent, and tied on the mucous surface, so that if there is any ulceration they may fall into the cavity of the bowel ; (3) that the sutures should be sufficiently close (eight to the inch at least) and pass sufficiently deep to secure a firm hold. Each F.c 4o6.-Lemberfs Suture. should take up the serous layer, the whole thickness of the muscular wall (which is much thmner in the ileum than the jejunum"), and a few fibres of the submucous coat. Especial care is necessary when working near the attachment of the mesentery, as the serous ENTERFCTOMY. 943 layer at this spot is separated by a cellular interval from the structures beneath, and it is nearly always here that extravasation occurs. 'Hie last requisite is that the method should be one capable of rapid ajjplication. Fine China twist is the best material, and one row of sutures at least should be interrupted, taking care that they are not sufficiently tight to cause sloughing. Continuous sutures are admirably adapted for securing contact and for strength- ening weak places ; moreover they prevent over-distention of the bowel, but if it contracts they become loose at once. Treves advises that there should be two rows : one through the mucous mem- brane, which, as soon as the bowel is divided, becomes everted ; and a second, further back, turning this in again, through the serous and muscular layers. Yox the latter, I,embert's is the most useful ; the" needle is entered about three to three-and-a-half lines from the margin, passed down through the serous and muscular coats until the resistance of the submucous layer is felt ; and then, after picking up a few fibres of this, brought up again about one line from the cut edge, and introduced into the opposite end of the bowel in the reverse direction. Czerny combines Lembert's with another row inside, passing, not through the mucous membrane only, but through the whole thickness of the bowel. One or two sutures should always be passed across the cut edges of the mesentery immediately above its attachment, in order to obliterate as far as possible the triangular space that normally exists there, and allow all t , • c o 1 .' ./^-o'l-u Fig. 407. — Lembert s Suture the sutures to pass through the serous coat. Greig bmith Tied, speaks very highly of Halsted's plain quilt suture, and makes a most ingenious use of it. "The intestine has been cut away, the mesentery divided as close to the bowel as deemed desirable, and no wedge-shaped portion removed. Two Makins clamps, covered with rubber tubing, have been applied, at a distance of about half an inch from the divided ends of the bow^el. A purse-string stitch has been so arranged along the divided margin of the mesentery that it draws together the gap of cellular tissue and the attached margins of gut, while it leaves free small flaps of peritoneum, which may be grafted on to the base of the line of union. Four quilt sutures have been inserted on the opposite sides of the divided gut, in the exact line in which the Lembert sutures are to be placed ; the two on each side are to be gathered together in the blades of catch -forceps, and gentle and steady traction made on them by an assistant. This raises a well-defined fold along the edge of the bowel : into this fold the sutures are inserted. The traction on the quilt-stitches makes certain that equal distances of the bowel are arranged for suturing, and also, by raising a fold, makes the insertion of Lembert's stitches more easy and ensures their being placed in a straight line." The quilt-sutures are tied the last of all, and, finally, any redundant mesentery is fixed along the line of union of the bowel. Any spot that appears weak may be strengthened by Dupuy- tren's or Apuolito's continuous suture applied outside. Senn ('"'Annals of Surgery," 1888), who has performed on animals an in- valuable series of experiments, prefers a modification of Joubert's suture where direct union of tw^o cut ends is required. The time is very much shorter ; there is less danger at the mesenteric edge ; the number of sutures is smaller, the risk of their giving way prematurely and of their perforating the mucous membrane is not so great, and there is not so much fear of gangrene. The direction of the bowel is first ascertained by Nothnagel's test (a crystal of a sodium salt placed upon the serous surface, causing ascending peristalsis), the upper end, which is to become the intussusceptum, is lined with a soft pliable rubber ring (made from a flat rubber band, one-third to one-half of an inch in width, by securing the two ends together with catgut sutures), which is stitched to the wall at its lower edge with a continuous catgut suture. The two ends of the bowel are then fastened together with four catgut sutures, placed at equal distances, 944 DISEASES AND INJURIES OE SPECIAL STRUCTURES. and the upper one, supported by the ring inside, is pushed into the other so as to invaginate it. The intussusceptum must be a little longer than the ring, so that there may be a distinct neck which can be grasped by the intussuscipiens. A few superfici;il sutures are recpiired to prevent disinvagination. The ring acts as a splint, keei)ing the part at rest, and its pressure (which must not be too great) is useful in securing the apposition of the serous surfaces. When the catgut softens it comes away of itself. There is no doubt that by this process the operation may be jjerformed in less than one-fourth the time, and that in animals it succeeds perfectly. It must be remembered, however, that the human intestine is of larger calibre, and its walls for the most part thinner. Probably it would not succeed in cases of obstruction where the ui)per part of the intestine is filled with fajces, or its walls much softened and congested. For such the formation of an artificial anus is to be preferred. In perforating wounds, however, where perhaps several resections have to be per- formed, the gain in point of time alone would be of immense advantage. Fig. 408. — Drawing to Show Method of Intestinal Sntiire. (Greig Smith.) Senn has also practiced a most ingenious system of omental grafting, both in ordinary cases of circular suturing and in his modification of Joubert's method. A flap about an inch in width (or a little more), and sufficiently long to reach round the bowel, is taken from the margin or the middle of the omentum, and laid upon the line of junction ; two catgut sutures are used to fasten it, each i)a.ssing twice through the flap (once at its base and once at its free end), and through the mesentery of the bowel in between, care being taken that when the sutures are tied they correspond in direction to the course of the mesenteric vessels. At first the attachment of the base of the flap to the omentum was preserved intact ; but in his later experiments, owing to the possible objection that kinking might be prdduced by this, perfectly isolated strips were used and succeeded equally well. Slight scarification of the serous surface, not sufficient to cause bleeding, is, ac- cording to the same authority, of additional advantage in securing early and firm adhesion of the coats. Where it is not advisable to return the bowel into the peritoneal cavity, the COLECTOMY. 945 two ends are sutured rarefully to the skin around tlie abdominal wound. A few stitches should be put in first to connect the parietal i)eritoneum to the skin and exclude the muscles, and the external openinj; closed as far as possible ; then the muscular and serous coats of the intestine are fastened with silk at as many points as may be necessary all round to the conjoined peritoneum and skin. If the bowel has not been em])tied, but merely the contents prevented from descending by means of a clamp, this should not be removed until everything is secure, for fear of the faeces in their first rush finding their way into the peritoneum. The peritoneal cavity itself should i)e interfered with as little as possible, if blood has escaped into it in any quantity it must be sjjonged out ; but all bleeding ]joints should be secured before it is opened, and the section through the bowel (which, owing to the congested condition of the walls, often bleeds freely; should not be made until it can be well isolated. Fsecal extravasation is very much more serious, but even then recovery has followed after the peritoneum has been thor- oughly washed out with a hot solution of boracic acid ; whether a drainage tube should be used or not must depend upon the amount of peritonitis. Whether the bowel should be returned into the peritoneal cavity at once and the abdominal wound closed, or an artificial anus formed, must be decided for each case by the condition of the patient and of the intestines. There is no doul)t that, for obstruction at least, the former of the two is the less successful, but it must not be forgotten that. an artificial anus high up in the small intestine prac- tically means starvation, and that if the patient is to be cured there is all the risk attendant upon the second operation. In case of wounds, where the bowel is healthy and the patient not too much depressed, there is no doubt the operation should be completed at once. In a few instances an intermediate course has been followed ; the bowel has been returned just within the wound and secured in that position by one or two sutures. This may be done if there is any doubt as to the security of the stitches in the bowel, and several cases in which it has been adopted have recovered after a slight discharge of fceces through the abdominal wound. Colectomy. Resection of the colon has been practiced in cases of gangrene (upward of fifteen inches of the transverse portion have been excised successfully in umbilical hernia), irreducible intussusception, gunshot injury and stricture ; but so far, at least, as malignant disease is concerned, and this is the chief of the causes for which colotomy is performed, the advisability of such a proceeding is very doubt- ful. It rarely ha|)pens that the case is diagnosed, or that such a serious operation is agreed to by the patient in time for complete removal ; adhesions are nearly always present, either to the neighboring viscera or to the parietes of the abdo- men, and recurrence within a short time is only too probable. As Kendal Franks has shown, the primary mortality is exceedingly high (though the percentage with improved methods is certainly growing smaller), and of those who recover more than half are known to have suffered from a recurrence within a few months. Colotomy can give such com])lete relief with such small risk, that before colec- tomy is preferred it must be shown that there is a reasonable prospect of cure. The operation for the transverse colon is performed through the middle line, and portions of the ascending and descending colon have been removed in the same way, but this must be considered exceptional. As a rule, so far as these are concerned, colectomy is only possible when the seat of disease is opposite the lumbar incision and the bowel is sufficiently free for it to be well pulled out. The method is the same as in enterectomy ; peritoneal surfaces must be brought together as far as possible ; and where this cannot be done the muscular coats must be accurately sutured, but this greatly increases the risk of suppuration and retro-peritoneal abscess. 946 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CitCECTOMY. This operation, which is essentially of the same description, has been per- formed on several occasions, the whole of the ccecum being removed and the ileum joined to the ascending colon. Intestinal Anastomosis. By this is meant the formation of a fistulous opening between two i)ortions of intestine, or between the intestine and the stomach, so as to secure the direct transit of the contents from one to the other. As an alternative to resection and circular suture or implantation it should certainly be preferred in all cases in which it is impossible to remove the cause of obstruction : in which, after re.sec- tion, continuity cannot be restored without undue traction, and in which the pathological conditions causing the obstruction are not such as of themselves to constitute a danger to life. Its importance in connection with carcinoma of the pylorus alone may be imagined from the fact that, in Liicke's clinic, out of fifty- two cases selected for pylorectomy, only five were free from metastases, and that the mortality of the operation was 75 per cent. The particular name of the operation depends upon the locality, gastro-enter- ostomy, jejuno-ileostomy, ileo-ileostomy, ileo-colostomy, etc. The principle is the same in all cases. Senn' s Methods. I. Where the two Segments are Placed Side by Side. — Decalcified plates of bone, one inch wide by three inches long, are prepared from the tibia of an ox by soaking them in hydrochloric acid ; when sufficiently flexible they are washed free from acid, dried between plates of tin so that they may not curl up, and kept until wanted in absolute alcohol. In the centre of each plate an opening is drilled five-eighths of an inch by one-sixth ; and around this four smaller holes for sutures, one on each side, one at each end, about one-sixth of an inch from the central opening. The sutures, which are of fine China twist (catgut of suffi- cient strength is too coarse and the knots too large) are secured beforehand on the inner surface of the plate and passed through the holes to the other side. A longitudinal incision is made on the convex side of the intestine, away from the mesentery, sufficiently long to allow the plate of bone to be slipped inside and arranged parallel to the bowel, against its mucous surface. The two end sutures are allowed to hang out through the opening ; the two lateral ones, which have needles attached to them, are passed through the wall of the bowel, near the incision, so as to fix the plate and prevent eversion of the mucous mem- brane. A second plate is arranged in a similar way inside the other portion of intestine ; and then the serous surfaces are brought together so that the orifices correspond, and the opposite sutures tied. The knots of the lateral ones lie be- tween the peritoneal surfaces. By this, accurate approximation is secured over a surface corresponding to the size of the plates ; there is no risk of cutting off the blood-supply by the mul- titude of sutures ; the plates act as splints and secure perfect rest ; and the time of the operation is only fifteen minutes. Senn found that, in dogs, bone-plates, if thoroughly decalcified, were digested too soon in the stomach : but it must be re- membered that the gastric juice is much more acid in them than it is in man. 2. Where the End of one Segment is Implanted into the Side of the Other. — In this case the proximal end of the distal segment must be thoroughly invaginated and closed with a continuous catgut suture pa.ssing through the peritoneal and muscular coats. Senn has shown that if it is treated in this way it soon atrophies and shrinks up, and there is no fear of its becoming the seat of fKcal accumula- tion. For this Senn makes use of the modification of Joubert's suture already de- ARTIFICIAL ANUS AND F.HCAL FISTULA. 947 scribed (p. 944). A rubber ring is secured in the distal end of the proximal segment ; two catgut sutures, each jjrovided with two needles, are passed from within out, at opposite sides, through the upper margin of the ring and the whole thickness of the bowel; each needle is then passed into the wall of the colon, about one-thirtl of an inch from the margin of the opening, penetrating the peri- toneal, muscular, and submucous coats only, and emerging on the same surface. As soon as they are all secured at corresponding i)oints, gentle traction is made upon them while the end of the proximal segment is pushed into the side of the Bone Plate. Fig. 409 Introducing the Bone Plates. -Entero-Anastomosis. {After Senn.) distal one, so as to form a limited invagination. The sutures are then tied only sufficiently to prevent any disinvagination. The pressure of the ring keeps the part at rest and secures accurate adaptation, and the invagination prevents any escape of the contents and secures the sealing of the wound. Superficial sutures are not required. This method, of course, is only applicable where a smaller segment can be implanted into a larger one, and therefore cannot be used in the case of the stomach. Artificial Anus and Faecal Fistula. In artificial anus there is a free communication between the skin and the bowel, the whole or nearly the whole of the intestinal contents escapes, and the part below shrinks and collapses. In faecal fistula, on the other hand, the chan- nel is narrow, it may be long and tortuous, and the greater portion of the con- tents follow the natural route. The one arises from the loss of a loop of intestine, or from destruction of the greater portion of the circumference of a short segment, the bowel being sharply bent upon itself; the other from sloughing of a small part only of the wall. The most important practical distinction is the existence in the former of a spur or septum opposite the opening, which prevents the contents passing on. The posterior wall of the bowel is pu.shed forward from behind by the weight of the viscera ; a ridge is formed on the mucous surface, and this grows more and more prominent until at length it overlies and closes the opening of the lower segment ; the vv-hole of the faces then discharge themselves externally, and this part of the bowel, from being never used, shrivels up to a narrow cord. 94S DISEASES AND INJURIES OF SPECIAL STRUCTURES. The most common cause is hernia, and for this reason the opening is gen- erally situated in the femoral or inguinal region ; but it may arise from injury, car- cinoma, internal strangulation, fcecal abscess [tubercular], circumscribed peri- tonitis, and many other causes ; and the communication may be formed with the bladder or vagina, or, in very rare cases, with other parts of the bowel. If the Oldening is of any size, prolapse of the mucous membrane is almost sure to occur ; and, sometimes, owing to the stretching of the adhesions between the two por- tions of bowel, or between the bowel and the skin, hernial protrusions make their appearance by the side, Treatment. — Where there is merely a fistula, and the passage below is fairly open, the orifice often closes in of itself. The discharge becomes less ; the cica- tricial tissue round contracts ; the patient regains strength (unless the opening is high up in the intestine) ; and, even if the cure is not complete, the operation is less extensive, and the condition of the patient more satisfactory. This .some- times occurs in that form of artificial anus which follows femoral hernia ; and the process may be hastened by pressure steadily applied, by drawing the edges together with strapping, button sutures, or hare-lip pins, or by the use of the actual cautery. Sometimes a small plastic operation will succeed. In most cases of artificial anus, and whenever the orifice is high up, so that the patient is in danger of starvation, further measures are essential. 1. Where the chief difficulty arises from the presence of a spur, an attempt may be made, either to divide it or to press it back. The simi)lest method is that suggested by Mitchell Banks : a stout piece of rubber tubing, secured by a liga- ture so that it shall not escape, is passed through the orifice into the upper and lower ends of the bowel, resting against the edge of the spur. The contents of the intestine, especially if the opening is high up, pass through it more or less, and by its pressure it wears the jirojection back, and brings the two portions into the same line again. If this fails, and the spur is very distinct, it may be divided by means of Dupuytren's enterotome. This consists essentially of a pair of forceps, the ends of which are broadened out into flattened discs or circles ; one of these is passed on each side of th(* septum, and then, after making sure that there is no loop of intes- tine caught between, they are slowly and cautiously tightened up from day today, until at the end of a week the septum sloughs through. Adhesions meantime form around and completely shut out the peritoneal cavity. The mortality attend- ing this procedure is exceedingly low (no more than 8.5 per cent.) ; but, of course, it is only applicable to selected cases. 2. Where the opening is very high up, and the patient is gradually losing ground ; where there is no well-defined spur, and where there is more than one opening, resection and suture of the bowel afford the only hope of cure. This must be done on the principles that have been already described, but even when every precaution has been taken, the mortality, according to Makins, amounts to nearly forty per cent. The patient, for a day or two before, is fed wholly with enemata ; the bowels and the skin round are thoroughly cleansed, and an incision is made into the peritoneal cavity to ascertain the amount and extent of the adhe- sions, and the direction of the bowel. After this, the ends are carefully freed from surrounding structures, drawn well out of the wound (which is immediately plugged with sponges ; clamped if necessary, resected, and sutured. If the lower end of the bowel is much contracted, there may be great difficulty in this, and it may be necessary to divide it obliquely so as to secure a full extent of cut surface ; but every attempt should be made, both before and during the operation, to dilate it quietly and gradually. Afterwards the bowel is returned into the peritoneal cavity, and the abdominal wound treated as in laparotomy. If there is any doubt as to the security of the sutures, it is well to retain the bowel close to the surface. After-treatment. — The after-treatment of operations upon the intestine is essentially the same as that of hernia ; as soon as the jiatient comes round from the an?esthetic, he must be placed under the influence of morphia and kejJt tem- ABSCESS OF THE LIVER. 949 porarily ciuiet for at least eight days. A little ice may be given to allay thirst, but he must not be allowed to suck it constantly ; the temjierature must be main- tained, and where the ui)i)er part of the intestine is concerned, the strength kept up with nutrient enemata. Barker has shown that, in a case of gunshot wound, six days suffice for sound union, but probably the time required in obstruction would be considerably longer. Artificially digested food should be given at first, and in very small (piantities. In colotomy, of course, the method is different, and nourishment may be taken by the mouth from the first. If the bowel has been retained, the wound does not require dressing for five or six days, unless a drainage tube is used, or peritonitis was present. Sometimes a small discharge of faices takes place for a time, and then gradually ceases, caused probably by the giving way of one or two of the sutures. Where an artificial anus is left, large absorbent and antiseptic pads should be used and changed as often as required, the skin being protected, as far as possible, by vaseline or simple ointments. When the opening is near the upper end of the intestine, the ex- coriation may prove a difficulty. SECTION VII.— SURGICAL AFFECTIONS OF THE LIVER AND PANCREAS. ABSCESS OF THE LIVER. Abscess of the liver may arise from wounds and contusions, from exposure to cold, or from suppuration in connection with hydatid cysts ; bul in most instances, they are secondary to infection from the intestine, and occur chiefly in those who have lived in tropical climates and have suffered from dysentery. Sometimes they are multiple, scattered through the liver in all directions, as in fatal cases of pye- mia ; more frequently, they are single or few in number, though they may have been formed by the gradual coalescence of numerous small foci, and then they may be very large, capable of holding four or five pints of fluid. The pus is usually dark chocolate in color, and sometimes fcetid. At first, the abscess may be deeply seated ; as it enlarges, it approaches nearer the surface, until either it bursts into the pleura, peritoneum, or pericardium, or else, if this is prevented by the formation of adhesions, discharges itself externally, or into the bowel. Diagnosis. — The diagnosis of deep-seated abscess in the early stage is ex- ceedingly difficult. A history of residence in a hot climate, or of any rectal trouble, even years before ; the occurrence of rigors, or of general feverishness, with pain and tenderness over the region of the liver ; a muddy, perhaps jaundiced, complexion ; irritability of the stomach, with vomiting and other signs of hepatic congestion, may excite suspicion, but no positive diagnosis can be made, without exploration by means of an aspirator. In the later stages, when there is a distinct enlargement of the liver, or when the skin over the surface of the abdomen is red and oedematous, this difficulty disappears ; but the abscess must usually attain a very large size before it can produce such an effect. Hydatids of the liver may be differentiated by the slowness of their growth, and by the absence of pain and fever ; but this fails if the cyst is suppurating. A certain amount of difficulty may arise in the case of large single gummata of the liver, and of rapidly-growing tumors either of this organ or of the kidney. Pleurisy and pneumonia are not unfrequently pres^it, especially when the abscess is situated near the posterior surface, and very great care may be required to make certain of the cause. Treatment. — i. If the skin over the swelling is red, and pits on pressure, there can be little doubt either as to the existence of an abscess or the presence of adhesions. In such circumstances an aspirating needle may be used as a prelimi- 950 DISEASES AND INJURIES OF SPECIAL STRUCTURES. nary, to act as a guide, but as soon as it has entered the cavity and the diagnosis is confirmed, the opening should be enlarged, so that the pus can escape as freely as possible, and a full-sized drainage tube inserted. The following day, when the adhesions are firmer, the abscess cavity may be explored with the finger to make sure there are are no other sacs in the immediate neighborhood, and, if necessary, washed out with iodine or some other antisejjtic. 2. When there is no certainty as to the presence of adhesions the choice lies between aspiration, drainage with a trocar and cannula, and incision. Aspiration is chiefly of use for exploration ; it rarely happens that an abscess cavity is comjjletely emptied, and nearly always the swelling appears again within a few days. In a few instances, however, a cure has followed after two or three repetitions. Puncture with a trocar and cannula is also open to grave objections. If ad- hesions are present already, it is more satisfactory to make a free incision and allow of thorough exploration and drainage ; if they are not, the peritoneal cavity is opened without any safeguard to prevent the i)us entering it. Further, the con- stant movement of the liver in the abdominal cavity frequently renders the reten- tion of a tight-fitting cannula or of a stiff drainage tube a matter of very considerable difificulty. Incision directly into the abscess sac can only be practiced when the skin over it is reddened and it is certain that the walls are adherent. If this is not definite, either the operation must be carried out in separate stages or an incision made into the abdomen over the swelling, the surface of the liver exposed, and the abscess opened with the usual precautions to prevent its contents entering the peritoneal cavity. The preliminary steps are the same in both, but while in one the incision is only carried down to the parietal peritoneum, and is then plugged, so that adhesions may form beneath, in the other the abdominal cavity is opened at once and the surface of the liver examined. In a few cases omentum has been interposed, or it has been found that the abscesses are multiple and that there is no hope of thorough evacuation ; but if no difficulty of this kind is apparent, the wound is carefully packed round with sponges and an aspirating needle thrust into the swelling. As soon as the pus is found the opening is enlarged freely with the knife, and the contents of the abscess allowed to escape completely ; the assistant, meanwhile, carefully supporting the liver on either side so that it shall not fall away from the surface of the abdomen. When the sac is emptied the cavity may be explored with the finger and the walls stitched to the skin margins of the wound all round. An aspirating needle may be thrust through the two layers of the pleura and the diaphragm for the sake of exploring the posterior surface of the liver without risk ; but if a permanent drain is required, a free incision should be made down to the parietal pleura, a portion of one of the ribs being resected if necessary, the two layers of the pleura accurately sutured together with catgut (there is no diffi- culty in this in the lower intercostal si)aces). and then the trocar and cannula thrust through, so as to avoid the risk of air or pus entering into the pleural space. Hydatid Disease. Hydatid cysts are of common occurrence in connection with the liver, and not unfrequently attain an enormous size, diverticula having been known to extend down into the iliac fossa, and even under Poupart's ligament. As a rule they are single, lined with a characteristic laminated membrane, and contain a clear, non-albuminous fluid, the sjjecific gravity of which is under 1015 ; but more than one may be present, and most of the larger ones contain numbers of smaller ones in their interior. Outside is a vascular layer formed by the continued irrita- tion of the surrounding structures. The symptoms to which they give rise are very obscure at first, and depend mainly upon the locality. Their increase is slow and painless, without any fever; DISEASES OF THE GALL-BLADDER. 951 they may occur at any age, forming a tense elastic swelling which slowly extends in the direction of least resistance. Sometimes there is a smooth rounded promi- nence on the front wall of the abdomen, dull on percussion, and tense, without being tender. Occasionally fluctuation can be made out, or what is known as hydatid fromitu.s — a peculiar thrill only felt over cysts of consideral)le size. Often the cyst grows downward, simulating enlargement of the liver, and in a few cases it has reached so far as to be mistaken for hydronephrosis, and even for ovarian tumor. Not unfiecpiently serious consequences arise from pressure upon neigh- boring organs. Syncope has been known to occur ; vomiting is not uncommon ; respiration may be interfered with ; or jaundice, ascites, or anasarca may follow. Rupture of the cyst into the peritoneal cavity may occur, as the vascular adventitia is often defective on the serous surface, and is generally fatal at once. Communications occasionally form with the lung, so that the cysts are coughed up in numbers ; but, as a rule, if the patient recovers, it is only after a long and severe illness. In a few cases the hydatids have been known to remain stationary for years and at length undergo degeneration and dry up into a calcareous mass ; but suppuration with high fever and severe constitutional disturbance is more common. The diagnosis rests mainly upon the age of the patient, the smooth, even shape of the swelling, and the absence of pain and feverishness. The chief diffi- culty arises with pleurisy, hydronejjhrosis, ovarian cysts and tumors of the liver ; but as a rule exploratory puncture is conclusive. When supi)uration has set in it is impossible to distinguish it from abscesses due to other causes. Treatment. — There is no doubt that hydatid cysts are easily killed by with- drawing a small quantity of fluid from their interior, and when they are of mode- rate size and are deeply imbedded in a solid organ, there is a reasonable hope that if this can be done they may become calcified. In the case of larger ones, however, this is seldom satisfactory, partly owing to the risk of suppuration, partly to the impossibility of getting rid of the daughter cysts they so often con- tain. For these free incision is the only method. As in the case of abscesses, this may be carried out in two steps, an incision being made down to the parietal peritoneum and plugged so as to procure adhe- sion between the opposing surfaces some few days before the cyst is opened ; or, preferably, the whole operation may be completed at once. The surface of the liver where the cyst projects must be exposed by a free incision through the abdo- minal wall, the opening carefully packed with sponges, and then, while an assistant supports the liver by external pressure, a free incision is made into the sac and its contents evacuated. The side of the cyst is hooked up with the finger, the wall of the sac peeled off, disturbing the adventitia as little as possible, and the edge accurately sutured to the skin. In some cases the sac has been sponged out with iodine afterwards. Tapping hydatid cysts with an aspirator is occasionally followed by urticaria, vomiting, and other symptoms of poisoning. I have known one instance in which sudden death occurred, and Bryant has recorded another ; it may have been due to the sudden entry of some of the cyst fluid into one of the large branches of the hepatic vein, but more probably to shock. Diseases of the G.\ll-Bl.a.dder. Biliary Calculi. Gall-stones are generally formed in the gall-bladder, although a itw are met with in the hepatic duct, coming from the liver, and they may become impacted either in the neck of the gall-bladder, probably held by the peculiar folding of the mucous membrane, or in the hepatic, cystic, or common ducts. Sometimes they are single, or, at least, few in number, and of very large size; sometimes 952 DISEASES AND INJURIES OF SPECIAL STRUCTURES. they are multiple, occurring by the hundred, and having facets from mutual fric- tion. Some are small, rough, and soft, composed chiefly of bile pigment, others formed of cholesterine are hard and brittle. They are most common in women, and after middle life, although instances of their occurrence in children are not unknown. The symptoms to which they give rise are variable : it is not uncommon to f\x\6. post-mortem that the gall-bladder is full of them, without there having been any reason to suspect their existence during life. In some cases there are frequent and excessively i)ainful attacks of biliary colic, with or without jaundice, according to the exact situation of the obstruction. The i^atient is never free from pain, there is a constant weight or dragging in the hepatic region, made worse by movement, and coming on with especial severity a few hours after food, causing vomiting and great prostration. This may end sud- denly and finally w'ith the passage of the calculus, or, on the other hand, the stone may drop back into the gall-bladder, and all the symptoms return again within a few hours. If the calculus is impacted, the consequences are still more serious. When the obstruction is in the cystic duct, the gall-bladder only is involved, and it may either become immensely distended (dropsy), or inflamed and suppurate (em- pyema) ; when it is in the common duct, in addition to this, the liver is affected, jaundice sets in, and at length, unless some relief is given, cholremia follows. Usually, this proves fatal within the tw-elvemonth. [Occasionally the gall-stones dilate the gall-bladder so there is a distinct pro- trusion of the abdominal wall. The writer cut down upon such a swelling in the Saturday clinic at Rush Medical College in 1891, and removed twenty-seven small faceted gall-stones. These were contained in a pouch or diverticulum of the gall- bladder. A fistula persisted for some weeks after the operation, but finally healed after repeated injections of tincture of iodine.] Dropsy of the Gall- Bladder. Distention of the gall-bladder is nearly always due to imjmcted calculus ; in some rare instances other foreign substances, fragments of carcinoma, trema- todes, etc., have been found instead, and occasionally it results from stricture, gum- mata, or peritoneal inflammation. The contents soon become altered in character ; the bile becomes more watery ; after a time it loses its color altogether, and at length it is replaced by a fluid that is either perfectly clear or is turbid from the amount of mucus it contains. The bladder itself swells up into a pear-shaped or semi-globular tumor which grows downward toward the umbilicus. Usually it is overlapped at its margin by intestine and there may be a clear note on percussion between it and the liver. The surface is smooth and uniform, firm and elastic to the touch, but sometimes very painfiil. The walls are nearly always thinned, and there is practically no limit to the size it may reach. Empyema of the Gall-Bladder. Suppuration in the gall-bladder, which, according to Tait, is usual when only a few gall-stones are present, rarely leads to a tumor of such size. The walls are thickened in some parts and thinned in others, adhesions tying it down to all the structures near ; the tissues become soft and easily torn, and. if the gall-bladder itself does not slough, the pus gradually works its way through the wall at some point or other. Sometimes it bursts into the peritoneum, causing fatal peritonitis ; more often it discharges itself either into the stomach, duodenum, or colon \ per- haps most frequently of all, adhesions form between the fundus and the abdominal parietes, and the abscess is either opened or breaks externally. If the obstruction is in the cystic duct this may give complete relief; if, however, the common duct is involved, a permanent biliary fistula is left, which usually proves fatal in the course of a year or two, from exhaustion. OPERATIONS UPON THE GALL-BLADDER. 953 Diagnosis. — Malignant disease of the liver, pancreas, ])ylorus, or of the gall-bladder itself, may cause a certain amount of difficulty. This is especially the case with the first mentioned, as biliary calculi are not unfrequently associated with carcinoma, though it is not easy to say in what relation they stand to each other. According to Tait, the presence of jaundice jjoints distinctly to malignant disea.se, and, so far from rendering an operation advisable, suggests exactly the opposite conclusion, unless it is done merely as a temporary expedient for the re- moval of an obstructing calculus or the relief of biliary colic. Out of twenty cases operated on, carcinoma was i)re.sent, or was very highly probable, in every one in which there was jaundice. Tumors of the kidney, ])articularly hydronei)hrosis and floating kidney, have often been mistaken for distended gall-bladder, especially when there has been a history of the previous passage of gall-stones, and vice versa. The shape of the tumor and the relation that it bears to the bowel are the most important diagnostic points ; but in many ca.ses it is im])o.ssible to be certain without a preliminary ex- ploratory incision. Hydatid cysts, dermoid cysts, tumors in connection with the omentum, ovarian cysts, and other rarer forms of tumors, have occasionally given rise to difficulty. In any such case, a small exploratory operation is infinitely more safe and more certain than needling or aspiration. Operations Upon the Gall-Bladder. According to Greig Smith, operation is required in all cases of empyema, dropsy, and persistently recurring colic. When jaundice is present, the prognosis is much more grave, not only for the reasons mentioned above, but because of the much greater risk of hemorrhage and the feeble power of repair. Still, it may be necessary to avoid the occurrence of cholsemia, and sometimes, even under these conditions, it is possible to effect a permanent cure — by crushing, for example, a calculus impacted in the common duct. Aspiration through the abdominal wall cannot be recommended ; it is not likely to effect a permanent cure, and it may lead to leakage through the puncture and peritonitis. Free incision can only be practiced where there is an abscess pointing through the skin. Incision into the gall-bladder after exposure through an opening in the ab- dominal parietes (^c hole cystotomy) is a most successful operation. A vertical incision is made over the most prominent part of the swelling, and the muscles and periton- eum divided in the ordinary way ; the finger is then introduced to ascertain the condition of the gall-bladder, and, if it is much distended and not too much bound down by adhesions, a fine trocar and cannula is thrust into it to draw off some of the contents, and allow it to be pulled out through the wound, the greatest care being taken to allow none of the fluid to enter the peritoneal cavity. If catch or tooth forceps are used, they should be placed above and below the opening of the trocar, so that if the tissues, which are often very thin, are bruised, the injured part may lie in contact with the parietal peritoneum. As soon as the wall of the bladder is drawn out through the wound, a free incision is made into it, the rest of the contents allowed to escape, the interior carefully sponged out, and the finger introduced to ascertain if there is any obstruction present. Loose calculi present no difficulty, but if they are impacted far down in the neck, or in the cystic duct, the greatest care is required to avoid injury. Sometimes they may be removed by special forceps, the surface being gradually nibbled away, while the stone is fixed by the forefinger of the other hand pressing against it from outside the duct. On one or two occasions the stone has been broken by pressure from the outside, for- ceps guarded with rubber tips being used to avoid bruising as far as possible. Needling has been recommended to break them up. The mucous membrane has been very carefully nicked from the inside. The calculus has been left and the 61 954 DISEASES AND INJURIES OF SPECIAL STRUCTURES. fistulous opening syringed out constantly with warm water for a fortnight, and finally, when everything else has failed, the gall-bladder has been excised. In a few cases the wound in the gall-bladder has been successfully sewn up and the emptied sac returned into the abdomen, but Tait, who has jjerformed more of these operations and with better success than any one else, condemns this strongly. The walls are often exceedingly thin, it is very often impossible to make sure that the opening into the bowel is patent, and if any further operation is required it is decidedly advantageous to have the fundus of the gall-bladder ad- herent to the cicatrix. The walls of the sac, the parietal peritoneum, and the skin, should be accurately sewn together. Tait uses two continuous sutures, one for each side of the wound, the ends being tied together afterward, above and below. A large drainage tube is inserted, so as, if possible, to carry all the bile away from the wound, and ordinary absorbent dressings are applied. When the wound is healed the drainage tube may be withdrawn. If the obstruction has been removed the bile soon finds its way into the intestine again ; if, on the other hand, this is impossible, a biliary fistula is left which may be dealt with later on. Cholecystectomy, or removal of the whole gall-bladder, is a more serious oper- ation, and should only be practiced when, from the condition of the parts at the time of the operation, it is clear that incision and drainage either are impracticable or would fail to give relief. Sometimes this occurs after prolonged inflammation ; the gall-bladder is so utterly disorganized that it is not possible to suture it securely to the abdominal wound ; and it may happen in cases of impacted calculus, if it is not possible to extract or crush the stone without injuring the wall of the duct. The preliminary steps are the same ; the gall-bladder must be separated from adhesions, all hemorrhage carefully stopped, the peritoneal flaps united with a con- tinuous suture, and the end of the cystic duct tied. Surgical Diseases of the Pancreas. Large cysts, associated with obstruction of the main duct, are practically the only form of disease of the pancreas that comes within reach of the surgeon. They project forward, either beneath the right lobe of the liver or in the left hypochon- drium, pushing the stomach to the right, the spleen to the left, and the transverse colon downward. In some cases fluctuation is very plain ; in others there is com- municated pulsation from the abdominal aorta, or the tumor moves up and down with respiration. General emaciation is not uncommon ; as it occurs even with small cysts it has been suggested that it maybe due to interference with the solar plexus. There may be a sense of oppression or paroxysmal attacks of pain, deep between the ensi- form cartilage and the navel, with a feeling of intense anxiety. Undigested muscu- lar fibre may be present in the stools ; vomiting is not unfrequent : the bowels are often very irregular, and sometimes at least the complexion becomes peculiarly earthy. The diagnosis can only be verified by aspiration. The fluid may be dark brown and turbid, like pea-soup, or the contents may be clear, or they may be mixed with pus or blood. In several cases the presence of similar ferments to those of the pancreatic juice has been ascertained by experiment. Hydatids of the liver and other organs, ovarian, mesenteric, omental, and renal cysts, dropsy of the omental bursa, and distention of the gall-bladder, closely resemble it, and, in many cases, have only been distinguished at the time of operation. Extirpation may be practicable occasionally ; in most instances, incision and drainage are to be preferred. The openings should be made over the most promi- nent portion of the tumor, the contents partially removed by aspiration, and the cyst drawn out and secured by sutures to the parietal peritoneum and the skin. If the discharge irritates the skin, boracic acid dressings should be used. MALFORMATIONS OF THE RECTUM AND ANUS. 955 CHAPTER XIX. INJURIES AND DISEASES OF THE RECTUM. MALKnRMATIONS OF THE ReCTUM AND AnUS. Of these there are two chief varieties. In tlie first the original cloacal outlet persists to a greater or less extent, and the bowel terminates in the bladder, vagina, or urethra. In the second the communication with the genito-urinary organs is shut off, but the rectum does not open upon the surface ; like the former, this is due to an arrest of development. The intestine is formed from the innermost of the germ- inal layers ; at either end it terminates blindly, the anus as well as the mouth being developed by an invagination from the exterior. Consequently three degrees of defect are possible : the anus may be wanting, and the rectum well formed (the most common) ; the anus may be well formed and the rectum wanting (the most serious) ; or, finally, both may be present, but the septum between them persist, either as a definite membrane or as a mere epithelial layer. Besides these, in exceptional cases, the orifice of the anus may be very small, and displaced, either forward, or to one side, apparently by a growth prolonged forward from the coccyx in the middle line of the perineum. The diagnosis is usually apparent at once. If, however, a distinct anal diverticulum is present, the malformation of the rectum may be overlooked until suspicion is aroused by distention, persistent vomiting, and the absence of meco- nium. The condition, if unrelieved, is nearly always fatal within a few days ; a few cases have lived for some time, even years, with regular fajcal vomiting. An exception may be made in the case of a vaginal opening, as this may not be dis- covered until adult life. If there is a communication with the urinary passages, death is usually caused by cystitis and pyelonephritis. Treatment. — The child must be held in the lithotomy position (especial care is required to keep it straight), a catheter is passed into the bladder or vagina, according to the sex, and a thorough examination made. In the slighter cases the bulging caused by the rectum when the child cries and the dark color of the meconium are visible at once, and all that is required is to tear through or divide a thin partition, leaving a little oiled lint in the opening as soon as the bowel has emptied itself. In most, however, either from the anus being absent, or from the thickness of the tissues between it and the bowel, a median incision must be made through the skin from the site of the anus to the tip of the coccyx, and the dissection carried backward, guided by the catheter in front and the bone behind. If the bowel is near the surface it may be drawn down and sutured to the margin ; but this is valueless if there is much tension. In this case a stricture is almost sure to follow unless special precautions are taken, a catheter or the tip of the finger being intro- duced at first every day. After a time the tendency to contract appears to diminish. If the rectum is not exposed in this w^ay, firm pressure should be made upon the abdomen, while the finger is in the perineal wound ; sometimes the end can be felt, or the bulging is so plain that there is reason to believe it is not far off, and then the dissection may be continued along the sacrum until the peritoneum is reached, the coccyx being resected if necessary. When this does not succeed, the choice lies between inguinal and lumbar colotomy, preference being generally given to the former, not only on account of the more convenient situation of the anus, but because when the lower part of the rectum is not developed, the rest of the large intestine is very likely to be displaced and inaccessible from behind. 956 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Opening the peritoneal cavity through the perineum has been advocated, on the ground that it saves the risk of a double operation, and that as the external sphincter is usually present in these cases, the inconvenience of incontinence would be avoided ; but the difficulty of recognizing the character of the intestine at such a depth is very great, and the power of selection very small. When there is a communication with the vagina a bent jjrobe may be passed through it into the rectum as a guide ; but it rarely happens that the opening is on the side of the bowel, with a blind pouch running beyond ; nearly always it lies at the end. In this case, and also when the rectum communicates with the urinary passages, an anus must be formed, if possible in the natural situation, and the com- munication closed by a subsequent operation. Examination of the Rectum. In many cases it is advisable to give an injection beforehand, so as to bring down the upper part of the bowel. The patient should lie well over on the left side with the hips and knees flexed, and the back to the light. The character of the skin and of the orifice of the anus is noted first, whether there is any discolora- tion, swelling, or abnormal opening. Then gentle pressure is made all round to ascertain if there is any induration or fluctuation, or any very tender spot, espe- cially near the margin. The mucous surface of the orifice is then inspected. The fingers are placed upon the buttocks, and, with the thumbs quite close to the anus, the sides are firmly separated while the patient strains down. Small ulcers and fissures at the margin, polypi, and internal piles can often be seen at once. The finger is then introduced, well oiled, and the angles of the nail filled in with soap. The pulp should be placed over the orifice and the patient told to bear down ; as the muscles relax they carry it in with them. If there is any evidence of fissure slight pressure should be made toward the opposite margin. Except in the case of polypi, the marginal part of the mucous membrane is always examined first ; painful ulcers, the orifices of fistulae, and the like, are in the majority of instances within an inch of the edge. Then the investigation is carried higher, the character of the surface ascertained, and, by deeper pressure, the condition of the neighboring organs. By making the patient bear down, especially if he is standing, an inch or more of the rectum can be brought down on to the fingers : but in cases in which the disease is situated high up, or there is a difficulty of diagnosis, it is advisable to give an anaesthetic. When the muscles of the floor of the pelvis are well relaxed, the perineum can be pushed in in front of the knuckles, and the finger can generally reach the promontory of the sacrum. If this fail, further examination may be carried out with the speculum, the long tube, or the hand. The most convenient form of speculum is a short conical metal tube, open at the end and on one side ; but thii, of course, only exposes the part immediately inside the anus. If it is wished to inspect the deeper portion the patient must be placed under an anaesthetic, in the lithotomy position, with the jjelvis well raised so that the intestines may sink toward the diaphragm, and the sphincter be dilated. Metal tubes, then, of various sizes, may be very carefully introduced, the mucous membrane being lifted from off the opening from time to time with a sponge on a holder. Rectal bougies as a means for diagnosis are dangerous and misleading. They nearly always catch, either against the sacrum or behind some fold of mucous mem- brane, and very often give rise to the suspicion of a stricture where none exists. Enema tubes are a little better, as by injecting fluid through them the mucous membrane may be lifted off from the end out of the way. Sometimes then the tube can be passed a few inches further, proving that there is no stricture ; but, if it cannot, no conclusion can be drawn. Finally, the hand, provided it is under seven inches in circumference, can be HEMORRHOTDS. 957 introduced in most wcU-fornied adults. I'he patient must be under an anaesthetic ; the sphincter very gradually dilated ; and then the fingers slowly wormed in with a screwing action until the broader part sli|)s inside. (Jil or vaseline should be freely used. 1 have on several occasions done this myself, and have found it once or twice of very great use in diagnosis. The proceeding is not without danger ; there are several cases on record in which sudden death occurred, ])rol)abIy from rupture of the peritoneal band that surrounds the bowel. This can be felt like a cord passing across it obliiiuely, about four inches up, and it must on no account Fig. 410. — Allingh.-im's Rectal Speculum. be forced. The sphincter, of course, loses its power for some days, but I have never found any permanent paralysis follow. If the hand cannot be introduced, owing to the peritoneal fold, a combination of these two methods is very useful, the long enema tube being passed up the pal- mar surface, and guided by the fingers into the smooth tubular portion above. Injuries of the Rectum. Lacerations of the margins of the anus are occasionally caused by the passage of hardened faeces, or by the rough use of enema tubes, and sometimes they degene- rate into very painful ulcers. The anus, too, may be torn in parturition, the pe- rineum giving way completely. Foreign bodies of all sorts occur from time to time, some, such as fish bones, enteroliths, gall-stones, and other foreign bodies, coming down from the bowel, others introduced from below ; and it may require very great ingenuity to extract them without inflicting serious injury. Hemorrhoids. The veins that surround the lower part of the rectum are exceedingly liable to become distended and varicose. Sometimes they remain in this condition ; more frequently, owing to the congestion and oedema, and from the constant irri- tation to which they are subjected, the cellular tissue around becomes inflamed ; the lymph that is poured out becomes organized, and at length distinct tumors, known as hemorrhoids, are formed. These maybe classed as external, internal, or intermediate, according to their situation under the skin, under the mucous mem- brane, or partly under the one, partly under the other. Their frequency is due to the structure of the part. The hemorrhoidal plexus lies under the mucous membrane, inside the margin of the anus, and a short dis- tance up the bowel. The blood from this returns partly by the superior hemor- rhoidal veins, which commence close to the edge, and run up in the sub-mucous layer before piercing the muscular coat ; partly by the middle and inferior ones. 958 DISEASES AND INJURIES OF SPECIAI STRUCTURES. which end at length in the internal iliac. Of these the first are by far the most important ; the others merely drain the anal margin and the region of the external sphincter ; and the communicaticJa between the two is so poorly developed that it is of little use in affording relief ; an injection thrown into the hemorrhoidal i)lexus through the inferior mesenteric does not pass on into the iliac veins. This plexus, therefore, lies at the root of the valveless portal system, and feels the strain first and most severely when anything impedes the flow of blood upward through the abdomen and liver. Another point is that while the veins of the rest of the abdomen are sup- l)orted by the walls, and jjrevented from becoming distended when the muscles of the abdomen contract, the hemorrhoidal plexus is entirely unprotected, and, owing to the peculiar laxity of the tissue in which it lies, is quite incapable of resisting the increased blood-pressure. Straining or bearing down, if there is the least dilatation, makes the veins swell out at once, and the mucous membrane becomes ])uri)le. This, of course, subsides again as the muscles relax, but it can easily be understood how the frequent repetition slowly but surely makes the dila- tation worse and worse. Verneuil attributes much imijortance to the su]:)erior hemorrhoidal veins pass- ing through valvular openings in the muscular wall of the bowel a short distance above the anus, believing that the contraction tends to constrict them and check the flow. If, however, this were the case, it would easily relieve them from the backward pressure of the blood higher up in the portal system. The exciting causes are of the most varied description. Every impediment to the return of the blood helps : valvular disease of the heart ; chronic bronchitis and emphysema ; cirrhosis of the liver ; abdominal tumors ; pregnancy; accumu- lation of fKces ; everything, in short, that directly or indirectly checks the return circulation. Constant straining, whether arising from constipation or from causes con- nected with the urinary tract, calculus, stricture, or enlarged prostate, acts in the same way, perhaps more rapidly. Active congestion, such as arises from the repeated use of unsuitable purga- tives, over-indulgence in alcohol, sexual excesses, and, in women, from uterine or ovarian affections, often brings them on. Still more frequently it precipitates an acute attack, and is the immediate cause of the patient applying for relief. Whether hereditary influence has any effect of itself, as distinct from that which is due to the same habits and the same mode of life, is very doubtful. Few people attain old age without some enlargement of the hemorrhoidal veins ; this is the natural result of the anatomy of the part. In the majority of cases, unless there is some additional reason, causing hyperoemia for some considerable time, and leading either to inflammation or to chronic congestion and oedema, the con- sequences are not sufficiently serious to make them apply for relief. External hemorrhoids differ from internal ones in so many respects that it is advisable to deal with them separately. There is rarely any difficulty in distin- guishing one from the other. The former are covered with skin, and, unless there is a large throml)us in some superficial vein, are some shade of pink, according to the pigmentation present and the degree of inflammation. Moreover they cannot be returned into the bowel by pressure. The latter are covered with mucous membrane ; their surface is soft and smooth, and their color bright red or purple. If they have been prolapsed for some time they become dry and rough ; but they can always be returned as soon as the sphincter is relaxed. Intermediate ones, partly subcutaneous, partly submucous, with the white line that marks the junction of the two surfaces passing over them, are very com- mon. Clinicallv thev resemble internal ones in most of their features. EXTERNAL AND INTERNAL ILEMORRHOIDS. 959 External Hk.mourhoids. These liegin as dilated veins around the margin of the anus and form soft, livid swellings which disajjpear on pressure and grow firm and hard when the patient strains. As such they may last for an indefmite time without the least inconvenience. Sooner or later, however, chronic congestion and (jedema set in ; lymph is poured into the cellular tis.sue ; the veins are obstructed ; and then, as the exudation becomes organized, the skin grows out into thickened, irregular folds, which, when once developed, are permanent. These are sometimes called cutaneous piles. When these are irritated or become inflamed, all the symptoms are aggra- vated. In some cases the central vein is plugged with a thrombus ; and a hard and tender knot, dark i)urple in color, forms in the centre of the pile. In others the cellular tissue is chiefly concerned ; the pile becomes many times its former size ; and the skin over it grows tense and pale from the amount of fluid it con- tains. Very often, just inside the anus, at the base of the pile, there is a small crack or abrasion from which the inflammation starts. In severe cases the whole circumference is involved, so that the opening seems buried in the centre of a swollen ring. When the vein is primarily affected the pile is sometimes called thrombotic ; when it is chiefly the skin and cellular tissue, Kciematous ; but in many instances it is impossible todistinguish them. Symptoms. — In the slighter cases there is merely a sense of heat and irrita- tion about the anus, with itching, especially at night. Defecation is attended with a certain amount of pain, and there is rather a tendency to strain ; but, so long as the bowels are moderately relaxed, there is little more than discomfort in the intervals between the motions. When the inflammation is severe, the paiYi may be intense, especially if the part is touched, and when the bowels are acting ; in some cases it is almost as bad as in fissure, though it rarely lasts so long. The throbbing is constant; there is a persistent sense of fullness; the sphincter is in a state of spasmodic contraction ; and, if the bowels are confined, the straining and tenesmus scarcely cease. Sometimes the constitutional disturbance is very severe, and in nervous, excitable people, there may be a high degree of fever. Suppuration is not uncomQ\i d& fissure of the anus ; when, on the other hand, they are higher 972 DISEASES AND INJURIES OF SPECIAL STRUCTURES. up, above the level of the external sphincter, they are at first very vague. Diar- rhoea is the most prominent ; as soon as the patient gets out of bed there is an immediate desire to go to the closet, and a small quantity of liquid faeces with some mucus, like white of egg, comes away. The same thing occurs perhaps once or twice in the morning; and then, if the ulceration is not far advanced, the rest of the day is passed in comparative comfort; the rectum is empty and there is nothing to irritate it. In all but the slightest ca.ses, however, there is a constant .sense of fullness and tenesmus ; normal motions are never passed ; the amount of discharge increases ; it loses its simple mucous character, and becomes dark, like coffee-grounds. Control over the sphincter is lost ; the skjn around the anus is constantly moist ; it becomes covered with vegetations and excres- cences, between which fissures form. Then the pain becomes more severe ; after each motion it is intense, and in the intervals there is always a constant dull aching. Finally, the diarrhoea becomes almost continuous ; health and strength fail; the appetite is lost; colicky spasms and pains over the lower part of the abdomen grow more frequent ; abscesses and fistulae form around the bowel ; the emaciation becomes extreme; and the patient sinks from exhaustion, if he is not carried off by some intercurrent disorder. Diagnosis. — In advanced cases the appearance of the anus at once suggests the presence of more serious mischief. The thickened and pigmented folds, with deep and painful ulcers in between, and the eczematous condition of the skin, can only be caused by long-continued irritation ; but the diagnosis can only be made with the finger or the speculum. The former is nearly always sufficient ; the latter can only be used with an anaesthetic, and with either the utmost gentleness is es.sential. Immediately inside the anus the mucous membrane is generally un- affected, though both in syphilis and advanced tubercular or lupoid disea.se it may be nearly as bad as the rest ; higher up the normal soft character of the bowel is entirely lost. The surface is rough and irregular ; hard nodules project here and there ; in some places the walls are dense and thick, like stricture tissue, and the passage is narrowed ; in others there are soft smooth patches, surrounded with overhanging edges, which bleed at the least touch ; and the finger when it is with- drawn is smeared with blood-stained mucus. Sometimes it is jjossible from this alone to form an opinion both as to the extent and cause of the disease. Syphilitic ulceration is often accompanied by other signs ; tubercle rarely leads to the formation of dense cicatrices, and nstulae generally make their appearance very soon. Dysentery, on the other hand, may destroy all trace of normal mucous membrane, and often extends far beyond the reach of the finger. In the majority, however, a careful inquiry into the history, and into the other symptoms that are present, is essential ; and even then it is sometimes difficult to exclude the idea of malignant disease. Treatment. — Rest is the first consideration. The patient must lie down for at least the greater i)art of the day, with the foot of the bed raised to prevent venous congestion. The faeces must be kept as soft and as small as possible ; everything that is stimulating or indigestible, or likely to leave a bulky residue, must be strictly avoided. Pure milk diet for a time is often advantageous. All straining must be prevented ; the bowel must be washed out night and morning with warm water or an astringent lotion — nitrate of silver in the ca.se of dysen- tery, lotio nigra for syphilis ; and after this a simple unirritating ointment (calo- mel, gr. X ad 5J (.60 ad 32), nitrate of bismuth, iodoform, or nitrate of mercury), may be applied either as a supi)ository or with a suitable ointment introducer. Starch and opium injections are excellent means of controlling the diarrhoea. In the meanwhile constitutional treatment must not be neglected. Iodide of potash must be given in syphilitic cases. Cod-liver oil. if the patient can take it, often answers better than anything, as there is nearly always great loss of flesh and strength, and it tends to keep the motions soft ; if iron is given care must be taken that the bowels are not confined. In a few cases where the ulcer is low down, and the spasmodic contraction of the sphincter is severe, perfect rest may PERIPROCTITIS. 973 be obtained by subcutaneous division of the nuisclc or by stret( hinj; it ; but this is seldom of any good in the more severe forms. In these, when all local treat- ment tails, colotomy is the only resource. Periproctitis. Inflammation around the rectum may occur at the anus, in the ischio-rectal fossa, or higher up in connection with the insertion of the levator ani and the recto-vesical fascia. 1. Injlamination around tlic margin of the anus in many cases is symptomatic of some deeper di.sorder : there is a constant offensive discharge from the anus; the ])arts are continuall)' moist ; the ejiidermis is macerated ; and the deejjer papillary layer of the skin exposed. Inflamed external hemorrhoids, small cutaneous boils, suppuration in connection with the hair follicles, and syphilitic eruptions are not uncommon. Very often it is due to injury, repeated straining, the passage of hardened fseces, or the abuse of enemata ; or it may occur after parturition. Of itself it may be trivial in character, but it becomes of great importance from the tendency it has to leave behind it painful fissures and super- ficial fistulae. 2. Ischiorectal abscess \i \\\\\c\\ more serious. It maybe acute or chronic. In the former case the symptoms closely resemble those of i:»roctitis. It may com- mence with a rigor ; the pulse is quick, the tongue furred ; there is the most intense throbbing in the perineum ; sitting down is almost impossible ; the rectum feels as if it were loaded with fjeces, but the least attempt at relief brings on the most violent pain and straining. On examination there is a hard, brawny swelling by the side of the anus ; the skin is red and oedematous, pitting on pressure ; and if the finger ia introduced into the bowel, the hardness can be felt through the wall for some distance above. Sometimes the inflammation is even more acute than this, and a form of gangrenous cellulitis which may prove fatal sets in. In the chronic form, on the other hand, the swelling is painless, and often lasts for weeks. There is merely a soft fluctuating swelling, filling the whole of the ischio-rectal fossa and extending up by the side of the bowel, covered in with a thin layer of discolored skin. Not unfrequently the patient is almost unaware of its existence, and it may attain a very large size and burrow for a considerable distance before the skin gives way. When this happens, the opening is always large and ragged, with thin, overhanging edges, like those of a scrofulous sore, and a fistula is almost certain to be left. The frequency with which these abscesses occur is accounted for partly by the ease with which septic absorption takes place through abrasions of the mucous surface, partly by the anatomy of the region. Owing to the rapid variations in size of the bowel, the tissues are badly supported ; the circulation is feeble ; there is a large amount of loo.se fat with dilated veins ; and the vessels have even a greater tendency to become varicose than those of the lower extremities. Phlegmonous inflammation is rare, except in those who are thoroughly broken down ; most of the cases recorded have been in persons who were suffering from sj)ecific fevers. Acute abscess may usually be traced to exposure to cold ; injury ; perforation of the mucous membrane from the inside by a fish-bone or other foreign body ; tearing of the mucous surface from straining or the passage of hardened faeces, or bruising of the subcutaneous tissue, leading to extravasation in the ischio-rectal fossa or venous thrombosis. The chronic form is probably due in a very large number of cases to the breaking down of tubercular deposit in connection with the adenoid tissue of the rectum ; or it may be a complication of stricture, begin- ning either from an ulcer on the mucous surface, or independently of this in the lowly organized inflammatory exudation surrounding the bowel. In addition to this, suppuration may extend into the ischio-rectal fossa from distant organs : urinary abscess is not uncommon ; necrosis of the sacrum or 974 DISEASES AND INJURIES OF SPECIAL STRUCTURES. coccyx occasionally gives rise to it ; coccygeal dermoid cysts may cause it ; and it has been known in caries of the lumbar vertebrae. Ischio-rectal abscesses should be oj^ened at once and freely, or a fistula is almost certain to form. Even if there is merely a tense, hard, and j)ainful swelling, it is better to run the risk of not finding pus. If the abscess is small and close to the rectum, so as to give rise to the suspicion that it is really intramural, the patient should be placed upon his side, with the knees drawn up, and the finger introduced into the bowel to fix the swelling and make it project toward the skin. Then a straight bistoury is introduced, and an incision sufficiently free to give exit to the ])us, made radially from the anus. Some of the outer fibres of the external sphincter are divided, and the opening will not close too soon. True ischio-rectal abscesses, on the other hand, must be laid freely open by a longitudinal incision, parallel to the anus, midway between it and the ischium ; and as soon as the pus has escaped, the finger must be introduced, the cavity explored, and the partitions inside broken down. Afterward the opening must be kept patent to ensure the abscess healing from the bottom. Lint should be avoided, as the discharge is liable to collect behind it, and its removal is very painfiil. Gutta-percha tissue, folded irregularly so as to fit inside the orifice without blocking it, is the most con- venient. The cavity, if the dressing does not come away easily, can be syringed out behind it, and it does not absorb the discharge. The patient should be kept in bed, or at least lying down, until the abscess has healed. If it is an acute one, this will not be many days ; if it is chronic, the greatest care is necessary to pre- vent it degenerating into a fistula. The bowels should be well opened once, and then kept confined for several days, the diet being very light, so that there may not be an accumulation of fceces. When they are opened an effectual purge should be given to avoid straining. 3. Inflamination oti the Visceral Surface of the Levator Ant. — This is nearly always caused by extension from some of the neighboring viscera, and i-f it involves the rectum is nearly always associated with stricture. Occasionally it originates from the bowel, much more frequently from the uterus, following parturition or metritis, and probably it is for this reason that stricture of the rectum is so much more common in women than in men. The inflammation may be acute, attended with high fever, and soon ending in suppuration ; or chronic, spreading from one part to another until they are firmly bound down to each other and to the pelvis by bands of cicatricial tissue which may be almost of cartilaginous hardness. When it starts from the region of the uterus, the anterior surface of the rectum is first involved. 'I'he inflammatory exudation spreads into the substance of the muscles until the fibres become atrophied and the walls hard and unyielding; the mucous membrane becomes rigid and unable to unfold itself; the constant irritation caused by the passage of the f^ces gradually leads to hypergemia and thickening of the submucous tissue ; and at length a definite stricture is formed, which maybe either tubular in shape, extend- ing for some distance along the bowel, especially on the anterior surface, or sharp, well-defined, and annular, about an inch and a half or two inches above the anus. If suppuration occur the abscesses may break into the bladder or vagina, or they may extend through the sacro-sciatic foramina, or even burst into the peritoneal cavity. Fissure of the Anus. A distinctive name has been given to a small ulcer which occurs on the margin of the anus or on the mucous membrane just inside, because of the extraordinary severity of the symj^toms to which it gives rise. It usually lies upon the posterior wall, very often hidden by a small external pile ; and so long as the anus is contracted, it has the appearance of a fissure lying between two rather oedematous muco-cutaneous folds. If, however, these are separated and the anus distended, it is seen to be a circular or oval ulcer, lying sometimes on the white line at the junction of the skin and mucous membrane, FISSURE OF THE ANUS. 975 sometimes wholly on the latter ; in this case the symptoms are less severe. In some instances it is ijuite superficial ; in others, it extends completely through the mu- cous and submucous tissues, and exposes the fibres of the sphincter beneath. As time passes, the edges become thick and oedematous, and, not unfrequently, the mucous membrane is undermined, so that a short sinus runs upward in the sub- mucous tissue. Occasionally, a fold grows out into a polypoid form, and lies in the fissure when the anus is closed ; and, if the disease lasts any time, the sphincter and the levator ani always become hypertro[)hied, from their persistent contrac- tion, so that the orifice is tightly drawn up when the least attempt is made to expose the ulcer. An ulcer of this kind may be formed by any slight tear or abrasion ; very often, patients assign it to the passage of some especially hard motion ; it is not uncommon after parturition ; it may follow diarrhoea, and, not unfrequently, some syphilitic abrasion forms the starting point ; or it may be due to an inflamed ex- ternal pile, an irritating discharge, or chronic congestion kept up by uterine dis- placement. In some people, the orifice of the anus seems almost as prone to crack as the mucous membrane of the lips, but, fortunately, most of these little sores get well of themselves, or with very simple treatment ; it is only a few of the cracks and fissures that give rise to the characteristic symptoms of fissure of the anus. Symptoms. — Of these the chief is pain — pain of the most excruciating character, coming on as the bowels are acting, and lasting perhaps for hours with- out abating. It is usually described as the pain of a red-hot iron, or of violent tearing ; the patient is in a state of collapse, unable to move ; the pulse is scarcely perceptible ; and the forehead covered with perspiration ; and this, in the worst cases, may continue for almost the whole day. In others, it is less severe ; when, for example, the ulcer lies above the white line, it often does not come on at once, and may only last for a short time ; but, even so the patient may be entirely pre- ■ vented from doing any active work. Often the symptoms are aggravated by con- stipation ; the patient dreads each action of the bowels, and postpones it as long as possible, so that the faeces become hard and dense, and the suffering tenfold more severe. Retention of urine is a common consequence in men, and menstrual disorders in women. Dyspepsia, loss of strength, extreme anaemia, violent pains down the back and loins, and other effects soon make their appearance, until at length the sufferer and his friends are firmly convinced that symptoms of such intensity can only arise from malignant disease. The diagnosis rarely presents any difficulty ; neuralgia of the rectum is the only trouble likely to be mistaken for it ; no other affection causes such peculiar and severe pain. Sometimes a stain of blood or mucus is noticed upon the mo- tions, or there is a slight mark upon the skin. The anus, when it is inspected, is tightly drawn up and contracted, the glutei closely approximated, and the sphinc- ter feels hard and firm ; sometimes, there is a small external hemorrhoid near the margin, or the edge of the ulcer may be seen. Examination with the finger is so painful that, where the symptoms are well marked, it is always advisable to give an antesthetic. The orifice then can be dilated, and, as the mucous membrane is everted with the pressure of the fingers, the whole of the ulcer becomes visible, first as a fissure, and then as a small, round, granulating surface, the base of which is sometimes covered with a thin slough. The extreme severity of the symptoms is accounted for by the exposure of some nerve-filament upon the floor of the ulcer. The degree of pain varies very much in different cases ; it is always less when the mucous membrane only is affected, and, not unfrequently, the excessive sensitiveness of the surface is limited to one or two small points, evidently spots where the nerve-fibres are lying bare. Treatment. — In the early stages the ulcer can sometimes be cured by keep- ing the motion soft, and applying a mild astringent ointment, nitrate of mercury, calomel, or sulphate of zinc, night and morning, and after every action of the bowels; but, as a rule, something further is required. The object is to give the 976 DISEASES AND INJURIES OF SPECIAL STRUCTURES. ulcer perfect rest ; if this can be done, and if there is no ]jolypoid growth hanging over it, i)reventing its closing, it will generally heal in the course of a few days. The simi)lest i)lan is to apply caustic to the surface — nitrate of silver or the acid nitrate of mercury. The patient must be placed under an anaesthetic ; the floor of the ulcer freely exposed, and then well cauterized, so as to cover it with a pro- tecting layer. Afterward the bowels must be prevented from acting for a day or two, and the patient kei)t in the recumbent position, until the .sore has healed. If, however, the sphincter is hypertrophied, or if there is a ])olyi)oi(l growth overhanging the ulcer, this is not enough, and, in most cases, even when neither of these conditions is present, it is advisable to adopt a more thorough i)roceeding from the first, dividing the superficial fibres of the muscle, or stretching it so that it cannot contract. A coml)ination of the two is the most useful, though either will succeed alone ; the patient is i)laced under an anaesthetic, and the anus thor- oughly dilated with the fingers ; then, when the floor of the ulcer is exposed, an incision is made across it, about a quarter of an inch in depth, so as to divide the superficial fibres of the sphincter. If there is a small sinus under the mucous membrane, it should be slit up at the same time ; overhanging edges of mucous mem- brane should be excised, and any small polyi)oid outgrowth or hemorrhoid removed as well. Complete division of the external sphincter is an unnecessarily severe proceeding ; a very slight cut is usually sufficient, especially in those cases in which there is one exceedingly painful spot ; if the nerve upon which this depends is divided, the pain ceases, the spasmodic contraction of the sphincter begins to relax ; the ulcer is placed at perfect rest, and begins to heal at once. It is diffi- cult, however, to make sure of doing this, and if the sphincter is very tense, stretch- ing or superficial division is usually advisable. Sometimes the ulcers are multiple, but only one incision is required. While the patient is under the anaesthetic, the opportunity should be taken for thoroughly examining the rectum higher up. If there is any complication present, or if in women there is any displacement of the uterus, and this remains unrectified, it is highly probable either that the ulcer will not heal, or that, if it does, it will form again as soon as the patient begins to get about. Fistula in Ano. By fistula, in the general sense of the term, is meant a sinus in the neighbor- hood of the anus, left by an abscess which has healed up to a certain point, and then either remained stationary, or even grown worse. It may be complete with one opening in the bowel and the other on the skin ; or incom])lete, the internal or external o])ening only being present. The former of these is known as a blind internal fistula, the latter as a blind external one. In point of importance, fistulae may be divided into anal or rectal. The former merely occur near the margin of the anus, and are either entirely subcuta- neous, or are merely covered in by some of the fibres of the external sphincter; the latter are larger and deeper, running from the ischio-rectal fossa, between the sphincters, or even above the internal one, and are often com])licated by sinuses under the skin or in the submucous tissue. The causes of fistulx are essentially those of the abscesses which give rise to them ; injury to the mucous membrane, from fish bones or other foreign bodies ; tubercular deposits; stricture; extravasation in the loose fatty tissue of the ischio- rectal fossa; inflamed hemorrhoids ; cutaneous boils, etc. The reason of their persistence is to be found in the mobility of the part, the spasmodic contraction of the sphincter and the levator ani, and, if there is an internal opening, the con- stant entrance of irritating substances from the bowel. Blind internal fistulae are the most rare ; complete ones by far the most common, although it is sometimes a little difficult to find the internal opening. Prol)ably, most are incomi)lete at first, but the second opening is soon formed ; the abscess, as it enlarges, works its way simultaneously toward the bowel and the skin, and, unless it is opened FISTULA IN A NO. 977 early, the mucous membrane is separated from thesul)jacent tissue to such a degree that it gives way by ulceration even after the pressure of the jnis is relieved. A fistula may be either a straight passage from the skin to the bowel, or it may be complicated by sinuses running from it in every direction. The most common of these is in the submucous tissue ; the internal orifice is nearly always on a level with the internal sphincter, seldom more than an inch or an inch and a half from the anus ; but the sinuses may run \\\i from this under the mucous mem- l)rane for several inches. More rarely, instead of taking this direction, it passes round the bowel, causing what is known as horsc-shoc fistiihe, and opening some- times on one side, sometimes on both. In other cases, especially where there is a stricture of the rectum, these offshoots extend under the skin of the buttock, and even open several inches away. The walls of a recent fistula are covered over with granulations, and secrete a thin, purulent fluid ; after repeated attacks of inflammation, they become thick and dense, the lining smooth and glistening, like the surface of a chronic ulcer on the leg. The external orifice may be a mere pin-hole, or lie in the centre of a little button-like mass of granulations; or, in tubercular patients and after the rupture of a chronic abscess, there may be a large, irregular opening with undermined edges, like a scrofulous ulcer on the neck. The internal orifice presents very much the same character ; sometimes it feels like a distinct little papilla resting on a base that is firmer than the surrounding parts ; sometimes, on the other hand, especially in the case of blind internal fistulae, it is a large, irregular ulcer. Symptoms. — So long- as there is free exit for the discharge, fistulas merely give rise to inconvenience and discomfort. The skin around the anus is constantly moist, the surface becomes tender and eczematous, and little cutaneous boils are apt to form. In the worst cases there may be an escape of f^ces and flatus through the orifice, but there is never the agonizing pain of fissure. Now and then the orifice becomes blocked ; the discharge collects ; the skin becomes hot, and red, and tender ; the action of the bowels is attended with pain, and a small abscess forms. When this breaks, or is opened, the symptoms subside again, but each time it means either an increase in the density of the tissues around or the forma- tion of an outlying sinus. Diagnosis. — There is rarely any difficulty in this : the patient is usually aware already of the cause of his suffering ; and the presence of a small orifice by the side of the anus, from which a drop or two of thin semi-purulent fluid can be squeezed, is conclusive ; but this is not sufficient. It is necessary to ascertain the kind of fistula ; whether it has an internal opening, and where it is ; whether there are many sinuses in connection with it, and where they run ; and, particularly, whether there is any cause for its persistence other than the action of the sphincter and the mobility of the part. There may be, for example, a stricture of the rectum, high up, and a complete fistula with its internal orifice in the usual situa- tion near the anus ; or, what is even more perplexing, there may be a complete fistula and necrosis of the sacrum or coccyx at the same time ; the diseased bone has caused the formation of an ischio-rectal abscess, and this has led to the devel- opment of the fistula. Of course, in either of these cases, an operation upon the fistula only is worse than useless. The patient should lie upon a couch, on the affected side, with the knees drawn up. In most cases the orifice of the sinus is visible at once, but sometimes it is very small, concealed behind folds, or closed for the time being. If it cannot be seen, the induration can nearly always be felt, even when the fistula is a blind internal one, and very often a little pressure causes a drop of pus to exude. Sometimes the whole track of the sinus can be made out with the finger. When there is an opening a probe may be gently passed into it before any- thing further is done, in the hope that it may succeed in reaching the internal orifice without exciting the action of the sphincter. Usually the sinus runs almost under the skin toward the bowel. If this does not succeed the finger must be introduced and the mucous surface carefully explored just inside. Generally there 978 DISEASES AND INJURIES OF SPECIAL STRUCTURES. is no difficulty in feeling the opening; if, however, it cannot be found, either a speculum may be used or some milk or other colored fluid injected into the orifice ; nearly always some of it finds its way into the bowel. It is a common mistake to pass the finger in too far at first and overlook the opening. Blind internal fistulae differ from the others. They usually communicate with the bowel by an aperture of some size ; and from the fact that fnecal matter is con- stantly entering and setting uj) inflammation, they are very often attended with a good deal of i)ain. There is no discharge externally ; but the i)atient is usually aware of a swelling by the anus emptying itself every now and then into the bowel with tem])orary relief. Digital examination nearly always reveals a hard and painful mass in the ischio-rectal fossa, and an irregular ulcer often of considerable size in the bowel. Occasionally the sac can be emptied by jjre.ssure ; but to make the diagnosis certain, a probe bent like a hook must be passed down into the sinus through the anus. Fistulae of this kind are usually caused by a foreign body per- forating the mucous surface of the bowel, or by the softening of some tubercular deposit in the wall. Treatment. — As a rule, fistulas can only be cured by operation. In ex- Fic. 414. — Grooved Probe passed through Anal Fistula before its Division. Fig. 415. — Method of Dividing Anal Fistula. ceptional cases, in which there is no internal opening and in which the patient will submit to prolonged treatment, the sphincter may be stretched, the sinus stimulated with strong carbolic acid or tincture of iodine, and the external orifice kept widely open in the hope that it will close ; but it nearly always ends in failure, after a long waste of time. The only method that deserves reliance is division of all the structures between the fistula and the anus, so as to lay it open from one end to the other and give it complete rest. An aperient is given the night before and an enema the morning of the oper- ation. The patient is placed under an anaesthetic, and laid on the affected side, close to the edge of the table, with the knees well drawn up, and held by an assist- ant, who also raises the upper gluteal fold. The sphincter is gently dilated and a director passed from the external orifice along the sinus into the bowel. Care must be taken to bring it out at the internal opening and not make a fresh one, except in the case of a blind external fistula. Then the point of the director is brought out through the anus, so that the structures to be divided are stretched over it like a bridge, and a clean incision made through them with a sharp-pointed bistoury (Fig. 414). FISTULA IN A NO. 979 If this cannot be done, the finger is introduced into the bowel, a blunt- pointed bistoury i)assed along the director until its end can be felt coming through the orifice, and then, after withdrawing the director, the finger and the bistoury are brought out together so as to divide with one sweep all the structures that lie between them (I'ig. 415)- After this. exi)loration must be made for outlying sinuses. A submucous one may be laid open with a pair of blunt-pointed scissors ; or if from its position there is any risk of serious hemorrhage, an elastic ligature may be passed through it by means of a suitable probe and tied as tightly as possible. Those under the skin are treated in the same way ; or if they are of great length a drainage tube may be passed along them and brought out through an incision at the other end. If one is overlooked, an abscess is almost sure to form before the wound is healed, and render a second operation necessary. In the case of old fistuhe lined with a smooth layer of false mucous membrane, the walls must be scraped out thoroughly, with the sharp spoon, so as to insure removal of all the indurated mass. Polypoid outgrowths and hemorrhoids are dealt with at the same time ; and loose and undermined flaps of skin are cut away, though discretion is necessary. Any bleeding point is tied or twisted at once, the wound packed with iodo- form gauze, and a firm pad placed over the anus and secured in position with a T bandage. The following day all external dressings are removed and the deeper layer allowed to separate in a bath. The wound is cleansed night and morning and after each motion, pain being prevented by cocaine, and a single fold of lint laid between the edges. The application should be varied from time to time, ac- cording to the state of the granulations. The bowel should not act for four or five days after the operation, and the motions should be kept soft until the wound is perfectly sound. The recumbent position is essential until healing is completed, although it is not necessary for the patient to be kept actually in bed for more than a week or ten days. I have succeeded in obtaining union by the first intention by thoroughly re- freshing the base of the sinus after the sphincter had been divided, and bringing the surfaces together in accurate contact with deep wire sutures. It is necessary, however, to remove them at the least sign of suppuration, or secondary sinuses may form. Probably buried catgut sutures would answer better ; but this can only be tried when the fistula is recent and simple in character, and when the patient is young and healthy. In cases in which there are deep sinuses, where there is much reason to fear hemorrhage, or where the patient is exceedingly nervous, an elastic ligature may be used to divide the tissues gradually. It should be a solid cord, passed through from the bowel into the sinus, drawn as tightly as possible, and secured by means of a leaden clamp. Generally it cuts through in from six days to a fortnight, and without pain; but sometimes it is followed by serious inflammation, and if there are any secondary sinuses present (and it often happens that this cannot be determined until the fistula is laid open), it is almost sure to fail. The length of time that the wound takes in healing is approximately the same as after other methods of division. Incontinence of faeces is always present for two or three weeks after the opera- tion, and inability to control flatus for some time longer; but if the sphincter is divided at right angles, and in only one place, there is seldom any permanent loss of power. According to Allingham, it is fairly safe if ever so narrow a ring of the upper part of the band of the internal sphincter is left. An exception, how- ever, must be made in the case of anterior fistulcC in women ; the sphincter vaginje and the sphincter ani decussate in the perineum, and a free incision through the front part of the anus is not unlikely to be followed by incontinence. It is recom- mended in these cases to apply the actual cautery freely to the old cicatrices, and to the external and internal sphincters as well, in several places, so as to narrow the orifice of the anus by the subsequent contraction ; and it is said that the mus- cular fibres, which are always very much degenerated, soon regain a considerable 9So DISEASES AND INJURIES OF SPECIAL STRUCTURES. degree of their former power, probably because the dense scars formed in tliis way afford a firmer and l)etter l)ase for their action. Phthisical patients are exceedingly liable to fistula, but, except in cases of rapid tuberculosis, or where the patient's health is distinctly failing, this is not of necessity a bar to operation. Very great care, however, is e.ssential ; the sphinc- ters are often weak and should be interfered with as little as possible ; the diet must be good ; the patient must not be kept in bed too long, and a time should be chosen when the cough is not very troublesome ; but even then the wounds are not unfrequently exceedingly slow in healing. Stricture of the Rectum. Stricture of the rectum may be simple or malignant. The former is either congenital or the result of injury and inflammation ; the latter is always due to cylindrical epithelioma starting from the follicles of the mucous membrane and gradually extending into the submucous tissue. In addition to this sym]>toms of obstruction may be caused by foreign bodies, by new growths occupying the interior of the bowel, or by tumors pressing upon it from the outside so as to close it more or less completely. Congenital stricture occurs a very short distance inside the anus, where the rectal and anal portions of the intestine meet in the course of development. It usually takes the form of an annular constriction, and is really a minor degree of the defect which gives rise to one variety of imperforate anus. Simple Stricture. This is much more common among women than among men, in the propor- tion of at least six to one. It may be annular or tubular, situated near the orifice, or at the junction of the anus and rectum, or higher up in the bowel. Generally it is single ; but it may be multiple, or it may spread over a considerable extent. Sometimes it feels like a cord tied around the bowel ; more often the surface is rough and irregular, deeply ulcerated in places, and covered with cicatrices in others ; and the walls, instead of being soft and yielding, are hard and rigid. The muscular fibres are wasted, and the connective tissue in and around the bowel so hard and dense, that the portion involved is converted into a rigid tube, down which the faeces are forced by the accumulation above. Generally the anterior part of the rectum is more affected than the rest, and not unfrecjuently the fibrous tissue around it for a considerable distance is as dense and hard as cartilage. Above, the bowel is distended and its muscular coat hypertrophied ; very often there is ulceration from the pressure of the f?eces, and occasionally small hernial protru- sions of the mucous membrane are formed, like those of the bladder in chronic cystitis. Below, the mucous membrane is always in a .state of chronic congestion ; and catarrh, piles, prolapse, and fistula commonly occur. Outside, in the cellular tissue around, suppuration always breaks out sooner or later, sometimes starting from the mucous surface, sometimes independently ; and pelvic abscess, recto- vesical or recto-vaginal fistula, or even general peritonitis from rupture into the peritonea] cavity, may follow. Causes, — Stricture close to the orifice may result from imperforate anus (the after-treatment not having been properly carried outj or from injury, ulceration around the margin, or operations upon external hemorrhoids. Higher up in the rectum, it may commence from the outside — inflammation of the cellular tissue extending into the bowel from the uterus or other organs ; or from the interior, the mucous membrane becoming ulcerated and the submucous and other coats involved. The latter may be due to dysentery, a large portion of the sigmoid flexure and even of the colon being implicated ; or to tubercle or syphilis, the ulceration extendinjj more or less round the bowel. Sometimes it is the immediate result of operation, too much of the mucous membrane having been removed with STRICTURE OF THE RECTUM. 981 internal hemorrhoids or jirolapse ; more often it is due to the wound that is left failing to heal for a long time. Owing in part to venous congestion, in part to the irritation of the faeces and the constant contact with septic material, wounds of the bowel sometimes refuse to heal, and gradually extend by ulceration until, ■when at last cicatrization does occur, the scars are rigid and hard and extend over a considerable area. Finally, many of these cases are assigned to parturition, whether they are due to sloughing of the mucous membrane from injuries received at the time, or to inflammation of the cellular tissue around the bowel afterward. Spasmodic stricture of the bowel, as such, has no existence, but there is no doubt that many cases of ulceration and of organic stricture are complicated, and the symptoms made infinitely more severe, by spasmodic contraction of the invol- untary muscular fibre in the wall, and perhaps of the levator ani as well. Whether this, if long continued, can at length lead to atrophy and fibroid degeneration is open to question. Symptoms. — The symptoms of stricture of the rectum are partly those of obstruction, i)artly those of irritation and inflammation. Generally the latter are present first, but sometimes, when the stricture is higher up in the bowel than ustial, obstruction occurs almost without warning. Diarrhoea in the morning, on first getting out of bed, and again after food ; a constant discharge from the anus, keeping the skin moist and sore, and leading to the formation of tags and fissures ; a sense of fullness about the part, with persistent desire to strain ; and general uneasiness about the loins and down the thighs, are nearly always present. After a while there is difficulty of defecation ; attacks of constipation alternate with diarrhoea ; normal motions are never passed ; the fseces are in small, hard pellets, mixed with mucus, like white of egg at first, later with coffee-ground debris. The pain becomes more severe, radiating from the perineum all over the branches of the sacral plexus ; the griping never ceases \ the abdomen becomes distended with flatus ; there is loss of power over the sphincter, so that wind and liquid faeces are constantly escaping ; sympathetic troubles about the bladder and uterus set in ; and the patient rapidly becomes worn out by the constant suffering. If the disease is allowed to continue, the ulceration of the bowel becomes deeper and deeper; suppuration occurs in the tissues around, leaving fistulae, which may open on the exterior or communicate with some of the neighboring viscera ; the suffering becomes intense ; and death ensues at length from exhaus- tion, hectic, and profuse suppuration, or from peritonitis or intestinal ob- struction. Diagnosis. — The diagnosis of fibrous stricture of the rectum must be made by digital examination ; the finger meets either with an annular constriction, or a hard tubular canal, the walls of which are rigid and unyielding. Only in a very few cases is it too high up. By placing the patient under an anaesthetic, slightly dilating the anus, and pushing the perineum well up, the whole of the region in which fibrous stricture occurs can generally be explored. If nothing is felt, and the symjjtoms point definitely to obstruction, an attempt may be made to carry the examination further by the long enema tube, or by passing the hand into the bowel wMth the precautions already described. Occasionally olive-headed bougies, similar to those used for examining the urethra, only on a larger scale, are of use for determining the length of a stricture. Treatment. — i. General. — The diet must be nutritious, but such as to leave a very small residue ; the motions kept soft ; the bowels not allowed to act too often, and every assistance given them in the shape of enemata of glycerine or oil. Inflammation and ulceration of the mucous membrane are always present in bad cases of stricture as a consequence, if they are not the cause, and no pains should be spared to relieve them, and i)rocure cicatrization, by rest and mild astringent ointments. Iodide of potash should be given if there is any evidence of syphilis, with enemata of lotio nigra ; but it is only of use when there are specific ulcers ; it has no effect upon the scars. Cod-liver oil is of great benefit even in cases that are 982 DISEASES AND INJURIES OF SPECIAL STRUCTURES. not tubercular ; jjure milk diet may be tried with advantage for a time ; and, in short, every attempt nuist be made to restore strength, while soothing the affected parts as much as ])Ossible. 2. Local. — Gradual dilatation'x-r, the most successful ; forcible stretching, un- less the stricture is actually at the orifice, is dangerous. Where the opening is small and the tissues dense, a laminaria tent may be used ; but in most cases gum- elastic bougies of different sizes, well softened and well greased, are preferable. A small injection of oil is given first, the patient lying on his side, and the bougie very gently guided into the narrowed part, remembering that, particularly in old- standing cases, the walls are very soft in places and easily torn. As a rule, the bougie should not fit the stricture closely, but if, after one or two trials, there is no pain or sign of irritation, tapering ones may be used with caution. In some patients the bougie must be withdrawn after a few minutes; others will tolerate them for several hours, so that no definite time for their withdrawal can be men- tioned. A suppository of acetate of lead and opium, or a small injection of starch and laudanum, should be introduced as soon as the bougie is removed. It is suffi- cient in most cases if this is done every second or third day, gradually increasing the size. Where it is possible, the treatment should be kept up until a bougie an inch and a quarter or an inch and a half in diameter will pass with ease ; and even then it is essential to make use of them occasionally afterward, in order to prevent a relapse. Xot unfretiuently, after the treatment has been carried out for a short time, the rectum becomes irritable ; the skin round the anus red and tender ; the amount of discharge increases ; and there is a certain degree of feverishncss. In this case, the bougies must be left off at once, the patient confined to bed, and local seda- tives applied until the inflammation has subsided again. If the treatment is per- sisted in, ulceration, and perhaps abscesses and fistula, will follow. Internal division o{ rtctdX stricture has little to recommend it; sometimes, when the constriction is near the anus and the mucous membrane only is involved, it may be jtracticed ; but unle.ss great care is taken, it is not unlikely to be followed by ulceration, which may be very persistent. In the congenital annular form, where the surface is healthy, and there is no induration beneath, there is not the same objection. The bowels are thoroughly opened, the anus stretched under an anaesthetic, and the sharp margin of the projecting ring divided at three or four points, care being taken not to penetrate too deeply. The patient is kept lying down, and the bowels confined for three or four days ; then a purgative is given, and, after the motion, the mucous membrane is thoroughly washed out with a weak antiseptic. Bougies should not be passed for two or three days, and the finger should be carefully introduced first to make certain that the wounds are healed. Electrolysis has been tried for stricture of the rectum, as for the stricture of the urethra, the negative electrode being applied to the face or the interior of the nar- rowed part; but, except that it is, perhaps, more rapid in its action, it is doubtful if it possesses any advantage over gradual dilatation, and it is certainly more likely to be followed by irritation and ulceration. Linear Proctotomy. — Unless great care is taken, and bougies are passed at fre- quent intervals, relapses are almost sure to occur, sooner or later, except, perhaps, in the congenital form. P2ach time the stricture becomes harder and denser, and at length more or less of the bowel is converted into a rigid, unyielding, cartilagi- nous tube, with, perhaps, abscesses and fistulse around it. If this is within a short distance of the anus, an attempt may be made to relieve it by what is known as linear proctotomy. The rectum is thoroughly washed out, the patient placed in the lithotomy position, and the finger passed through the stricture, some of its fibres being divided to effect this if necessary; and then, with a long, curved, sharp-pointed bistoury, the whole of the stricture-tissue is divided as near the mid- dle posterior line as possible, right down to the sacrum, and out at the anus. Sometimes there is free hemorrhage, especially high up at the angle of the wound, and to avoid this it has been recommended to use the ecraseur ; but it can usually MALIGNANT STRICTURE. 983 be checked without difficulty by pressure. The operation is followed by profuse suppuration ; but the drainage is good ; there is free escape for the pus ; and the part is placed at perfect rest. All that is required is that the cavity should be well irrigated once or twice a day. As soon as the wound is granulating freely and the sloughs have separated, generally at the end of a week or ten days, a soft bougie may be passed, to prevent recontraction. Colotomy. — Finally, where this has failed or is impracticable, when there is obstruction owing to stricture high up in the bowel, or when there are fistula, especially if they communicate with neighboring viscera, colotomy is the only resource. Malig/iant Stricture. Epithelioma of the anus is not a very common affection. It is always the squamouscelled variety, and usually commences a,s a small nodule or wart, which may at first be mistaken for an external pile. Before long, however, the surface breaks down and ulcerates, and a sore is left, which, if it lies on the junction of the skin and mucous membrane, may be as painful as fissure. Epithelioma of the rectum, on the other hand, is of very frequent occurrence, and like that which is met with elsewhere in the large intestine, may appear not only in old age but during young adult life. It may involve any portion of the bowel; but usually there is a clear ring of mucous membrane for an inch or so just inside the anus ; and not unfrequently the surface is free as far as the junction of the sigmoid flexure with the rectum, so that the growth is out of reach of the finger. Its appearance varies very much in different cases. At the very commence- ment there may be merely a hardened, slightly raised patch, seemingly covered by the mucous membrane ; soon, however, this begins to spread, both in extent and depth. The surface becomes rough and uneven ; sometimes it grows out in the form of a nodule, which projects into the bowel and attains a very considerable size before it breaks down ; more often it begins to ulcerate almost at once, and the destruction may extend so deeply as to leave but little of the growth at the base. The margins of the sore are raised, thickened, and hard ; generally they are very irregular in outline ; the base is exceedingly uneven, not unfrequently covered with sloughs, and at times bleeds freely; and the tissues lying beneath it are as hard as cartilage, and so fixed as to be quite immovable. Very often the ulcer surrounds the intestine like a ring, and the contraction of the tissues outside is so great that, in spite of the destruction, the canal is almost, if not altogether, closed ; in other cases it forms a deep excavated sore on one side or behind, ex- tending far beyond the limits of the bowel ; and in others, again, the whole of the interior of the tube for some inches is ragged and irregular on the surface, so that nothing can be felt but the breaking down epithelial growth. The starting point of the growth is undoubtedly in connection with Lieber- kiihn's follicles, and in every example some portion of the tumor can be found with the characteristic adenoid structure of cylindrical epithelioma ; but in some cases the epithelial element is in excess, and large vascular masses of new growth are formed, soft, like encephaloid, and sprouting into the interior of the bowel ; in others the fibrous part is more developed, and the base of the ulcer, the muscular coat of the bowel, and the fatty tissues around are infiltrated with a dense cica- tricial mass to such an extent that when cut across it has all the appearance of scirrhus. The sacral and coccygeal glands are not involved till late : secondary deposits, unless the case terminates early, are usually found in the liver. Colloid degeneration of small portions of the growth is not uncommon, and little masses like boiled sago may be frequently found here and there in its sub- stance ; much more rarely the whole growth is involved. Other forms of malig- nant disease are very rare. One or two examples of sarcoma are recorded, and melanotic growths have been known to occur. Symptoms. — The onset is peculiarly insidious, and, especially when the 984 DISEASES AND INJURIES OF SPECIAL STRUCTURES. growth involves the uiijier i)art of the rectum, and assumes the annular type, com- plete obstruction may occur sucUlenly and without warning of any kind, the orifice being blocketl either with a small mass of hardened f;^ices or by a fold of the mucous membrane. As a rule, however, all the symptoms of non-malignant ulceration and stricture are present in an aggravated form. At first there is merely an uneasy consciousness of the existence of the part, with a certain amount of irritation about the anus ; or there is a slight discharge of blood-stained mucus, and the i)atient imagines that he has piles; then it be- comes distinctly painful, especially after exercise or when the bowels have acted. Sometimes this pain is of a dull, aching, continuous character; or more often it takes the form of violent neuralgia, shooting down all the l)ranches of the sacral plexus, especially on the left side. Occasionally it is relieved by the passage of the faices ; much more often every action of the bowels makes it tenfold worse, and, in spite of the constant desire and sense of fullness in the rectum, the patient looks forward to it with dread. As the passage becomes narrowed, the straining and tenesmus grow more and more severe ; the faeces come away in hardened lumps; attacks of constipation alternate with a kind of spurious diarrhoea; a blood-stained and very offensive discharge is continually oozing out; the skin becomes inflamed and sore; prolai)se of the mucous membrane or hemorrhoids occur; abscesses, with violent throbbing and high fever, form in the cellular tissue around, and leave behind them fistulre, which may open on the exterior or com- municate with the bladder or vagina; and at length the patient becomes utterly worn out by the suffering. Death may be caused at any time by peritonitis, hemorrhage, or obstruction ; or, if no com])lication of this kind sets in, secondary deposits make their appear- ance in the liver, the legs begin to swell, there is complete inability to take any food, night sweats come on, and the patient sinks from exhaustion, worn out by the constant pain, and emaciated to the last degree. The duration is very vari- able, and, owing to the insidious character of the earlier symptoms, exceedingly hard to estimate. As a rule, it is very much more rapid in the young than in the old ; some of the quickly-growing {"ungating forms prove fatal within a few months ; others, in which the hard and dense fibrous stricture tissue predominates, last for five and even six years. Unless some accidental complication appears, three years may be taken as the average. Diagnosis. — In advanced cases there is no difficulty ; the severity of the pain, the peculiarly offensive character of the blood-stained discharge, and the appearance of the anus, surrounded with piles and inflamed folds of skin, are suf- ficient. If the finger is introduced, it comes into contact with a hard, uneven stricture, generally about two inches from the anus. The orifice is often very small, and any attempt to pass even the tip through is attended with extreme pain ; the surface is rugged and dense, but breaks down at once with pressure, bleeding freely ; and above there is a large, irregular cavity, the walls of which are ulcerated all over. It is only in very extreme cases of syphilitic or dysenteric ulceration that anything similar is produced. In the earlier stages of the disease, which are rarely seen, careful examination is necessary, especially as this form of carcinoma is not at all uncommon in young adult life, and any growth in the bowel \vhich is surrounded by induration, or which cannot be moved freely upon the subjacent tissue, should be regarded with very grave suspicion, and a thorough investigation under an anaesthetic, with the anus well dilated, insisted upon. When the growth occurs in the higher part of the rectum, above the reach of the finger, the patient may complain of attacks of diarrhcea alternating with con- stipation, but asa rule nothing else is noticed, until the constriction is far advanced and obstruction imminent. Treatment. — i. Radical. — In all cases in which it is possible to remove it thoroughly, the affected portion should be excised without delay. It is very diffi- cult to say how long a patient affected with carcinoma of the rectum may live without operation, but there is no question that, if the diagnosis is made before MALIGNANT DISEASE OF THE RECTUM. 985 the disease is far advanced, and the whole of it is removed, it may be years before there is any recurrence ; and, in the meanwhile, at the risk of what is not at that time a serious operation (whatever it may be later), the patient is relieved from a source of unceasinjj; i)ain. For this to succeed, however, certain conditions are essential. The patient must be in a good state of health ; extreme old age is, of course, a bar, but even (juite late in life, if the kidneys are sound and the patient is not ])lethoric, excision is successful, provided the local conditions are good. The growth must be within a reasonable distance of the anus ; that is to say, the finger must be able easily to reach above its highest limit all round the bowel. In the female, the peritoneal fold is usually less than three inches from the anus ; in the male it is an inch higher, and it may be raised still more by moderate distention of the bladder ; so that, especially in the latter case, a very considerable portion of the bowel may be removed. If, however, the anterior surface is involved high up, an operation is rarely advisable, not so much from the fear of opening the peritoneum, as because the growth is almost sure to have extended to it. Further, the wall of the rectum must be freely movable on the outside tissues. The case is most favorable when the disease is limited to the posterior wall or the sides of the bowel. If it involves the anterior surface to any extent, or if it has formed a complete ring, there is almost sure to be extensive infiltration of one part or an- other. In this respect, again, the prospect is distinctly not so good in women as it is in men ; the vagina becomes implicated much sooner than the prostate ; and though, according to Cripps, the operation is practicable so long as the vaginal mucous membrane remains free, it becomes very much more serious. Finally, there must be no secondary deposit in the liver, and no glandular enlargement, either sacral, or, if the anus is involved, inguinal. Excision of the Rectiun. — The patient is prepared in the usual way, by enemata, placed under an anaesthetic, and secured with Clover's crutch. The incisions are : (i) a crescentic one on each side, surrounding the anus (through the skin, if the external sphincter must be removed; through the mucous mem- brane inside the bowel, if this is not affected), and (2) a median one nmning back from this to the tip, or a little to the left side of the coccyx. The former should open up the ischio-rectal fossae thoroughly on each side ; the latter should divide the posterior wall of the bowel, from above the growth down its whole length. It is usually recommended to make the vertical one first, by transfixion with a sharp-pointed bistoury, from within the bowel, as this enables at once a thorough examination of the growth to be made in every direction. The levator ani must be cut through with scissors, the anterior wall dissected off the prostate or vagina, as the case may be (a catheter or the finger being used to give notice of any approach to these organs), and the sides of the bowel separated as high up as required. As soon as it is thoroughly detached, the lower end is carefully cut off with stout curved scissors, clamps being placed at once on any vessels that bleed. If the peritoneum is widely opened, it must be secured with sutures ; under other circumstances the sides of the wound fall together. The bowel should not be drawn down and sutured ; the tension is too great, and it encourages the retention of the wound secretion. A large drainage tube should be inserted, and the whole cavity lightly plugged with iodoform gauze. This may be allowed to come away of itself in forty-eight hours, by placing the patient in a warm boracic bath. As a rule, granulation and cicatrization are very rapid, and but little after- treatment is required ; the upper end of the bowel is drawn down and the sides fall together. As soon as healing is well established, a bougie should be passed at frequent intervals as often as required ; or if this is not sufficient, the patient should wear a suitably shaped vulcanite plug. The operation is a severe one even when the peritoneum is not opened ; but if the removal is complete and early, there is no doubt the duration of life is pro- longed. The degree of comfort depends upon the success with which contraction 63 9S6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. is avoided. In rare cases the patient regains control (this is one reason for leaving the external sphincter when possible) ; more frecjuently they are comfortable so long as there is no diarrhuea, but a bougie must be used regularly. Occasionally the cicatrization is very obstinate. If a strip of mucous membrane can be left the contraction is less .severe, but the risk of recurrence is greater. Resection of the Rectum. — In Germany operations on the rectum have been carried very much further than in England. Kraske, of Freiburg, for example, does not hesitate to remove the coccyx, divide the left sacro-sciatic ligament, and, if necessary, chisel off part of the sacrum. In this way the side of the rectum is exposed, the diseased part can be freely excised, and the upper end of the bowel drawn down and secured to the lower. Bardenheuer does not limit the operation to malignant growths, but includes cases of recto-vaginal fistulas with a very large defect or with considerable kinking of the bowel, and some cases of stricture (although the presence of inflammatory adhesions usually prevents this). The whole of the rectum and part of the intestine above (upward of ten inches) have been removed. The incision runs from the posterior margin of the anus to the middle of the sacrum ; the soft parts are detached from the bone, the sacro-sciatic ligaments divided, and the sacrum itself cut across at the level of the third vertebra. The wound is widened by tearing the tissues in the middle line with the index fingers, and everything on the inner aspect of the levator ani that surrounds the bowel is detached by degrees until the rectum (below the growth) is thoroughly isolated. A loop is then passed round it, the peritoneum separated off (opened if necessary), and the bowel drawn down and divided about an inch and a half above the growth. The mucous and muscular coats are then united by separate sets of sutures and the wound plugged with iodoform gauze. 2. Palliative. — Where excision of the disease is impracticable the only thing left is to render the patient's life as endurable as i)ossible and treat the symptoms as they arise. The general treatment must be the same as in ulceration and stricture due to other causes: the motions must be kept soft and small, the diet must be nutritious and easily digested, and the pain relieved by sedative injections, but care should be taken to avoid establishing a morj^hia habit in the earlier days of the disease ; in the later ones it cannot be helped. Diarrhcea must be checked at once by starch and opium ; the less frequently the bowels act the better, so long as there is no obstruction. Constipation caused by early contraction of the stricture is more difficult to deal with ; as a rule, when the disease is high up, it is an indication for colotomy ; but if it is quite close to the anus, and an operation is not thought advisable, relief maybe obtained by bougies ; this, however, is only jjracticable in exceptional cases, and even then the pain is so severe, and the risk of perforating the bowel and setting up inflammation around it so great, that it can scarcely be recommended. Sometimes, when there is a great fungating mass in the interior of the bowel, it is possible to tear it away or scrape it out, the anus having been dilated first, so that there may be free access to every part ; and it is said that if the operation is rapidly performed, there is but little hemorrhage ; but every precaution should be taken beforehand. Finally, if obstruction sets in, if fistulce form, whether they open on the exterior or into one of the neighboring viscera, or if there is intense pain caused by the passage of the faeces over the ulcerated surface, colotomy should be performed, as already described, either in the inguinal or luml)ar region. Unhappily, it can do little or nothing in the way of relieving the intense neuralgia which is caused by the disease involving the sacral plexus. Villous Tumor of the Rectum. Villous growths, similar to, but rather coarser than the fimbriated papilloma of the bladder, are occasionally met with in the rectum. AUingham, who has had the widest experience of them, describes them as forming a soft, lobulated, spongy mass, either sessile, or with a pedicle formed from the subjacent mucous membrane. VILLOUS TUMOR OF THE RECTUM. 987 In most cases they grow from the posterior wall rather hi^'h up, and by far the greater number occur in people over fifty years of age. \x\ some they caused severe hemorrhage, and the growth occasionally became prolapsed ; but the most striking feature is the constant discharge of large (piantities of thin, watery mucus. The diagnosis, unless some portion of the growth is forced out through the anus, is exceedingly difficult, owing to the jjeculiar soft, velvety feel of the mass, which prevents its being distinguished from the natural folds of the mucous membrane. The only treatment is free excision ; and this is especially necessary, as in a large proportion of cases malignant disease followed. Nrevus of the rectum is occasionally met with, and may give rise to very pro- fuse hemorrhacre. 988 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER XX. INfURIES AND DISEASES OF THE KIDXE VS. ABNORMALITIES. Form and Number. The kidneys are occasionally united together more or less closely. There may be only a fibrous band between them, or the upper or lower ends may be joined together, so as to form a horseshoe-shaped mass in front of the vessels ; or they may be fused into an irregular disc, lying somewhere near the middle line and not un frequently as low down as the sacnmi (Fig. 416). As a rule there is but little inconvenience from this ; but cases are recorded in which thrombosis of the great veins and hydronephrosis have occurred ; and in one instance the pain during the menstrual period was so great that an opera- tion was undertaken for the removal of the offending mass without its being known that it was the only kidney. Size and Position. Variations in size are still more com- mon. One kidney may be absent, and that too without the other showing any remark- able change. Both ureters may be present coming from the single kidney, one crossing to the other side. More often, without being altogether deficient, one kidney is so small that it is doubtful whether it could, single- handed, be sufficient for the work of the /t a body. This occurs so frequently as the con- y F-al sequence of disease that in all cases in which / f ^ I'fA ^^^ removal of a kidney is contemplated it 1 //^i^ ^^ essential to obtain definite information X_, j ^ y [j with regard to the efficiency of the other. The vessels are often abnormal, both in position and origin. The most serious deviation is when an artery arises from the aorta higher up or lower down than ordinary, or from the common iliac. This is said to occur about once in seven. The ureter may be double either at its commencement or for the whole of its course. Usually its direction is fairly straight ; but sometimes it is seriously distorted or compressed by tumors ; and occasionally, just where it springs from the pelvis, there is a valve of mucous membrane which may act as a very grave obstruction to the flow of urine. The kidneys are not unfrequently found lower down in the abdomen or in front of the vessels, especially when there is any malformation. Sometimes they lie over the sacro-iliac synchondrosis, or even in the iliac fossa ; and they may be the source of very serious trouble from enlargement at the menstrual period, -'uUV \\. \N Fig. 416. — Single Median Kidney lying below the Bifurcation of the Aorta. DISEASES OF THE KIDNEYS. 989 or from acting' as an obstruction during i)arturition. Pressure as a rule causes a i)eculiar sickening pain, and sometimes after handling blood appears in the urine. Movable and Floating Kidneys. Owing to the loose character of the surrounding tissues, the kidneys are always slightly movable. If the lower end is exposed from the loin it may be seen to ascend and descend with resjiiration ; and it can be pressed forward with the finger or pushed back again by the hand upon the abdomen. When this move- ment is so free that it can be felt plainly from the outside, the kidney is said to be movable ; it is floating if the range is greater still, so that it comes into contact with the front wall of the abdomen. In the latter case there may be a mesone- phron, or fold of ])eritoneum investing the kidney like a portion of the small intestine, but it is very unusual. Movable kidney is more common on the right side than on the left, and in women than in men. The former fact is probably to be accounted for by the downward pressure of the liver and by the shortness of the left renal artery ; the latter by various reasons, of which the use of stays, the effect of repeated preg- nancies, causing great relaxation of the abdominal wall after great tension, and the comparatively sudden alterations in the amount of perirenal adipose tissue common under the same circumstances, are the most important. Conditions like hydronephrosis, calculus, or new growths, which increase the weight of the organ, may assist, but of themselves are scarcely sufficient. In most cases the immediate cause is stated to be an accident of some kind, such as a fall in the sitting position. Symptoms. — Sometimes a floating kidney merely causes inconvenience; sometimes, on the other hand, even when it is only slightly movable, it gives rise to intense suffering. A feeling of weight or of dragging, or of something being loose, is always present, and during the menstrual period and after exertion is very severe ; riding is out of the question ; and stooping and walking are very painful. Attacks resembling renal colic, attended with vomiting and great prostration, are of frequent occurrence ; occasionally there is jaundice, or oedema from pressure upon the veins ; sometimes the ureter becomes partially blocked from twisting, causing temporary hydronephrosis ; dyspepsia and loss of health and strength are almost always present, and in many cases the patients become hysterical or hypochondriacal, so that they have even been known to make away with them- selves. The shape of the kidney can sometimes be recognized through the abdominal wall ; the patient should be placed in the recumbent position with the hips well flexed ; and if there is much pain or tension, an anaesthetic may be given. If the organ is not much out of place, it can usually be grasped between the hands, one buried deep in the flank, outside the erector spinse, the other working downward on to it ; in other cases, when it lies in the iliac fossa or on the crest, the outline can be felt at once. Very often a better idea may be obtained by placing the patient upon the hands and knees, that the weight of the organ may bring it for- ward. Percussion in the flanks is rarely of much service ; and unless the handling is very rough or the kidney disea.sed, there is no reason why the secretion of urine should show any change. There is some reason to believe (though it cannot be considered proved) that movable kidneys, independently of the accidents that may befall them from twist- ing of the ureter, are more liable to be affected by disease than others. Diagnosis. — Floating kidney itself is rarely mistaken, but many other con- ditions have been taken for it. Distended gall-bladders, facal masses in the colon, omental cysts, tumors of the pancreas, carcinoma of the pylorus, ovarian cysts, floating spleen, and many others having been diagnosed as such, and in some instances the mistake was not apparent until the abdomen had been opened. Even when the tumor is superficial, it is easy to be misled by a vague resemblance 990 DISEASES AND INJURIES OF SPECIAL STRUCTURES. in sha]ie ; when it is deep and scarcely movable, there may be nothing but the peculiar character Of the renal pain to serve as a guide. Treatment. — In the slighter cases the patient may be fitted with an elastic abdominal belt, reaching well down to the pubes and Poupart's ligament, with an air-pad over the displaced organ to hold it up and press it back into the loin. ^'iolent exercise, especially riding, or anything attended with jolting, must be avoided. If attacked by renal colic, the patient should be placed in bed, the bowels well opened, and dry cups and hot fomentations applied over the loins. If this does not give relief, and the condition of the patient is such that it is necessary to adopt a more active line, the kidney may be exposed in the loin and stitched in situ {jicphrorrhaphy) . The incision is almost the same as for lumbar colotomy ; the structures are divided in the same way, and the perirenal fat exposed. This should be freely divided, and (while an assistant from in front pushes the kidney back into its place) several catgut sutures passed through its capsule, so as to fasten it to the lumbar aponeurosis over as wide an area as jjossible. A drainage tube should be introduced down to the surface of the kidney, with the view of exciting a certain degree of inflammation. Probably, the ultimate benefit many of these cases derive is dependent more upon the adhesions that form around the kidney than upon the sutures, which must soon be absorbed. A healthy kidney should never be removed merely because it is floating, but a large proportion of true floating kidneys are diseased in some way or other, and then the conditions are completely altered. The abdominal operation is always preferred in these cases, as it enables a better idea to be formed, not only of the diseased kidney, but of the other one. INJURIES OF THE KIDNEY. Contusions and Lacerations. Tearing or bruising of the kidney is usually the result of direct violence, such as a blow upon the lumbar region, or crushing, as in railway accidents ; or it may be produced by a sudden fall in a sitting position. The extent varies from merely a superficial contusion to complete disorganization, and the symj^toms depend partly upon the hemorrhage and the escape of urine, partly upon the injury inflicted on neighboring structures. Hemorrhage. — The amount of blood lost is very variable; in injuries of the cortex only there is rarely very much, but if the rent traverses the hilum, or one of the larger arteries has given way, particularly if the peritoneum is torn so that there is a large space for it to collect in, the patient may bleed to death. Usually, it pours down the ureter and collects in the bladder, either at once, or after an interval of a few hours. If the quantity is large, coagulation is not uncommon, and long, worm-like clots may form in the ureter, giving rise to the symj^toms of renal colic, or even causing obstruction and hydronephrosis. In other ca.ses, the bladder becomes filled ; there is severe pain over the pubes and at the end of the penis, and, if means are not taken to break up and remove the coagula. decom- position may occur, and cause acute cystitis. The color at first is bright ; but, unless the hemorrhage persists, in a day or two it becomes smoky, and then grad- ually clears up. Hemorrhage around the kidney may occur in severe injuries ; a swelling forms rapidly over the loins, and, later, staining makes its appearance in the in- guinal region, and even in the scrotum, as the blood-stained serum travels down- ward along the course of the vessels. Extravasation of urine is rare, unless the pelvis of the kidney or the ureter is torn. Sometimes it escapes into the peritoneal cavity ; more frequently it col- lects in the loose cellular tissue around the kidney, and, setting up a certain amount of inflammation, gradually forms a thin-walled cyst, which grows larger INJURIES OF THE KIDNEY. 991 and larger, until it can be felt from the loins to the abdomen. This has been called spurious or traumatic hyJronephrosis, but the condition is entirely different. As a rule, after a few days or weeks, the extravasation becomes general, and either acute peritonitis sets in, or the patient sinks from septic absorption, caused by the suppuration and sloughing around the kidney. The other symptoms are not characteristic. Pain is always present, usually of a peculiar, sickening character, especially when any pressure is made upon the part, and, in many cases, it radiates down the thigh or to the testicle. All over the lumbar region there is great tenderness. The muscles, both of the abdomen and in the loins, are rigidly contracted ; the body is bent to the injured side and the hip is kept in the flexed position. Sometimes there is pain along the course of the lumbar plexus, and very often the testicle is retracted up to the ring ; but, if the injury is confined to the kidney, shock is rarely very severe. When the patient is much collapsed, there is always reason for fear either that the peritoneum has given way, or that the hemorrhage has been extensive. Injuries of the kidney may be followed by true hydronephrosis from occlu- sion of the ureter ; by peritonitis from extravasation of the urine or extension of the inflammation ; or by suppurative nephritis and pyonephrosis, the suppuration occurring partly in, partly around the kidney. When this happens, if the patient survives, urinary fistulas are sometimes left, discharging through an opening in the loin, or in the inguinal region. In one or two instances, total suppression of urine has followed, possibly from obstruction to the renal vessels, but almost cer- tainly in one case at least from the reflex influence of the nervous system. The same thing has been known to occur after operations on the kidney. The prognosis depends upon the extent of the injury and the nature of the complications that follow. The majority recover without consequences of any kind ; but, if there is extravasation of urine, or much loss of blood, either at once or later, from giving way of the clot or the formation of an aneurysm, the ques- tion becomes very serious. Recovery, either complete or with the formation of a fistula, may take place even after suppuration ; general peritonitis is almost hope- less, as this rarely comes on unless the injury is very extensive. Treatment. — In the slighter cases all that is necessary is to confine the pa- tient to bed on low diet, and empty the colon thoroughly by enemata. If bleeding continues, the side may be bandaged, or Leiter's coils arranged over the lumbar region, and half-drachm doses of liquid extract of ergot given every two or three hours,* only allowing the patient small quantities of ice to suck. A small amount of clot in the bladder may be left to soften and come away of itself; but, if there is much distention or pain, it should be withdrawn with one of Bigelow's evacu- ating tubes and a suction apparatus, for fear of decomposition and cystitis. If the hematuria persi-sts, and it is almost certain from the amount of blood that is lost, and the rapidity, that some large branch is torn, an incision should be made in the loin, and, if the bleeding cannot be checked by ligature or plugging, the kidney must be excised. Extravasation of blood around the kidney may be treated in the same way. If the swelling is very large and threatens to suppurate, the bulk of it may be re- duced by aspiration, and subsequently the abscess opened and drained. When it is due to urine, the swelling rarely appears until some days have elapsed, and the diagnosis cannot be certain until some of the fluid is withdrawn. If this contains urea, and if it can be shown by the aid of the cystoscope that no urine enters the bladder from the corresponding ureter, nephrotomy should be performed at once, the most convenient time being chosen after the patient has rallied from the shock, before there is any septic absorption. In other cases aspiration may be tried, and then, if necessary, incision — the fistula, if it persists, being dealt with later. * [Pills of gallic acid will also be found useful.] 992 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Wounds of the Kidnf.y. The kidney may be wounded, either through the loin or the abdomen ; in the latter case the peritoneal cavity is opened, and probably other organs injured as well. In one or two cases prolapse has occurred, the whole organ being S(jueezed out through a wound in the loins. The symptoms are the same as in contusion of the kidney, with, in addition, those due to the wound. The prognosis dejjends upon the nature of the injury; incised wounds heal readily; gunshot injuries, on the other hand, are very likely to be followed by -suppuration and sloughing ; but extensive urinary infiltration is not common. The lumbar ple.xus may be torn, the colon opened, and even the peritoneal cavity traversed by a bullet, without the result being fatal. Fistula however, and serious bladder troubles, phosphatic calculus and cystitis, not un- fre<]uently make their appearance afterward. Hemorrhage should be checked as soon as possible, and any foreign bodies that can be found removed at once, but prolonged exploration with a probe in order to find a bullet is not advisable. The wound should be left open ; and, as there is always a tendency for it to become valvular, a large tube should be intro- duced down to the bottom. Later on, if suppuration occurs, free incisions are necessary. In prolapse of the kidney, if it is much injured, a ligature should be placed around the pedicle and the organ removed ; in other cases an attempt may be made to return it. SURGICAL AFFECTIONS OF THE KIDNEYS. Suppression of Urine. The secretion of urine may be checked in various ways. A calculus may be impacted in the ureter ; acute nephritis may set in ; or some sudden shock may give the circulation such a check that the blood pressure falls too low ; and this may happen even when the kidney is healthy. If it is already diseased — if there is, for example, chronic interstitial nephritis, so that the secreting power is already impaired, and the fibrous tissue is hard and unable to accommodate itself to rapid changes in the blood supply — a very trivial reason is sufficient, and a cause that in a healthy kidney is scarcely enough to bring on a transient flushing, may be fol- lowed by such congestion as to stop the secretion altogether. Causes. — i. Shock. — Suppression of urine may come on suddenly from one instant to another, from shock. The passage of a catheter may cause it, even when the kidneys are sound ; if they are diseased, not only is this more likely to happen, but when it does it is infinitely more serious. In the one case it is transient (though instances to the contrary are not unknown) ; in the other it may be final. This is one of the chief reasons why operations on the urinary organs are a matter of such grave consideration when the kidneys are diseased. So long as no extra strain falls upon them they may be equal to their work ; the least disturbance, reflex or direct, is enough to stop the secretion altogether. The way in which the sui)pression is caused is not always the same. It is due, no doubt, to the influence of the nervous system ; but in some instances the nerves of the kidneys only are involved, in others the effect is general. In the former case there is intense renal congestion ; only a small amount of fluid is excreted ; its specific gravity is high, and often it is mixed with blood. In the latter the pressure is so low that, as in injuries to the upi)er part of the spinal cord, or in the shock that is associated with injury to the ])eritoneum, the blood lies almost stagnant, and no urine at all is formed. In the vast majority the secretion recommences of itself; but the result may ])rove fatal, either from general shock or from persistence of suppression, especially when the cause is a continuous one, such, for example, as a catheter tied in the urethra. It happens in women as well as in men ; it has been known in children ; and it is especially common after SUPPjRESSION of urine. 993 injury to the urinary organs, excluding the i)enile urethra. Nephrotomy on one side has been known to cause su|)pression on the other, so that there was for some time reason to fear tliat there might be only one kidney ; calculus impacted in the ureter nearly always gives rise to it ; there is hardly an operation about the bladder which it has not some time followed ; while it is notorious after passing a catheter through the fixed portion of the urethra, especially in cases of recent stricture ; in old ones the mucous membrane and the nerve endings in it seem to lose their sensitiveness altogether. 2. Acute Inflammation. — Scarlet fever, cold, cantharides, extensive lesions of the cutaneous surface, and other causes occasionally lead to such extreme conges- tion as to cause suppression. The kidney becomes immensely swollen ; the cap- sule is so stretched that it flies apart if it is divided with a knife ; the cortex is thickened and either deeply congested or paler than natural, according to the relative amount of vascular and epithelial change ; and the urine (such as is secreted) is stained with blood, of high specific gravity, and loaded with albumin. Gradual sui)pression is met with chiefly in suppurative pyelonephritis. This is the condition which has received the exceedingly misleading name of surgical kidney, and which so frequently proves the cause of death in cases of long stand- ing stricture or enlargement of the prostate. The kidney is already in a state of chronic inflammation, the interstitial connective tissue is hard and den.se, the secreting structure proportionately degenerated, and the specific gravity of the urine constantly too low; suddenly some irritant (a catheter, or ammoniacal de- composition of the urine) causes acute inflammation of the bladder ; the ureters, the pelvis, and the substance of the kidney speedily become involved by direct extension ; suppurative pyelonephritis sets in ; a number of minute absce.sses make their appearance in the cortex ; the circulation becomes more and more embar- rassed, the secretion more and more difficult, and in a few days or weeks the patient sinks into a low typhoid state with partial suppression of urine. 3. Obstruction of Ureter. — Sudden closure of one ureter is usually followed by intense congestion of the corresponding kidney, and partial suppression of urine in the other from shock. If the obstruction continues the latter usually recovers, but the former gradually becomes more and more dilated, until at length hydro- nephro-sis follows. If one kidney is destroyed in this way, the other, provided it is healthy, undergoes compensative hypertrophy to make up the deficiency ; and the urine that collects behind the obstruction is pale, of low specific gravity, with a dimin- ished amount of urea, and sometimes a small quantity of albumin. If, on the other hand, the second kidney is actually or practically non-existent, suppression is complete from the first, without any warning other than that given by the pre- vious attacks of renal colic. In one lady under my care total suppression had already lasted nine days (there was a history of a previous attack that had continued for six, and had at length yielded with the passage of much blood and gravel). On the tenth day I opened the kidney on the left side through the loin, and found the pelvis at an enormous depth, but no calculus could be detected, even with a probe. The patient, who was at the time suffering from the most intense muscular weakness, rallied and lived for a month. Post-mortem it was found that the right kidney and • the right ureter were completely absent ; the left measured eight inches by four, and was somewhat displaced ; there was a large calculus impacted low^ down at the junction of the pelvis with the ureter. Symptoms. — Suppression of urine is in itself only a symptom, and the con- sequences that follow naturally depend upon the cau.se. JV/ien it is the result of shock, whether this is due to severe injury to another part of the body, or is the consequence of an operation upon the urinary organs, the secretion may return within a few hours, before any harm is done, or the shock may prove fatal. In nephritis the symptoms are to some extent the result of the suppression. The acute form — that, for e.xample, which occurs after scarlet fever — is seldom 994 niSEASES AND INJURIES OF SPECIAL STRUCTURES. met with in surgery, and cases are rarely seen with the tyi)ical symptoms of rapid anasarca, coma, and convulsions. The chronic variety, however, that which follows irritation of the urinary organs in cases of stricture and enlargement of the prostate, is exceedingly common. The symptoms are slow in their onset and very insidious ; there is no rigor, though the temperature may rise in the course of a day or two to 102° F. or 103° F. ; the pulse is (juick and feeble, the tongue hard, dry, and l)rown, and the strength fails rai)idly. The patient lies i)rostrate, in a state of semi-unconsciousness ; the mind is constantly wandering ; there is total inability to take food ; vomiting is not unfre(iuent ; very often there is great restlessness, and toward the end, sometimes coma; but convulsions are rarely present. Obstructive suppression, on the other hand, or that which follows the removal of the only working kidney, is totally different. For the first three or four days there is nothing at all remarkable ; then gastric disturl)ance, with, ])erhaps, vomit- ing, sets in ; but the most striking symptom is the failure of the muscular strength. The mind is quite undisturbed, the temperature is not raised, and the j^ulse is scarcely quickened. Generally at the end of a week, but sometimes not for ten days, a change sets in, and then the end comes rapidly. The pujiils become contracted, the muscles begin to twitch, the temperature falls below normal ; the respiration becomes difficult and panting, owing to the weakness of the muscles ; the patient is confined to bed ; sometimes there is apathy or drowsi- ness, but never coma or convulsions, and intelligence is retained to the last. Death seems to be due to resjiiratory and cardiac failure ; a week or ten days is not an unusual time ; in a few instances life has been prolonged for even greater periods. Hydronephrosis. By this is meant a gradual dilatation of the pelvis and calyces of the kidney, with absorjition of the secreting part, until at length a sac is formed, large enough perhaps, to contain a gallon of fluid, or, if it occurs before birth, to prove an obstacle to parturition. It may be congenital or actjuired, though the latter is the more common ; and, accord- ing to the cause, it may affect one side or both. In all cases it appears to arise from an obstruction to the outflow of urine ; the se- cretion continues, gradually stretching all the surrounding structures, until at length the renal substance is so thinned that it is no longer able to work ; and then sometimes, l)ut very rarely, the fluid may lie absorbed again. The secretion, under these circum- stances, differs from normal urine in con- taining all)umin and mucin with very little urea. Whatever the explanation may be, this always hapi)ens when there is any hindrance to the flow ; it may be noticed even when the obstruction is only of a temporary cha- racter, as in renal colic ; and, if the cause is removed before the kidney has undergone atrophy, the percentage of urea may rise again to the normal, and the albumin and Fig. 4' 7— Hydronephrosis with Complete Atrophy : flicqnnpar of Renal Tissue, but not much Enlargement. mUClIl Uisappeai . In the slighter cases the shape of the kidney is, to a certain extent, retained ; there is merely dilatation of the ]:)elvis and calyces, with widening of the collecting tubules, and increase in the amount H YDR ONEPHR OS IS. 995 of intersitial connective tissue ; in extreme ones, nothing is left but a thin-walled cyst, generally rather elongated, especially if the obstruction is low down, but so modified by pressure that it cannot be said to possess any form of its own. Pro- bably the largest cysts arise from comparatively sudden obstruction in a healthy kidney ; when it is gradual the wasting of the cortical part prevents much accumu- lation. Causes. — The obstruction is generally in the ureter, but in the bilateral forms it may be in the bladder or the urethra ; and it may be the result of some foreign body in the interior, of some structural change in the wall itself, or of pressure from the outside. 1. Of these the impaction of a calculus is by far the most common. Usually it is caught either at the commencement, just where the pelvis grows narrow, or at the end, perhaps half projecting into the bladder ; but it may occur at any point. Clots of blood and hydatid cysts are said to have produced the same result. 2. Structural changes may arise from various causes. Stricture of the ureter may occur from inflammation. Granulations may form on the mucous surface and become coated over with phosphates. Papillomata similar to those found in the bladder are occasionally met with. Cancer of the pelvis of the kidney may lead to the same result ; or there may be a fold of mucous membrane just at the com- niencement of the ureter acting as a valve. In a few instances congenital atresia and absence of a ureter have been recorded. Imperforate urethra ; stricture and other affections of the urinary passages ; even phimosis, and great increase in the frequency of micturition, sometimes occasion a slight degree of it in both kidneys, with or without dilatation of the bladder. 3. Very slight external pressure is sufficient to cause it. Mere twisting or looping of the ureter is enough, or the pressure of a tumor, such as the retro- flexed uterus. It has even been caused by an abnormal renal artery crossing the ureter, and by one ureter opening so close to the other as to impede the flow from it. Symptoms. — Hydronephrosis is rarely discovered until the swelling has reached a considerable size. It begins first high up, under the last rib, and spreads downward into the iliac fossa, and forward to the middle line, carrying the colon inward in front of it. If there is any doubt as to the position of the intestine, it can generally be made out by inflating it with air. Fluctuation is usually distinct ; there is absolute dullness on percussion, and a sense of deep-seated resistance on palpation. Sometimes the distention is so great as to interfere with the action of the boAvels and with respiration. If the obstruction is sudden, there may be a great deal of pain, with blood in the urine ; in most cases there is little more than a sense of discomfort with con- stant dull aching. Occasionally the volume varies in size ; the obstruction sud- denly gives way ; there is a profuse discharge of clear or slightly turbid fluid, and the tumor disappears. Intermittent hydronephrosis, the fluid being expelled as soon as the tumor reaches a certain size, and then collecting again, is not unknown. It may arise in some few cases from spasmodic muscular contraction ; but more probably from bending or looping of the ureter, as in floating kidney, or from compression by a tumor. Diagnosis. — From pyonephrosis it can only be distinguished by the consti- tutional signs. Hydatids of the liver, spleen, or kidneys are almost as difficult until they have been tapped ; the fluid they contain is of higher specific gravity, loio, or 1012, instead of 1004, and the proportion of sodium chloride is much higher. Ovarian cysts, as a rule, are more mobile ; they begin in the pelvis and spread upward ; and the relation they bear to the intestine, and especially to the colon, is not the same. Ascites in certain very rare cases is so limited by adhesions that it presents a close resemblance ; and a few instances are recorded of perirenal cysts wdiich scarcely admit of diagnosis during life. Rupture of the ureter occasionally leads to a subperitoneal collection of urine, which has been called spurious hydronephrosis, but the condition is very 996 DISEASES AND INJURIES OE SPECIAL STRUCTURES. different. Renal and perincphritic abscesses are quicker in their course and are attended with a much greater amount of pain. Hydroneplirosis, if left to itself, may prove fatal either from exhaustion, or pressure upon other organs, or from rupture into the jieritoneal cavity. Occasion- ally it remains stationary for years, until perhajjs the secreting power of the kidney is completely destroyed ; sometimes then the fluid is al)sor])ed again, and in a few instances spontaneous cure has resulted from the sudden yielding of the obstruction. Treatment. — The slighter degrees, those which arise from gradual or partial obstruction, are rarely diagnosed. When it is so large as to form a distinct tumor, it is usually necessary to take some steps for its removal. In a few cases manijju- lation and gentle kneading over the ureter, assisted by opiates and warm baths, have proved successful. Occasionally the tumor can be raised by external ])ressure, or shifted by changing the position of the body, so as to release the ureter for a time and allow the fluid to escape ; and in one or two instances ureterotomy has been performed with a good result ; but, as a rule, the obstructing cause is either beyond this or the walls of the sac are so softened and thinned that the danger of rupture into the peritoneal cavity is too great. Repeated puncture, aspiration, and injection with iodine have been tried in cases in which the renal substance has disappeared and there is nothing but the cyst to deal with. In the majority, however, free incision through the lumbar re- gion, with drainage, affords a better prospect ; especially as it is sometimes possible, by examining the upper end of the ureter in this way, to find and remove the cause. The great objection is that urinary fistula is liable to form, and that, if suppuration should occur as a consequence of defective drainage, the structures around the cyst wall are so matted together as to render its removal subserjuently a matter of greater difficulty. In many instances, however, the fistula gives rise to but little inconvenience ; and if it does, and if it is proved that the other kidney is sufficiently active, the renal substance can as a rule be enucleated much more easily through the wound, and with much less danger to the patient, after the cyst has contracted to moderate dimensions, than while it is still so large as to displace and compress all the neigh])oring organs. If, however, the condition at the time of the operation is plainly irremediable, and the cyst wall can be separated easily, nephrectomy may be performed at once. Tumors of the Kidney. Diagnosis. — New growths in the kidney must be distinguished from cystic degeneration, hydronephrosis and i)yonephrosis, from abscesses around the kidney in connection with the vertebrae, i)leura, caecum, colon, liver, or the pelvic, uri- nary, and genital organs ; from dermoid and hydatid cysts ; from cysts of the ovary and pancreas; from enlargement of the spleen, and in children from enlargement of the mesenteric glands. The history (family as well as personal) and the general synq)toms (especially if there is any pyrexia, or evidence of any diathesis) are of very great importance ; the urine must be carefully investigated, not only once, but for days together ; the abdomen and the loins thoroughly examined ; and finally, if there is still any doubt as to the nature of the swelling, it must be explored with an aspirating needle. To examine the kidney, the patient should be under an anaesthetic, to relax the muscles; one hand should be placed in the hollow of the flank, between the last rib and the crest of the ilium, the other just below the cartilages of the ribs, on the front wall of the abdomen. In this way the lower third of the organ* can be felt and fairly grasped, even when it is not enlarged, and the size, shape, mobility, and consistence can usually be made out. As it enlarges, it extends toward the middle line in front — (it never causes any prominence behind, although it may fill up the hollow of the loins) — but, except in the case of sarcomata or TUMORS OF THE KIDNEY. 997 cystic disease, it rarely reaches the middle line, or extends so far down into the pelvis that the hand cannot be introduced beneath it. New growths of the kidney are usually so soft as to give the sensation of fluctuation. The relation of the tumor to the colon is most important. It depends to some extent upon the side ; on the right, as the kidney enlarges, the caecum and the lower part of the colon are pushed back to the outer side of the tumor, while the upper part crosses obliquely in front. On the left side the colon lies well in front, and can be felt as a rounded cord rolling over and over under the finger ; or, if it is fdled with air, a line of resonance can be made out where the kidney is percussed. It very rarely happens that a coil of intestine intrudes itself between the liver or the spleen and the abdominal wall. Resonance in the flanks is never present when there is a renal tumor of any size. Finally, in case of doubt, the kidney may be explored behind the peritoneum with an aspirating needle. It may be introduced just at the outer edge of the erector spin^, on a level with the first lumbar vertebra, or, if the kidney is enlarged, midway between the last rib and the crest of the ilium ; and the direction of the needle should be forward and a little downward — in fact, as nearly as pos- sible toward the umbilicus. As a rule, if the trocar is about four inches long, there is no fear of injuring any important structure, and the sudden cessation of resistance, as soon as the shoulder of the instrument enters an open space, can be felt at once. Cysts. Cystic disease of the kidneys, like hydronephrosis, may be either congenital or acquired, and may occur on one side or both. In many instances the whole organ consists of nothing but cysts, of all sizes, from a pea to an orange, so that if both are affected, there is practically no secreting substance left. Not unfre- quently, on the other hand, its existence is never suspected at all, and it is only discovered /(?jY-/;wr/i'OT / the only symptom is the persistent low specific gravity of the urine, and even that is not invariable. Occasionally, in adult life, the cysts enlarge to such an extent that the tumor becomes the source of serious trouble from pressure upon neighboring organs. The cysts usually contain an albuminous fluid with a small quantity of urea : occasionally uric acid is found as well, and not unfrequently traces of old hemor- rhages. The consistence, however, may be so thick as to resemble colloid. The walls are always thin, and lined with a single layer of flat epithelium. In most cases they originate from the urinary tubules, which have been blocked, either by inflammation and degeneration of the epithelial cells (caused possibly by the infarcts of uric acid that are found in the kidneys shortly after birth), or by the organization of lymph thrown out around them. Sometimes they may be derived from the glomeruli. As a rule, these cases do not admit of treatment. When there is an enormous enlargement on one side, an attempt may be made to obtain relief by aspiration or by nephrotomy; and if it can be shown that the opposite kidney is, if not intact, at least capable of doing the whole work of the body, nephrectomy may be performed, but not otherwise. Besides these, cysts, sometimes of considerable size, are of common occurrence in granular kidneys, but they seldom require treatment. Dermoid cysts are occa- sionally met with, and they have been diagnosed by the passage of hair and debris wdth the urine. Hydatids are not common ; when they occur in the substance of the kidney they usually rupture into the pelvis, and the discharge of the daughter- cysts may give rise to repeated attacks of renal colic. They may be treated either by aspiration or by free incision and drainage ; if left to themselves, they some- times dry up and give no further trouble ; but not unfrequently they sui)purate, and then they must be treated by free incision, in the same way as other renal and perinephritic abscesses. 998 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Solid Gro7oths. New growths in connection with the kidney are nearly always malignant (car- cinoma or sarcoma). Tubular adenoma, fibroma (originating from the capsule), papilloma (growing in the jjelvis, and resembling the villous tumors of the bladder), angeioma, and lymphadenoma, have been described, but they are all very rare. Besides these, fatty tumors are said to occur, but it seems probable that they are really derived from portions of the supra-renal capsule detached from the main body in the course of development. Carcinoma rarely occurs before adult life, and is most common after forty. It seems especially prone to attack floating kidneys, and is not unfrcipiently asso- ciated with calculus, though it is difficult to be certain of the relationship that exists between them. It is nearly always encephaloid, though a few cases are recorded in which the fibrous stroma was so dense as to deserve the name of scirrhus ; colloid may occur secondarily. In many cases they originate in the structures about the hilum, and only penetrate the pelvis after a certain length of time, pushing the renal structure before them ; and perhaps this may explain the frequent absence of diseased products in the urine. Sarcomata maybe congenital, and are much more common in the young than in the old. For the most part they are small-celled and very vascular. In a few cases they have been found to contain large quantities of fibrillated bundles arranged in different planes, crossing one another in all directions, and composed for the most part of striped muscular fibres. Symptoms. — The signs of malignant disease of the kidney are, as a rule, very obscure, until it has reached an advanced stage and formed a definite tumor. Haematuria may be present, and when it is, it is generally profuse, but it may remain absent almost through the whole course. Pain is rarely wanting ; usually there is a dull aching in the loin ; and later, violent neuralgia shooting down the branches of the lumbar plexus ; and sometimes there is intense irritability of the bladder. Contraction of the psoas muscle, leading to lameness and a suspicion of hip disease ; jaundice, especially when the right side is concerned ; (Aidema of the legs from obstruction to the circulation; constipation from pressure upon the colon, and vomiting, probably reflex in character, are not uncommon. The urine may show no sign ; more frequently there is haematuria at one time or another ; albumin is only present when there is blood, and renal colic may occur under the same conditions. The question of operation under such circumstances is very doubtful. It rarely happens that a diagnosis can be made until the kidney is definitely enlarged, and then complete removal is almost hopeless. Sarcoma in children is probably the worst, and it is very rare to meet with a case in which nei)hrectomy is justifiable ; in the case of adults, and with carcinoma, there is a little more hope ; it is known that patients have lived for a considerable ])eriod without recurrence ; but the operation cannot be recommended unless it is probable, from the duration of the case, that the disease is still limited to the kidney. Rknal Calculu.s. Renal calculus may occur at any period of life, but is most common at the two extremes; and it may be formed either of urate of ammonium, uric acid, oxalate, phosphate, or carbonate of lime, ammonio-magnesium i)hosi)hate. cystin, or xanthin. Of these the first is most common in infants ; the next two during adult life ; while the rest, especially the last two, are very rare. Not unfreiiuently the calculi are laminated, layers of different substances, more or less pure, alternating with each other, according to the reaction and character of the urine at the time. Some are developed in the calyces, others in the epithelium of the urinary tubules. The former are composed of triple phosphate, and are either formed around blood- clots, or, in cases of pyelitis, as concretions on the roughened and RENAL CALCULUS. 999 ulcerated surtace of the mucous membrane when the urine becomes ammoniacal. The cause of the latter is more obscure. Some originate from the infarcts in the renal tubules of infants ; and these, though they may be multiple, if once removed, never return ; the condition which gives rise to them disapi)ears as soon as the urinary secretion is well established. In the case of others, the fault appears to lie in the e})ithelial cells ; their energy becomes impaired, whether from long-con- tinued overwork, old age, or disease; they lo.se their power of discharging into the urinary tubules the materials withdrawn from the blood ; and, as a result, the.se increase and accumulate until at length a nucleus is formed. It is i)rol)able that this only takes place when there is at the same time a morbid condition of the urinary passages leading to the production of a suitable colloid medium. There is evidence to show that when a material of this kind is present the urinary salts are precipitated, not as perfect crystals, but in a modified form, similar to the rounded masses that are found as nuclei ; and it is certain that the mere increase in the amount of urinary salts is not a sufficient explanation. However this may be, these calculi differ in one very im])ortant resj^ect from those that occur in infants : they are the result either of inheritance or of faulty modes of life, such as excess of nitrogenous food or of strong wines ; and as the causes usually continue in activity after the calculus is removed, recurrence is not uncommon. Symptoms. — Renal calculi may be small, round, and freely movable ; en- cysted, so that they are practically fixed ; or large, branching masses, reproducing somewhat the shape of the pelvis and calyces after the secreting part ha.s been par- tially destroyed (Fig. 419)- • The general symptoms are the same in all, but they vary greatly in intensity. In every case the family and personal history should be thoroughly investigated ; the tendency to the formation of calculi is undoubtedly inherited, and recurrence very common. Pain is always present. Two chief varieties can be distinguished, though there is every intermediate gradation ; one is dull, aching, and continuous, felt mainly in the loins, but radiating down the thigh, into the groin, and especially into the testicle. It is present in nearly all, and is especially severe after moving or jolting, as in riding, and after the pelvis has become inflamed. The other {f-enal colic) only occurs with small and movable calculi when they drop into the orifice of the ureter and throw its muscular fibres into a state of spasmodic contraction. It is usually brought on by some sudden movement ; often it begins with a rigor, and it is of the most intense description, shooting down to the testicle, into the thigh, and, perhaps, over the whole of that side of the body. Nausea and vomiting generally occur at the same time ; the patient rolls over and over with agony, lying curled up as much as possible to relax the muscles ; the face is pale and shrunken ; there is extreme collapse ; the forehead is covered with perspiration ; the skin is cold and clammy ; and the pulse at the wrist can scarcely be felt. It is not con- tinuous, but comes on in paroxysms, and may end quite suddenly; many patients never suffer from it at all ; in others it returns again and again at intervals of a few weeks or months, each time causing fresh mischief in the kidney, until the calculus is either passed or becomes so large and so surrounded by inflammatory exudation that it can no longer occupy the narrow part of the pelvis. The same symptoms may be caused by the passage of blood clots, and even by hydatid cysts set free in the pelvis. In many cases the pain is referred to other parts of the body, especially to the genito-urinary tract and along the course of the lumbar and upper sacral roots. Neuralgia of the testis is of frequent occurrence ; sometimes it is so tender that it can scarcely be touched ; irritability of the bladder is often present, and may, as in strumous pyelitis, be exceedingly severe ; sometimes there are paroxysms of pain, shooting down the foot or leg, similar to the lightning pains of locomotor ataxy ; or a constant burning sensation in the heel ; or intense sciatica. In fact, wherever paroxysmal pain occurs in the lower extremities, especially if it is attended by nausea and retching, or with any alteration in the con- dition of the urine, the possibility of renal calculus must always be borne in mind. Refraction of the testis is very significant. When the calculus is in the ureter. looo DISEASES AND INJURIES OF SPECIAL STRUCTURES. it is rarely absent, and the gland may be held tightly up against the abdominal ring. It is not so well marked or so constant while the stone occupies the pelvis. The examination of the urine is most important. IHood is almost always present at one time or another, esi)ecially after e.xertion, and it is always evenly mi.xed with the urine. If the hemorrhage is recent, the color is bright red ; if some time has passed, dark brown or smoky, or even almost black, like porter. The amount is rarely large, and coagula are not often met with, except after the spasm of renal colic ; then the whole organ becomes tender and congested, and it may pour out in considerable quantity. In other cases large quantities of gravel or brick-red crystals of uric acid may be found from time to time. Mucus is always j^rcsent and sometimes epithelium, which may be recognized as coming from the pelvis ; so long as the urine is acid, the quantity may not be great, but in the more severe cases, where the calculus is large or irregular in shape, and especially where the urine has undergone decomposition, and suppurative pyelitis is present as well, the discharge is profuse and loaded with crystals of triple phosphate. When this occurs other symptoms soon follow ; the temperature rises, especially in the evening, sometimes as much as two or three degrees ; headache and drowsiness are of common occurrence ; the appetite fails completely ; the tongue is dry and cracked ; nausea is almost constant ; and the patient rapidly loses flesh and strength. Tenderness in the loins and rigidity of the museles are always present. If there is more than one calculus, grating can sometimes be made out by deep palpation when the patient is under an anaesthetic. ICnlargement of the kidney is more common ; sometimes it is real, due to congestion ; but more often it is caused by condensation of the fibrous tissue around from continued irritation ; and not un- commonly it is only apparent, the kidney being dragged downward by the spasmodic contraction of the muscular fibres of the ureter. Diagnosis. — When there are repeated attacks of renal colic without the stone passing into the bladder, and apparently causeless vesical irritability, with the pres- ence of blood and mucus in the urine, the diagnosis of renal calculus is easy. In many instances, however, it is a matter of the greatest difficulty. Nephralgia, closely resembling renal colic, may occur in delicate women, during the menstrual period, from the physiological enlargement of the kidney ; it may be present with haematuria in chronic interstitial nephritis ; biliary colic and duodenal inflam- mation may imitate it closely on the right side; while there are many cases on record in which there has been great /6, '>;■, difficulty in distinguishing it from vesi- /"^ "■ ;\ cal calculus, lumbago, typhlitis, and /■ \ even aneurysm. : Cancer and tubercle affecting the / >^, * '- ' kidney are the most difficult, particu- /: // \ <}g^'^'^ larly in the early stages; renal colic y, . ^ "■ may occur in both, due either to coag- Y: ula or to broken-down caseous masses ^ v; traversing the ureter; lumbar pain, : '%- %. hematuria, and vesical irritability are ^|;' usually present ; and in many cases ;" X_ there is nothing distinctive in the urine. :;^ ' In malignant growths, however, the ' ^ hemorrhage is usually profuse and is '■i; \ U rather the cause of colic ; while in tu- V |i|l bercular pyelitis the amount of pus is V": ' *'|] always greater than in the case of cal- ..■ ,- jpll cuius, unless this is complicated by the .-^ '■'•^ presence of alkaline urine and septic decomposition ; and true renal colic Fig. 4.8.-Calculus Encysted in Lower Part of Pelvis. nCVer OCCUrS UUtil the CaSeOUS maSSCS RENAL CALCULUS. looi have begun to undergo disintegration. Searcli should always be made for cancer cells and for tul)ercle bacilli ; but unless the greatest precautions are taken they are very difficult of identification, esi)ecially the latter ; and the fact of their not being found even after repeated examination cannot be regarded as evidence of their non-existence. It is not uncommon for calculi to remain latent in the kidney for years with- out causing active mi.schief, and in many instances they have been found post- mortem without their presence having been suspected during life. In the majority, however, they give rise to symptoms of greater or less severity ; and in a very large number they lead to such extensive destruction of the kidney, and such seri- ous interference with health and strength, that the question of removal becomes imperative. It is least serious when the calculus is encysted in one of the calyces or fixed between the pyramids (Fig. 418) ; the renal substance around becomes absorbed and indurated ; a sac of dense fibrous tissue is formed ; and the amount of int'er- nil / ^-> Fig. 419. — Suppurative Calculous Pyelitis with Destruction of Renal Tissue (n) The Calculus Removed from its Bed. stitial connective tissue throughout the organ is increased ; but provided the size remains moderate, and suppuration does not set in, the stone may remain quiet and undisturbed for years. Small calculi lying loose in the pelvis are infinitely worse. On the one hand they cause repeated attacks of renal colic, which end at length in hydronephrosis and interstitial nephritis ; on the other, they set up acute inflammation of the pelvis, which spreads to the secreting tubules and finally destroys them. The mucous membrane first becomes irritated ; then the apices of the pyramids disap- pear ; the kidney substance is broken down and eaten away ; and at length, partly by absorption and dilatation, partly by ulceration and sloughing (especially after the urine has begun to decompose), a large irregular cavity is formed, in the centre of which lies the calculus, grown perhaps into a branching mass which al- most fills the interior. In extreme cases nothing is left but a shapeless bag of pus, formed by the capsule and the fibrous tissue condensed together, with perhaps some shreds of cortex, coated with a slimy mass of phosphates, still left upon the inner surface (Fig. 419). 64 I002 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Treatment. — In acute renal colic, the pain and spasm must be relieved with as little delay as possible, in the hope that the calculus may reach the bladder ; as soon as it leaves the ureter, the symptoms begin to subside. Opium is of the greatest value, and, if the kidneys are sound, must be given freclv, either the tincture mixed with an e(]ual (juantity of water, so that the amount of fluid is small, or morphia, with a minute (juantity of atropia, hyi)odermically. Chloro- form is of use when the spasm is severe, but the inhalation should not be pro- longed. The bowels should be emptied at once with a hot-water enema, not only because this prevents the pain caused by the pressure of a loaded colon, but be- cause it relieves the spasm of the ureter, and by the effort at expulsion helps the passage of the calculus ; the patient should be placed in a full-length hot bath (temperature 98° F. gradually raised to 101° or 102° F.) for twenty minutes to half an hour ; and if this does not soon give relief, the loins should be dry-cupped on both sides. Hot distilled water, or very weak tea, or barley-water may be taken freely ; there is no object in limiting the amount if the patient can take it, but not unfreijuently it merely increases the sickness. Generally speaking, after twenty-four hours the paroxysms become less severe ; if the stone passes into the bladder, they stop suddenly ; if it remains in the ureter, they continue longer, and cease very gradually, often returning again in a milder form with the least movement. In either case the patient is left in a state of ex- treme prostration, utterly worn out ; and though the color may return, and the face resume its natural expression within a few hours, it is not unfrequently many days before the strength is regained and the patient is able to move about again without the dread of recurrence. Impaction in the Ureter. — The calculus may be arrested at any point, but nearly always it is either at the commencement, where the pelvis narrows into the ureter, or at the end, so that it projects slightly into the bladder. In the latter case it can be felt as a round, hard mass, through the w-all of the rectum or vagina. In women the bladder can be explored with the finger under an anaesthetic ; but in men, unless the stone j)rojects so far into the cavity that it can either be seen with the endoscope or felt with a sound, this help is lost. The treatment must be guided by the symptoms, and particularly by the con- dition of the other kidney. If the amount of urine secreted does not fail, manip- ulation may be tried under an anaesthetic ; copious hot enematamay be given with opiates and warm baths ; and if the calculus can be felt near the end, an attempt may be made to hook it down further by means of the finger, or to extract it through a suprapubic or a perineal incision, making a small nick in the mucous membrane at the orifice if necessary. If the impaction is not relieved the symp- toms become le.ss urgent as time passes, the colic subsides, the kidney wastes, and hydronephrosis follows. It is much more serious when the other kidney is already disabled, whether this arises from a similar accident (which is not at all uncommon), congenital defect, or disease ; the secretion of urine is then arrested altogether, and unless relief is sjjeedily obtained, the condition must prove fatal. The same measures may be tried first, but if they do not succeed, either an incision must be made in the loin to drain the kidney, or the abdomen must be opened and the ureter traced until the obstruction is found. If the calculus is felt, the peritoneum and the wall of the ureter may be incised, the stone removed, the cavity cleansed, the wound in the ureter stitched together again, and the peritoneum united over it; or, if the obstruction is due to any other cause, it may be dealt with according to circumstances. Which of these operations should be performed depends upon the condition of the patient. The latter is the more thorough, and as both ureters can be examined, there is less likelihood of an operation on the wrong side, but it is the more serious ; the former, unle.ss the calculus is lying in the i)elvis within reach, can only be regarded as a temporary measure, leaving behind it a renal fistula in the loins, through which the whole of the urine must flow. /// the Pelvis. — .\ calculus in the pelvis may sometimes be so reduced in size INFLAMMATION OF TIIF KIDNEYS. 1003 by solution or disintegration that it becomes small enough to pass through the ureter; or if this does not happen, it may work out a bed for itself, and become fixed by fibrous tissue, so as to give no fiirther trouble. An operation should not be proposed until after the former of these, at least, has been tried. Solution can only succeed with small calculi, composed of uric acid or urates ; large ones are out of the question, and o.xalate of lime, and substances deposited from alkaline urine are not sufficiently .soluble. It is of most service where small masses of uric acid are constantly being formed in the urinary tubules, and dropped into the pelvis, as in the case of the pisiform concretions of old people, causing them to be dissolved and wasted away before they get too large, and acting rather as a preventive means ; but even after being in the ijelvis some time, calculi can be so reduced in size as to pass easily down the ureter, or at least give no further trouble. The citrate and bicarbonate of potash, which are often given in large doses for this purpose, are not of much service by themselves ; the urine must be very concentrated for them to have any effect, and as the alkaline fluid simply passes over the surface of the calculus, the chance of any appreciable solution is exceedingly small. Moreover, there is the danger that, if large or long-continued doses are taken, the urine may become too alkaline, and deposit a layer of phos- phates. Distilled or soft water, on the other hand, taken in large cpiantities, four to five pints a day, with occasional doses of citrate of potash, or of some alkaline water, such as that of Vichy or Contrexeville, is often most effectual. The specific gravity of the urine is diminished ; the rate of secretion is increased ; it acts to a slight extent as a solvent and, what is of more importance, by diminishing the amount of inorganic material, it assists the disintegration of the external laminae ; but for this to answer, the treatment must be continued for a considerable length of time, the urine must never be allowed to become concentrated, and the diet must be carefully restricted. Fish and white meat are to be preferred ; sweet fruits, especially cooked sugar and rich pastry, should be avoided ; bread should be toasted ; and the amount and kind of alcohol carefully prescribed. Probably patients with renal calculi would be better without any ; but in many instances they are so worn out by suffering that depriving them of it altogether would prevent their digesting anything else. Beer and strong wines, containing large quantities of sugar, are certainly injurious ; but the lighter ones, or small quantities of spirits, well diluted, and taken with the meals, may generally be allowed. [Poland Spring Water or Chippewa Spring Water, being pure, soft waters, free from mineral or saline constituents, have great usefulness.] Small doses of turpentine, given either in the form of emulsion, or, better, in capsules, are of great use in these cases ; not unfrequently a large amount of gravel is brought away in a very few days. Probably this is due to the effect that the turpentine has upon the lining membrane of the pelvis : the secretion of mucus is checked ; the growth of the calculus is arrested ; and the size of the passage through which it has to pass is materially increased by the diminution of the hyperaemia and swelling. If these measures fail, and if there is either a small calculus constantly rolling about, or a large one gradually destroying the kidney, an attempt should be made to remove it by operation. In the one case it will, if left to itself, lead, after repeated attacks of renal colic, to interstitial nephritis and hydronephrosis, with, very possibly, if it occurs on both sides, suppression of urine ; in the other it will end at length in septic decomposition and suppuration, which will spread from the pelvis to the kidney and destroy it. IXFL.AMMATION OF THE KiDNEVS. Inflammation of the kidneys maybe either primary (nephritis) or secondary, due to extension from the pelvis (pyelonephritis). I. Acute nephritis is not common, but it may be caused by exposure to cold IC04 DISEASES AND INJURIES OF SPECIAL STRUCTURES. and wet, by extensive lesions of the cutaneous surface, and by irritating sul>stances in the urine, such as cantharides or turpentine. Mild forms are occasionally met with in erysipelas and, very rarely, in secondary syphilis. Pathological Appearance- — The kidney is swollen and rounded ; the veins are prominently marked ; the capsule strips off readily, and when it is cut open the surface is deeply congested ; it may even drip with blood. In milder cases, where the symptoms have lasted longer, the cortex is paler, owing to the great increase in the epithelial elements in the tubules, and the contrast of the pyramids is still more marked. Symptoms. — Acute nephritis may set in with a rigor. The temperature may reach 103° F. the first day ; headache, vomiting, insomnia, and loss of appe- tite, are always present ; the pain and aching over the loins never cease ; often there is the most intense desire to micturate ; the quantity of urine is greatly diminished ; in severe cases there is almost complete suppression ; the specific gravity is high ; it is loaded with blood and casts ; and it nearly always throws down a turbid deposit of urates, epithelium, and broken down corpuscles. If the inflammation is severe and the excretion of urine seriously checked, dropsy may set in within twenty-four hours ; more frequently it does not aj^pear until the second or third day. Some- times there is only puffiness about the eyelids ; sometimes, on the other hand, there is general anasarca, invading the serous cavities, and even causing death from oedema of the glottis. Treatment. — The chief object is to reduce as far as possible the amount of work and to relieve the congestion. In mild "cases it is sufficient to keep the ])atient warm in bed, at an even temperature, with the bowels relaxed and the diet restricted ; in more severe ones great relief may be obtained by the use of hot-water and vapor baths. Cupping over the loins is often beneficial ; and where the fever is high, and the patient young and vigorous, venesection may be performed with advantage. The bowels should be opened with castor oil, or a small dose of calomel, and then kept relaxed with sulphate of magnesia ; it is doubtful if strong hydragogue purgatives do not do more harm than good. Nitrogenous food should be excluded from the diet, at any rate for the first few days ; after that small quan- tities of milk may be allowed ; but eggs, and other articles of food that consist largely of albumin, should be forbidden. As the symptoms subside, great care is necessary, both with regard to this and to the temperature ; relapses very easily occur, and there is great danger, if the symptoms persist for any length of time, that the condition may become chronic. 2. Chronic Nephritis. — Chronic interstitial nephritis is much more common and is more important ; on the one hand, it impairs general nutrition to such an extent that the tissues slough with the least injury ; on the other hand, it so pre- disposes the kidneys to the influence of shock, that any operation upon the urinary organs is very liable to be followed by complete or partial suppression of urine. It may follow an acute attack ; or be caused by the same influences (such as cold, wet, exposure, or irritating conditions of the urine), acting with less inten- sity but greater persistence ; or it may be the consequence of certain morbid conditions of the bladder or urethra. One of these is an impediment to the outflow of urine. Whenever this occurs, whether it arises from stricture, enlargement of the prostate, or any other cause, tension is exerted on the part behind, and this leads to a certain degree of dilata- tion and chronic inflammation. Even undue frequency of micturition, such as is met with in vesical calculus, is sufficient. This, however, is not the only one. Chronic inflammation (without dilata- tion) may be caused in an entirely difi"erent way. The passage of a catheter is followed, in many people, by sudden congestion of the kidneys ; as a rule, this subsides of itself ; but, if it is frequently repeated, or if there is a stricture in the deeper part of the urethra, causing a certain amount of spasm every time the urine passes over it ; or a vesical calculus constantly falling against the neck of the INFLAMMATION OF THE KIDNEYS. 1005 bladder ; or, if the urethra is in a state of chronic inflammation from repeated attacks of gonorrhtea, this congestion practically becomes chronic ; the connec- tive tissue grows more dense and fibrous; the vitality of the epithelium is im- paired, and the kidney becomes small, hard, and cirrhotic. It must remain, in most cases, uncertain how far this disease of the kidneys is the result of tension only, and how far it is due to the chronic congestion ; but this is certain, that no condition of the bladder or urethra which interferes in any way with their proper function can exist for long without producing a most serious effect upon the kidneys. The pathological appearances depend, to some e.xtent, upon the degree of obstruction. The kidney is generally smaller than natural, hard, and dense ; the surface is irregular ; the capsule adherent, so that it tears away with it small por- tions of the tubules ; the cortex thinned and w^asted, with small cysts scattered through it, and the pyramids flattened and compressed. The pelvis may be nor- mal, but, especially in those cases in which the interstitial growth is due to obstruc- tion, it is dilated, and there may be every degree, from incipient fibroid change with slight expansion to extreme hydronephrosis, with nothing left of the kidney but a thickened disc of connective tissue. Symptoms. — When fully developed, these are characteristic ; in the early stages the patient seldom comes under notice. There is a slight but distinct failure of strength ; the skin is dry and harsh, itching constantly ; headaches are of com- mon occurrence; occasionally, there are attacks of vomiting; neuralgia is not in- frequent, and is often very obstinate ; the patient grows thin and pale, and some- times hypochondriacal ; there is loss of sexual power and very generally increased frequency of micturition, especially at night. The pulse is full and incompres- sible ; the left ventricle is hypertrophied ; there is a tendency to epistaxis, and other hemorrhages, and in the final stages a certain amount of oedema. The urine is greatly increased in quantity, and its specific gravity is exceed- ingly low ; the color is generally bright, and there is rarely much deposit, though a very few casts with some epithelial cells and crystals of oxalate of lime are occa- sionally to be found. Very often there is no albumin, but, as the disease advances, especially if the amount of urine begins to fail, it may make its appearance, though never in any large f]uantity. Toward the end hemorrhages occur, in the retina among other places ; vis- ceral complications arise, and the patient may be carried off by pleurisy or pneu- monia ; oedema sets in ; the vomiting becomes more frequent ; muscular twitch- ings make their appearance and grow worse and worse, until, at length ur^emic convulsions and coma end the scene. Treatment. — The first thing is to remove the cause, whether it is stricture, calculus, or anything else. It is true that the risk of shock and suppression is very much greater than in ordinary circumstances, but waiting longer than is abso- lutely necessary to bring the patient into the best condition will not make it less. After this has been done, the kidneys must be saved as much as possible and pro- tected from injurious influences. Iodide of potash and bichloride of mercury, in very small doses, may have some influence in checking the hypercemia and assist- ing the absorption of the lymph, if given before the contraction is too dense, and in the later stages chloral allays the irritability of the skin, and checks muscular twitching. Most reliance, however, must be placed upon rest, warmth, and diet. During the subacute attacks that are frequently present, the patient should be con- fined to bed ; exertion, both mental and bodily, should be avoided ; long rail- way journeys are particularly injurious ; the clothing should be warm ; damp and chilly residences are especially injurious ; the diet must be light but nutritious ; alcohol should only be taken so far as is necessary for digestion ; eggs and other substances that contain a large amount of albumin should be partaken of very sparingly ; milk may be allowed freely, especially with farinaceous food and the lighter forms of meat ; but great care should be taken not to overload the digestive organs, or to run the risk of causing dyspepsia. ioo6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. PVKI.ms AND PVEI.ONEI'HKiriS. Inflammation of the mucous membrane of the pelvis of the kidney is rarely met with by itself. Except in the mildest cases, such as those caused by the accu- mulation of gravel in gout, the kidney almost always becomes involved before the disease has lasted any length of time ; and, in those in which suppuration breaks out, its whole substance may be destroyed, nothing being left but a sac distended with pus, with scarcely a trace of the original structure visible. Causes. — These are almost the same as tho.se of inflammation of the bladder. Cold is occasionally one. Injury is more common, whether it is mechanical, due to the irritation of a calculus, or chemical, arising from the action of no.xious sub- stances in the urine. Tubercle is not at all rare, while, in exceptional cases, new growths, carcinoma, and villous tumors similar to those in the bladder, have been the cause. Finally, it is often due to extension, especially from the ureters. At first, the inflammation is limited to the pelvis, but, if the cause is a large calculus with spreading branches, or if it is foul and sej^tic urine, or if the deposit of tubercle, instead of being confined to the pelvis, is scattered through the substance of the organ, the kidney rapidly becomes involved as well, and in a very short time the whole of it is either riddled wath minute abscesses, or converted into a sui^purating sac. Sometimes the ureter is obstructed, so that the pus is unable to escape, and then a huge swelling, pyonephrosis, forms in the loins. In very rare cases the closure is incomplete, and there is an intermittent discharge of fluid, as occasionally happens with hydronephrosis. Pathological Appearances. — These differ very considerably. /// simple catarrhal pyelitis, the mucous membrane is swollen, thickened, and redder than natural ; the surface is raw from the loss of its protecting epithelium, and in severe cases is coated over with lymph, mixed perhaps with blood. Sometimes there are older, darker extravasations, and, when the disease is of long standing, the color post-mortem may be almost black. In calculous pyelonephritis, when the stone is the only cause, the mucous mem- brane may show no further change ,; or, if the irritation has been of long duration, the substance of the kidney may be eaten away — the medulla esi)ecially having suf- fered — and the interstitial connective tissue thickened and hardened. Unfortu- nately in most cases the urine decomposes and suppurative ])yelonephritis makes its appearance in addition. When this occurs, the mucous lining becomes thick- ened, ulcerated, and coated with a slimy deposit of pus and phosphates ; the whole of the medulla and most of the cortex are eaten away, and nothing is left but a large irregular cavity full of foul and decomposing pus, with roughened and rugged walls lined with the debris of the broken-down and ulcerated cortex (Fig. 419)- Tubercular pyelonephritis may occur in the course of general miliary tubercu- losis, or at first, at least, as a local affection. In the latter case it may begin in the bladder or in the kidney ; but often before the disease has lasted any length of time, it extends from one to the other, and not infrequently involves both the kidneys, although in different degrees. In the earlier stages the mucous mem- brane of the pelvis is thick and soft, and the surface like sodden wash-leather ; here and there are small superficial ulcers with sloughing and ragged edges, due to the breaking down of the caseous deposit ; the pelvis is enlarged owing to increased difficulty in the discharge of the urine ; and according to the situation of the growth, there are either numerous small ca-seous foci in the .substance of the kidney, or the apices of the pyramids are eaten away. When the disease is of longer stand- ing, the tissue around the kidney is condensed and indurated ; the capsule is thick- ened and cannot be separated from the cortex ; the medulla is almost destroyed, and the cortical part is softened and disintegrated (Fig. 420). Ultimately suppuration occurs, as in other forms of advanced pyelitis, and the whole of the renal substance may disappear and nothing be left but a thickened shell of fibrous tissue, preserving somewhat the shape of the kidney, filled with a slimy mass of tenacious pus, like soft putty. PYELITIS. 1007 ^.*i^ Fig. 420. — Tuberculous Pyelonephritis. Siipptiiative pyelonephritis (surgical kidney so-called) such as is met with in old cases of stricture, vesical calculus, or enlargement of the prostate, after am- moniacal decomposition of the urine has set in, has already been mentioned. 'J'he kidney is generally small, hard, con- tracted and granular from the pre- existing interstitial nephritis ; minute abscesses, each surrounded by its zone of congestion, are present in numbers under the capsule, or buried in the cortex, or extending as long, slender streaks in the substance of the pyra- mids ; here and there between them are points where the inflammation has not yet culminated in suppuration ; the apices of the pyramids are eaten away ; the pelvis and calyces are irregu- larly dilated from the old standing obstruction ; and the mucous membrane is discolored, ulcerated, coated over with stinking pus, and even sloughing. Decomposition has occurred in the bladder and caused acute cystitis ; and the poison has spread directly upward to the pelvis and into the substance of the kidney. Very rarely the pelvis is healthy, in spite of the presence of advanced nephritis, the germs having, in all probability, gained the kidney by spreading along the lymphatics of the ureter and the capsule, until at length they reach the interstitial spaces that lie between the tubules and surround the glomeruli. Symptoms. — Pyelitis may affect one or both kidneys, according to the cause. When it is due to septic urine and cystitis, it is nearly always bilateral ; the tubercular form may begin in one, but very often it extends to the other at an early period ; and though the retention of calculi in the pelvis is in some measure the result of accident, their formation is due to constitutional causes, and if they are present on one side there is very great probability of their occurrence on the other. Local. — In the early stages the symptoms of pyelitis are very indefinite, unless the attack is acute, or there is a small calculus dropping constantly into the orifice of the ureter ; in the chronic forms, at the commencement of tubercular disease for example, they may be entirely wanting. As the inflammation spreads and involves the kidney, there is a constant dull aching in the loins ; the muscles are rigid and tender ; there is stiffness on moving, and not unfrequently either diar- rhoea or constipation. In the later stages of calculus and tubercular disease, when the tissues around are involved as well, the pain may be exceedingly severe, and the kidney may feel as if it were enlarged ; but there is rarely any distinct swell- ing unless the ureter is clo.sed and pyonephrosis has set in. Neuralgia radiating down some or all the branches of the lumbar plexus, into the groin, down the inner side of the thigh, or into the testicle, is always present, and is often severe when there is a calculus. Irritability of the bladder is almost as general ; in renal tuberculo.sis it is one of the earliest signs, and it is not un- common for the bladder to be sounded time after time for stone, especially in children, before the real cause is detected. In the later stages it may be simply agonizing. The character of the urine is most important. In simple catarrhal pyelitis it is acid, and varies but little in quantity or specific gravity ; but it is turbid, and ioo8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. yields on standing a sediment, in which the characteristic spindle-shajted or cau- date cells of the pelvis can be detected. Blood-corpuscles are generally jjresent if there is a calculus, but in the other forms they often do not appear until later. As the case i)rogresses the epithelium disappears, the amount of mucus increases ; and this in its turn is replaced by pus, which may be i)resent in such (piantity as to form a thick creamy deposit at the bottom of the vessel. In tubercular and calculous jjyelitis, the urine may continue acid quite to the end, in spite of the amount of i)us that is added ; in the septic form, on the other hand, it is alkaline and ammoniacal, and the i)us, mixed with phosphates, forms a dense, viscid, gelatinous mass, similar to that secreted by the bladder under the same conditions. Constitutional. — These depend partly upon the amount of sujipuration, partly upon the extent to which the renal substance is involved, and whether both kidneys are implicated or only one. In the so-called surgical kidney, consequent upon vesical disease, the symp- toms are essentially those of chronic nephritis, with partial and increasing sup- pression. There is rapid emaciation, with loss of strength, dryness of the skin, headache, neuralgic pains and vomiting. The pulse is small, (piick, and feeble ; the temperature rises to 102 F. or 103° F. 3 rigors occasionally occur ; and the patient gradually passes into a dreamy state, with low muttering delirium, until diarrhaa with a subnormal temperature, or coma, and perhaps at length convul- sions, follow. In tubercular and calculous pyelonephritis, if only one kidney is affected, the other may become hypertrophied, and, so far as the urinary secretion is concerned, compensate perfectly ; and sometimes w^hen this occurs the pus dries up (especially if the ureter becomes blocked), and the kidney is at length converted into a pasty,, mortary, or even calcareous mass, surrounded by a fil)rous ca])sule. Much more often, however, suppuration sets in, and symptoms similar to those present in any case of ill-drained abscess make their appearance ; the temperature rises, especially toward evening, or rigors occur ; the patient becomes weak and feeble ; night- sweats and diarrhcea begin ; and either hectic or amyloid disease, which is especi- ally serious when there is only one kidney active, follows. If both kidneys are affected, not only are these symptoms greatly intensified, but in addition the amount of urea and the specific gravity of the urine fall lower and lower until at length it ends in suppression. Diagnosis. — The diagnosis of pyelitis at its commencement is often very difficult, and rests chiefly upon the irritability of the bladder, for which no cause can be found, the shape of the epithelial cells in the sediment, the amount of mucus in the urine, and the character and locality of the pain. When cystitis is present as well, as it not unfrequently is in gout and tubercle, the difficulty is greater still. In older cases, when the kidney becomes involved, there is little or no trouble ; either the urine continues acid, in spite of its containing an enormous amount of pus, or, if it becomes alkaline and ammoniacal, the diminution in the amount of urea, the low specific gravity, the emaciation, and the other constitutional signs, render it clear that the disease, though it may affect the bladder, is not confined to it. Calculous pyelitis may generally be distinguished from the others, by the se- verity of the pain, the way in which it radiates down to the testicle, the occurrence of renal colic, the effect of exertion, and the presence of blood-corpuscles in the urine at a very early period. When the inflammation is due to gravel, genuine colic is rare, though there may be a great deal of pain ; and the urine is of high specific gravity, very acid and^ loaded with crystals. In either case, the history, the other constitutional symptoms, and the occurrence of previous attacks, are of great importance. Tuberculous pyelitis is more difficult to distinguish, especially at the begin- ning, for though caseous masses and bacilli may be found in the urine when the disease is advanced, they are seldom present until the kidney itself begins to break P YEL ONEPHRITIS. 1 009 down. Very often the diagnosis has to be made l)y a process of exclusion ; there is great irritabiHty of the bladder, without anything local to account for it ; the amount of mucus in the urine is undoubtedly excessive ; blood is seldom present ; the pain is not severe ; there is no renal colic ; and the urine does not contain either uric acid or oxalate of lime in excess. In these circumstances, the presence of tubercle elsewhere, especially in connection with the genito-urinary organs, must be regarded as of the gravest significance. Later, the amount of pus, the l)resence of caseous masses and of bacilli, and the acid reaction of the urine, are distinctive ; but this does not prove that both kidneys are not involved. Pyonephrosis can only be distinguished from hydronej^hrosis, of which it is not an infrecpient termination, by the pain, fever, and rigors, which occur with more or less severity. In the case of perinephritic abscess, the shai)e and the out- line of the swelling are not so distinct ; and the urine is not affected. Other ab- scesses in the same region, due to disease of the vertebrae, caecum, or liver, or even to an empyema working its way down, rarely present any difficulty. In a very few cases the discharge of pus is intermittent, and there is a pro- portionate variation in the size of the tumor. Treatment. — The treatment of calculous pyelitis and of that which is due to the presence of uric acid has been described already. If there is a stone, an attemi)t must be made either to procure its disintegration or to fix it in some out- lying part; if this fails, and it continues to give inconvenience, it should be re- moved by operation, and afterward the diet and mode of life regulated, so as to prevent concentration of urine and the accumulation of uric acid. When the pyelitis is due to decomposition of urine in the bladder, the growth of the ferment must be stopped by antiseptics and drainage. Meantime, every attempt must be made to restore the acidity of the urine, as this is a serious hind- rance to the micrococcus, and to spare the kidneys as much as possible and econo- mize the patient's strength by careful dieting and attention to the action of the skin and bowels. The treatment of tuberculous pyelonephritis depends upon whether it is merely part of a general tuberculosis, or of an affection of the whole urinary system ; or whether it is a local disorder, and still confined to one kidney. In the former case only palliative treatment is available ; the strength must be maintained ; the intense vesical irritation must be relieved by morphia ; and any symptoms that arise must be met by suitable measures. Median cystotomy and drainage, which are of such service when the strangury is due to local causes, such as malignant disease of the bladder, are useless, when it is dependent upon the reflex action of the nervous system. There is more hope when it can be shown that the affection is limited to one kidney, as it is in about half the cases, though it is very difficult to prove. The specific gravity of the urine may be good ; the amount of urea may not be below the normal ; and there may be an entire absence of pain on the opposite side of the body ; but, unless the urine can be collected from the ureters separately, in suf- ficient quantity to be examined, it is not possible to be certain. In some of these cases the pus gradually dries up, the ureter having been accidentally blocked in someway; for it is not \\Xicon\vi\ox\, post-mortem, to find kidneys consisting of nothing but a capsule full of calcareous or cheesy, mortary substance, years after all symptoms have subsided. This, however, cannot be relied upon ; the disease is much more likely to prove fatal by involving the ureter or other organs near, from general miliary tuberculosis, or after prolonged suffering, from hectic and exhaus- tion. Whether nephrotomy and drainage, or nephrectomy and removal of the whole mass, afford the best prospect of relief, depends upon the circumstances of each case. If the patient is too exhausted to withstand the shock of the major operation (and it often happens, from the dense adhesions between the capsule and the surrounding structures, that a very long time is required for complete enucleation), or if there is any doubt as to the condition of the opposite one, nephrotomy is the more suitable. If there is any need for it, the shriveled and loio DISEASES AND INJURIES OF SPECIAL STRUCTURES. contracted sac can be removed afterward. W'licre, on the other hantl, there is nothing left but a fibrous sac without, when it is laid open, any trace of secreting structure, and where the adhesions can be broken down without unduly prolonging the operation, there is no object in leaving it to be completed at a later date. Pkrinephritis. Inflammation of the cellular tissue around the kidney is occasionally primary, caused by injury or exposure to cold ; much more fretpiently it is consecutive to disease elsewhere. Sometimes, as in calculous and tubercular nephritis, it arises by direct extension from the kidney, the pus gradually making its way through the capsule, and bursting, i)eriiaps externally, so that the stone is discharged through an opening in the loins ; sometimes it originates from inflammation about other structures near — the colon, crecum, liver, or even the vertebrae. In a large number of cases it is due to the inflammation of the pelvic cellular tissue extend- ing upward, after wounds of the lower part of the vagina or uterus ; after child- birth, or after operations upon the testicle, spermatic cord, or rectum ; and, finally, it may be pyemic in character, following one of the acute exanthemata. Perinejjhritis is sometimes chronic, the capsule and the cellular tissue becom- ing thicker and denser, until the kidney is invested in a dense fibrous wall which cuts and feels like cartilage ; but, as a rule, suppuration soon sets in, and a large irregular abscess forms around the kidney, and spreads upward and downward as far as the yielding character of the tissues will allow. The kidney itself, unless the suppuration originated in it, usually shows no change ; but, occasionally, the cortex is softened, in a state of cloudy swelling, and even filled with minute abscesses. Both sides may be involved, especially when it is the result of pyaemia. Symptoms, — The early ones are very perplexing ; very often there is a rigor at first, with constant vomiting; the temperature is very irregular; the bowels are obstinately constipated; there is a dull aching pain across the back, and the patient feels perfectly crippled. The body is inclined toward the affected side, and slightly bent forward ; the thigh is flexed upon the abdomen, and the leg is rotated outward, as in the second stage of hip disease. The least move- ment makes the pain tenfold worse, and causes it to radiate down the lumbar plexus, but especially into the groin and the testicle ; and with all this, the urine is either perfectly normal (unless, of course, there is calculous pyelitis), or, in some exceptional instances, contains a certain amount of albumin and a few tube- casts. After a time, the tenderness in the loin becomes more localized ; there is a sense of deep resistance on jialpation ; and the skin becomes shining and oedematous, or even reddened, though fluctuation is seldom to be felt, even when the abscess contains several pints of fluid. If the case is left, and the constitu- tional disturbance does not prove fatal, the abscess either points over the crest of the ilium, between the obliquus externus and latissimus dorsi, or. else extends under Poupart's ligament into the thigh. In a few rare cases it has been known to burst into the lungs (so that an enormous amount of pus was suddenly coughed up), the intestines, the jieritoneal cavity, or even the ischio-rectal fossa. Diagnosis. — Perinephritis and perinephritic abscess are usually much more acute than hydronephrosis, pyonephrosis, and the other diseases that cause enlarge- ment of the kidney, and are not so sharply defined in outline. At first there may be some difficulty in distinguishing it from perityphlitis, and even from en- teric fever ; and it has been confused with hip disease (owing to the position of the limb), with caries of the spine, lumbago, faecal accumulations in the colon, and with abscesses resulting from disease of other neighboring structures. Treatment. — When the attack is subacute, an attemi)t may be made, by ap- plying leeches and poultices, and by keeping the patient at rest, to i)rocure reso- lution, but the result is rarely satisfactory. As a rule, rigors occur early, and mark the beginning of suppuration. The bowels should be well cleared out ; hot water enemata are often of some relief; the pain should be controlled by opium URINARY FISTULA. ion and belladonna ; ami as soon as suppuration is suspected, an exploratory punc- ture should be made with an aspirating needle. In a very few instances, if the abscess is emptietl in this way, recovery takes j)lace without incision ; as a rule, it is necessary to open it freely, wherever it is most prominent, and insert a large drainage tube. Urinary Fistula. Fistulous channels discharging urine, pus, or both together, are sometimes formed in connection with the kidney, its pelvis, or the ureter ; and they may discharge either externally in the loin ; or on the front wall of the abdomen in the inguinal region ; or into one of the neighl)oring viscera, the uterus or vagina most commonly, the stomach, intestine, and i)leura very rarely. The most frequent cause is calculous pyelitis leading to suppuration outside the kidney ; after the abscess had been opened the passage contracts down to a sinus, the walls of which are lined with a kind of granulation tissue, and perhaps coated over with phosphates. It may result, however, from gunshot wounds or other injuries, from operations about the female pelvic organs, especially hyster- ectomy, and occasionally, from tubercle. In some cases, as in cystic disease of the kidney, and hydronephrosis, a urinary fistula is formed as a temporary expe- dient, where it is not possible to obtain at the time exact information as to the condition of the opposite organ. After nephrotomy or nephrolithotomy, where the kidney is healthy and there is no obstruction in the ureter, the wound, though it may continue to discharge urine for a week or two, usually closes of itself. If it persists injections of iodine may be tried, or nitrate of silver fused upon a probe, or even a heated wire. When, however, in addition to the urine, there is a profuse discharge of pus, so that it is certain that the kidney is extensively disorganized, and there is fear of amyloid degeneration, or where the fistula is a source of intense annoyance and distress, and it can be proved that the opposite kidney is sound and not the seat of calculous disease, the best plan is to perform nephrectomy. It must not be forgotten that fistulse connected with the bladder and the urethra have been known to open in the inguinal region and even in the loin. In case of doubt the diagnosis can always be confirmed by the injection of milk or other colored fluids into the bladder. Methods for Distinguishing the Secretion of the Two Kidneys. In all operations about the kidneys, but especially when nephrectomy is con- templated, it is of great importance to obtain definite information with regard to the secreting power of each of them. As already mentioned, it is not uncommon to find that, as a result of congenital defect, accident, or disease, one kidney is either actually non-existent or else is so small as to be practically useless. Even in the abdominal operation this is not unnecessary, for all that can be ascertained by this is the size of the organ in question ; it tells next to nothing about its condition. Various methods have been devised, but none is satisfactory. The simplest is that suggested by Polk : one of the ureters is compressed just before its termi- nation, between a piece of block tin, shaped like a catheter with a very sharp curve, introduced into the bladder, and two fingers placed in the rectum ; or, if it is preferred, a curved spatula with a suitable groove on its upper surface. As soon as this is secured in position the bladder is washed out, and the urine from the other ureter allowed to collect, but it is very difficult to obtain more than half an ounce in an hour. Catheterization of the ureters can be managed in women either with the aid of the electric light, or, the patient being in the lithotomy position, by placing the fore and middle fingers of the left hand in the vagina, one on either side of the OS uteri, to which the orifices of the ureters nearly correspond, and, with these I o 1 2 DISEASES A ND INJURIES OF SPE CIA L S TR UCTURES. as a guide, manipulating the catheter with the other. On one occasion I slit up the urethra so as to expose the orifices more thoroughly. If catgut sutures are used, no incontinence should follow. Even in women, however, this will not always succeed, and in men it is out of the question. The left ureter may be compressed at the brim of the pelvis by means of Davy's lever introduced into the rectum ; the right cannot, unless there is a meso- rectum. Even when used for a short time, however, this is not without risk ; very serious bruising of the mucous membrane has occurred, although it was not I^ossible to assert that too much force had been used; and certainly it would not be advisable to keep up a sufficient degree of pressure for an hour. The same may be said of the various attempts that have been made to secure the orifices of the ureters either by clamps shaped like a lithotrite introduced into the bladder, or by suction api)lied to the orifices of the ureters ; they have only met with very partial success. When there is renal hematuria, the cystoscope is of some service ; the jet of blood-stained urine may be seen emerging from the orifice of one of the ureters, but, unfortunately, it does not seem probable that this will be of much avail in the class of cases that need it most. OPERATIONS UPON THE KIDNEY. Puncture of the Kidney. The chief use of this is for diagnosis ; it may, however, be required either as a palliative or as a permanent measure in cystic disease, hydatid cysts, and even in cases of hydronephrosis. The aspirator should be introduced into the most prominent portion of the swelling, where the fluid seems to lie nearest the surface, taking care to ascertain the position of the colon first by inflation, if necessary. Nephrotomy. Incision of the kidney may be required for suppuration, consequent on cal- culous or tuberculous disease (usually as a preliminary to further measures) ; for renal retention (when the ureter is blocked) ; or for hydronephrosis. In many of these cases puncture will have been performed first, and the more severe and radi- cal measvire is only adopted either because the milder plan has failed (perhaps in spite of repetition) or because the condition it has revealed is such as to require more active treatmeut. An operation of a closely similar character is necessary in cases of perinephritic suppuration. The incision is always lumbar, and usually oblique, parallel to the last rib, and an inch below it. The skin, superficial structures, muscles, and aponeurosis are divided, as in colotomy, and the kidney exposed. If it is distended into a sac this .should be opened either with a director and sinus forceps, or with a scalpel, according to the condition found, and after the contents have escaped, the space left should be explored with the finger to ascertain if there is any per- sisting cause, and drained. If, on the other hand, it is a case of renal retention, the cortex (which is always hard and congested) or the pelvis must be opened sufficiently freely to allow the urine to escape. Nephrolithotomy. There are two methods of approaching the kidney for this purjiose, either from behind in the lumbar region, or through the abdomen. That the former is the more suital)le in ca.ses in which the symptoms are definite and pointed plainly to one side, there can be no doubt, but it is still an ojjen ([uestion whether abdom- inal exploration is not advisable in some as a preliminary. A certain amount of information can be obtained as to the condition of the opposite kidney ; the posi- NEPHR OLITHO TO MY. i o 1 3 tion of the stone, whether it is in the ureter or not, may be ascertained ; and there is less risk of an operation on the wrong side. Moreover, it is ])ossible when operating through the loin to be misled by the presence of a perinephritic abscess, the interior of which is often divided into chambers like a sacculated kidney ; and it has happened before now, in the case of a very large and somewhat diseased kidney, that the finger has never entered the pelvis at all, but detached the thick- ened mucous membrane from the pyramids until a cavity was made closely resem- bling the true pelvis. As, however, a calculus cannot always be felt after the kidney has been removed, even the combined abdominal and lumbar method does not ensure perfect certainty. The patient lies upon the opposite side with a firm cushion under the flank. The kidney is supported from the front and pressed into the loin by an assistant ; but if the walls of the abdomen are rigid and dense with a thick layer of fat, it answers better, as soon as the kidney is exposed, to roll the patient nearly on to his back again, so that the convex surface may drop of itself upon the finger. An oblique incision, four inches long, parallel to and an inch below the margin of the last rib, is the most convenient. It should commence at the outer edge of the erector spinas, and should not come closer to the rib for fear of wounding the pleura, which sometimes descends as low as this. The superficial muscles are divided, the lumbar aponeurosis, which here is very thick, cut through upon a director, additional space being obtained, if necessary, by section of part of the quadratus lumborum, and the circumrenal fat exposed. Any point that bleeds should be tied at once, but generally there is nothing that requires it. As a rule, the tissue around the kidney is so loose and soft that it can be sep- arated easily with the finger and a pair of forceps ; sometimes, however, when there has been much inflammation, it is tougher ; and in old cases of suppurative pyelitis it may be exceedingly dense. As soon as the convex surface is exposed, the kidney must be thoroughly and systematically explored, first on the outside, passing the finger over the anterior surface and hooking it forward into the wound until the pelvis is reached ; then, as far as possible on the posterior, the fore and middle fingers passing behind it, while the thumb rests on it in front until it is fairly grasped. If nothing is detected in this way, no irregularity of surface or sense of resistance, the next step is to explore the substance of the kidney with a short stout needle set in a handle. It should not be more than two and a half inches long, for fear of wounding the vessels at the hilum. A number of punctures are made with this all over the cortex, always pointing in the direction of the pelvis. Sometimes a calculus is struck at once, but, especially when it is small, and it is often no larger than a pea, such good fortune is exceptional. If it is felt, the needle is used as a director ; an incision is made by the side of it with a sharp scalpel, and a pair of long forceps, like polypus forceps, passed along it until the blades are in a position to grasp the stone. Where this does not succeed, the i)elvis should be explored with a sound similar to that used for a child's bladder, but with a shorter beak. It is passed through the cortex into the lowest part of the cavity, and the whole interior and all the calcyces systematically examined, the sound being carried at once to the upper end, a distance of nearly four inches, and working gradually down. Finally, if this fails, the finger must be used in the same way, introducing it through the same opening, and gradually dilating and tearing the kidney substance. The bleeding at the moment is tolerably free, but the pressure of the finger soon arrests it. With a large branching calculus there is rarely any difficulty ; when it is* small, detection is often impossible. On one occasion I felt a small movable stone distinctly with the needle, but was quite unable to detect it afterward wnth the sound, forceps, or finger. Another case is recorded in which the kidney was excised, and afterward a stone was found in it, so buried that it could not be felt from the exterior, even after the organ has been removed. In a third case the calculus is reported to have come away subsequently in the dressings : and there is IOI4 DISEASES AND INJURIES OF SPECIAL STRUCTURES. a very large number on record in which no trace of a calculus was found. Fortu- nately the operation is one that, so long as the stone is small, is very rarely fol- lowed by serious consequences ; and in most cases, even when nothing has been found, the relief has been complete, probably from the calculus becoming fixed in the substance of the kidney by inflammatory adhesions or cicatricial tissue. (ireat care should be taken to extract the stone without breaking it, and, especially in the case of large ones with long slender branches, this may be a matter of some difficulty ; and after this is done the interior of the cavity must be thoroughly explored to see that nothing is left. The treatment of the wound is very simple. A large drainage tube should be passed into the kidney, so as to carry away at once all the urine that is .secreted, and the fascia lumborum sutured with catgut, leaving only an orifice at the posterior angle for the drainage tube. Usually the wound heals without suppuration. The tube should be removed the next day to clear it of any coagula, and introduced again down to the surface of the kidney ; the third or fourth day it may be short- ened so as to project only through the opening in the fascia. The urine pa.ssed by the bladder generally contains a large amount of blood for the first two days, then it should become clear. Retention is common at first, and may continue so long as the tube is in contact with the kidney. A urinary fistula persists for a week or two in the loin ; but if the kidney was healthy and the ureter is not blocked, it generally closes of itself. In cases of calculous pyonephrosis, when there is a large tumor in the loin, and the urine is loaded with pus, nephrotomy or nephrolithotomy should be adopted in preference to nephrectomy. It is true that the statistics of the latter operation under these conditions are more favorable, but, as Brodeur has pointed out, it is almost impossible to form a definite opinion as to the condition, or even the exist- ence of the opposite kidney. Later, when the patient has rallied, and it is clear from the amount and specific gravity of the urine secreted, that the power of the other kidney is not impaired, this operation may be performed, if the fistula per^ sists and gives much inconvenience, or if the discharge of pus is at all considerable. With only one kidney active, there is naturally greater risk if there is any amyloid change. It must always be recollected that, particularly in the case of adults, nephro- lithotomy can only be looked upon as giving temporary relief. The tendency to the formation of calculi is there still, and the same precautions as to diet and regimen must be taken after the calculus has been removed, for fear of recurrence. Nephrectomy. Excision of the kidney may be required for persistent hemorrhage following injury ; suppurative pyelitis (whether calculous or tubercular) in which the renal tissue is hopelessly destroyed and the disease limited to one side ; sarcoma or car- cinoma : and, as a sequel to nephrotomy when (the other kidney being sound) a fistulous channel is left. It may be performed either through the loin or the abdomen. I. Liunbar Nephrectomy. — Morris recommends an oblique incision parallel to the last rib, with, if more space is required for dealing with the pedicle, a ver- tical one running down from it, just in front of its posterior extremity. The further steps of the operation are the same as in nephrolithotomy until the surface is ex- posed. As soon as this is reached, it must be freed from the tissues around. In •some cases there are no adhesions ; in others they are so dense that it is impos- sible to divide them without using scissors. Occasionally it is better to open the capsule, and try to shell the kidney out from it. The next step is to secure the pedicle. It may be possible to draw the kidney so far out that the ureter can be isolated and a ligature passed round the vessels with ease. (Greig Smith recommends that, if this is done, all traction should be taken off before the knot is tied, for fear of the artery slipping back). In other SURGICAL ASPECT OF THE URINE. 1015 cases there is the greatest difficulty, and the mass must be secured with a clamp, or with an ccraseur, and cut away piecemeal before the deeper structures are suffi- ciently exposed. The artery and vein may be tied in one (if an abnormal branch is detectetl it should be dealt with by itself), and as soon as the surgeon has satis- fieil himself tliat the ligature is safe, the kidney tissue or the ijelvis divided at a sufficient distance and the rest of the mass removed. The ureter should be brought out at the lower angle of the wound, and fi.xed by a suture to the skin. In some cases the ligature has been placed almost on the side of the vena cava, but where it is possible a sufficient length of vessel should be left between. Finally the wound must be thoroughly dried, the peritoneum examined to see that it has not been rent, and a large drainage tube inserted. [When oozing persists, or indeed as a routine procedure, it is well to pack the wound with iodoform gauze.] 2. Abdominal Nephrectomy. — The incision is made through the corresponding linea semilunaris (after Langenbeck's method), and the peritoneal cavity opened sufficiently to introduce the hand. The intestines are held on one side with sponges, and the condition of the opposite kidney ascertained as far as possible. The posterior layer of parietal peritoneum must be divided on the outer side of the colon (so as to avoid injuring its vessels) and the surface of the kidney exposed and freed from its surroundings. As soon as everything is clear (the assistant holding up the torn edges of the peritoneum, and at the same time depress- ing the margins of the abdominal wound) the vessels are isolated and a ligature (double if possible) passed round them and tied. The separation is then com- pleted and the mass removed. The cut edges of the ureter may be inverted and stitched over, so that the stump may be left secure; or, if it is full of putrid pus or tubercular material, it may be pushed out through an opening in the loin and fastened to the skin. The plan of securing it in the anterior wound is objectionable, as tending to disturb the relation of the peritoneum. The cavity left behind the peritoneum must be thoroughly cleansed, the flaps that have been detached pressed back into it (they need not be fastened with any stitches), and then the abdominal wound dealt with. The relative merits of these operations are very differently appreciated. There is no doubt that in the case of very large masses the abdominal operation is the easier of the two (although if it is cystic, the size may be considerably reduced by tapping) ; that the pedicle is more accessible, and that a certain (very small) amount of information about the condition of the other kidney may be obtained. Further, if the nature of the tumor is doubtful, there is very much greater liberty of action. On the other hand, the peritoneal cavity is always opened ; the colon is endangered ; the ureter is difficult to deal with ; if the operation is performed for suppurative or tubercular pyelitis, there is considerable danger of infecting the peritoneum, and drainage is almost out of the question. SURGICAL ASPECT OF THE URINE. Examination of the urine is essential, not only for diagnosis in diseases of the urinary organs, but to obtain some idea concerning the activity of the metabolism of the body and the secreting power of the kidneys Except in emergency, no operation should be performed without this having been considered ; it influences the prognosis more than anything else, especially when the urinary tract itself is concerned. 1. Quantity. The amount passed during twenty-four hours must be ascertained in order to form an idea as to the reaction and the proportion of solids. It is sufficient in most cases to take the last two figures of the specific gravity and double them, or, if the urine is concentrated, multiply them by 2.33. This gives roughly in ioi6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. grammes, the total solids for looo c.c. of urine, and if it is collected for twenty- four hours the rest is easy. Important constituents must be estimated separately. When a i)atient is confined to bed the amount of urine (as regards both solids and liquid) is always diminished, so long as there is no fever. The quantity may be lessened by general causes, such as fevers, profuse sweat- ing, diarrhoea, etc. ; or from local ones affecting the circulation of the kidney, or its secreting power, or both together. Acute nephritis, for example ; congestion from cardiac disease ; vasomotor disturbance excited reflexly by irritation of the urethra, especially if the kidneys are diseased already; interstitial nephritis and amyloid and fatty degeneration in their later stages ; hysteria even occasionally ; and shock, as after railway accidents, are all attended by diminished secretion. Sometimes the difference is only slight ; in the worst cases there is complete sup- pression ; no urine is passed for days. When one ureter is blocked there is rarely much difference in the quantity, even at the first, owing to the increased activity of the remaining kidney ; but when both are affected, as when there is an insurmount- able obstacle to the exit of the urine, suppression must occur. In diabetes there is a great increase both in the amount of solids and of liquid ; in hysteria and simple polyuria, due to lesions of the nervous system, only the latter. In contracted granular kidney, cystic degeneration and the early stages of amyloid disease, there may be a noticeable increase in the amount, but at the same time the specific gravity is diminished so that the total solids may fall far below the normal. In the matter of prognosis this is scarcely less important than the pre- sence of albumin ; the drain upon the strength may be less severe, the loss of color and condition less marked, than when there is a constant daily waste of nitrogen ; but the elimination of effete products is often very much more defective. 2. Color. This depends partly upon concentration, partly upon the addition of foreign substances, such as blood, bile, melanin, and, under certain conditions, indican. Carbolic acid, when present in the blood in excess, gives the urine a peculiar dark- green smoky tint, which, if it is allowed to stand for some time, may become almost black. 3. Odor. In chronic cystitis the urine is often offensive, even f?ecal ; or it may be ammoniacal Irom decomposition. Characteristic odors are produced by turpentine and other drugs. 4. Reaction. ' Normal urine is acid, and this becomes more marked during the first iew hours, if it is allowed to stand in a clean vessel. Concentration, an excessive amount of nitrogenous food, and diminution in the quantity of alkaline phosphates, a condi- tion frequently found in ill-nourished strumous children, increase the acidity. Associated with this is a peculiar train of symptoms, such as are common in gouty patients ; the bladder is irritable, there are frequent attacks of dyspepsia, neuralgia, cramp, and palpitation; irritability of the skin is not uncommon; sometimes eczema and psoriasis occur ; gravel is present from time to time, and slight attacks of synovitis are of frequent occurrence. On the other hand, urine may be neutral or alkaline, from the presence of fixed alkali or of ammonia. {a) If there is fi.xed alkali, the blue color of litmus paper is i)ermanent. This may occur temporarily at certain hours of the day, depending upon the meals, without any special significance ; but when it is permanent, it usually points to some serious interference with the metabolism of the body. It has been noted as a precursor in affections of the nervous system, and in the early stages of cancer. {b) Carbonate of ammonia is always due to a micrococcus growing in the urine ; and the mucus assists it by rendering the urine less acid, or even alkaline. . SURGICAL ASPECT OF THE URINE. 1017 Solid Constituents. {a) Normal. Urea. — The amount depends, to a certain extent, upon the age and the activity of the individual. According to Ralfe, the average for each pound of the body weight, if between 40 lbs. and 60 lbs., is 41^ grains; between 60 and 120, 4 grains ; between 120 and 160, 3)4 grains; and between 160 and 175 lbs., only 3j<( grains. For clinical purposes the urea may be estimated with siifificient accuracy by the sodium hypobromite method, although the whole amount is not obtained by about 8 per cent. It increases in fever, after excess of nitrogenous food, and in diabetes. Diminution may be dependent upon diminished formation, as in diseases of the liver, especially acute yellow atrophy and extensive carcinoma ; or upon diminished excretion. The latter points to failing kidneys, and is a very serious element in prognosis for all operations, but especially for those involving the urinary tract. Uric (?<7r/ either occurs as such, forming a brick-red sandy deposit, or united with the alkalies or alkaline earths as a salt. I'hen it appears as a pink precipi- tate, rarely crystalline, which gradually settles down on the sides of the vessel as the urine cools. Neutral sodi.um urate is the most abundant in normal urine ; the acid salt, with small quantities of the corresponding calcium one, occurs in urinary calculi and gouty deposits. Acid ammonium urate is only found after decomposi- tion of the urea. Potassium and lithium urates are more soluble. The amount depends partly upon the supply of nitrogenous food, partly upon excessive tissue- waste and diminished oxidation. In gout, chronic diseases of the liver, and general malassimilation, it increases considerably, and is deposited wherever the circulation is feeble. Whether it occurs in solution or as a sediment depends upon the concentra- tion and reaction. The crystals may be recognized by their color (in the urine), by their whetstone shape, or by their being aggregated into rhombic bundles. Urates are generally amorphous, but sometimes they crystallize as rhombic needles, arranged in a stellate manner. Oxalate of lime is met with as a deposit in neutral, acid, and faintly alkaline urine. The crystals are either octahedral (envelope crystals) or dumbbell-shaped. In many instances it is only accidental, caused by the presence of oxalate of lime in the food fin rhubarb, tomatoes, onions, etc.), or by malassimilation ; and then it is usually found some hours after meals. In those, however, who are harassed, careworn, overworked, and hypochondriacal, it may be constant, and give ri.se to various anomalous nervous symptoms, such as frequency of micturition, pains across the loins, a sense of tightness round the chest, etc. Oxalate of lime is closely associated with the decomposition of mucus. It is found not merely in that which is secreted by the urinary passages, but in that from the uterus, gall-bladder, vesicular seminales and prostate, sometimes in the form of crystals. The importance of this in the causation of calculi can hardly be over- estimated. Phosphates. — Acid sodium and potassium phosphate are never precipitated ; phosphates of lime and magnesia are thrown down when the urine is alkaline, or sometimes if it is boiled. This may occur even when the urine is slightly acid, if the reaction is due to the presence of an acid salt. Phosphate of lime is usually amorphous, but it may form stellar crystals similar in some respects to those of uric acid. Acetic acid, however, dissolves them at once. Magnesium phosphate is deposited with it under the same conditions. If the urine is alkaline from the presence of bicarbonates, they may be precipitated without being in excess ; but under some circumstances, particularly in that state which is not seldom the precursor of diabetes and cancer, the alkaline and the 65 loiS DISEASES AND INJURIES OF SPECIAL STRUCTURES. earthy phosphates are both excessive. If they are deijosited in the bladder, they often cause a certain amount of irritation by collecting toward the end of mictu- rition and coming away in a thick, creamy mass, which leaves a wiiite crust as it dries. Fortunately, they rarely form calculi. When the urine is alkaline from ammonia, the tri])le phosphate of ammonia and magnesia is thrown down in triangular jjrisms (coffin-lid crystals; which form masses entangled in mucus. This is the crust that develops upon calculi, foreign bodies introduced into the bladder, and even upon the surface of ulcers in the pelvis of the kidney and bladder, as soon as the urine decomposes. (J)) Abnormal. Cystiii is an occasional cause of calculus. It may be recognized by its being thrown down from an alkaline solution on the addition of acetic acid. The crys- tals are colorless si.\-sided plates, and are readily soluble in ammonia. Its patho- logical significance is unknown ; from the large cpiantity of sulphur that it contains Ralfe is disposed to connect it with taurin. I have met with two families in which it was present ; several of the members of more than one generation were affected, but no calculi were formed; and they did not appear to be in any way inconveni- enced. The sulphur may be recognized by the black precipitate obtained by boil- ing the cystin in licpior potassae, and adding acetate of lead. Xanthin is still more rare. It has been met with as gravel, especially in youths, and a few calculi are recorded. It is readily soluble in dilute hydro- chloric acid, from which it may be obtained on evaporation in the form of hexa- gonal crystals. Like cystin, it does not give the murexide reaction, but if evaporated with nitric acid a red color is formed on the addition of liquor potassae. Albumin. — The ordinary forms are serum albumin and serum globulin ; egg albumin may occur in cases of excessive consumption ; hemialbumose has been noted in moUities ossium ; and peptones have been found in acute septic diseases, but they are hardly of surgical importance. Its presence may be ascertained by boiling, a few drops of acetic acid being added if the urine is alkaline ; by nitric acid, carefully pouring it down the side of the tube so tiiat the urine floats at the top, picric acid, or acetic acid and fer- rocyanide of potassium. If urates are present they must be dissolved by warm- ing, or filtered off; phosphates, which are precipitated by boiling under certain conditions, are soluble in nitric acid. The total amount passed within a certain time can be estimated by precipitation with heat, or picric acid, and allowing it to settle in a graduated tube ; but the method is very rough, even when the sample tried is taken from the day's collection. Excluding functional albuminuria (which may arise from derangements of digestion or of the nervous system, or from altered conditions of the blood), the albumin may come either from the kidneys or from .some other part of the genito- urinary organs. In the former case it may be caused by inflammation (as in all the forms of nephritis) ; congestion, as in cardiac disease ; lardaceous or fatty de- generation ; or the presence of new growths. In the latter it is derived mainly from the secretion of mucous membrane. The diagnosis as to locality must be made, either from the constitutional symptoms that are present, or from other features of the urine, such a.s alteration in specific gravity, the presence of casts, blood, epithelial cells, etc. It must not be forgotten that the two not unfrequently coincide. Renal albuminuria is of surgical importance for two chief reasons. In the first place, the daily waste of so much nitrogenous material represents a continual loss of strength and diminished power of repair. In the second, it points to a morbid state of the kidneys, in which they are scarcely able to do their work, even under ordinary conditions. The effect, when after some operation or injury an immense extra strain is thrown upon them can be imagined : the albu- SURGICAL ASPECT OF THE URINE. 1019 mill increases ; the excretion of urea and other waste becomes more difficult • wounds heal less rapidly ; and there is a much greater liability to inflammatory complications. The effect is the same in contracted granular kidney, when ordi- narily there is no albuminuria, but only urine of low specific gravity and abundant quantity. In operations on the deeper portions of the urethra, in patients suffering from albuminuria, there is a still further reason for anxiety. In all such there is a great liability to acute renal congestion, probably caused by the vaso-motor nerves. Even when the kidneys are healthy, the secretion may sustain a sudden check, and albumin and even blood appear in the urine ; if they are inflamed or seriously degenerated, the secretion may stop altogether, and the operation be followed by the worst and most fatal form of urethral fever. In all operations of expediency, therefore, the presence of albumin in the urine (and the specific gravity, if it is persistently low; must be carefully con- sidered side by side with the physical condition of the patient, before anything is settled. Unhappily, when the urinary tract is involved, the operation is usually one of necessity rather than expediency, and the disea.se itself not unfrequently the cause. Albuminuria due to amyloid degeneration of the kidneys is in some respects an exception. Even when it is constantly present, so long as the amount is small, complete recovery may follow the removal of the exciting cause. Albumin, derived from other portions of the urinary tract, whether from the pelvis of the kidney, the bladder, urethra, or vagina, is due to the addition of mucus, blood, or pus ; very rarely from the admixture of spermatic fluid. Except in the case of pyelitis, the amount is always small, and the chief importance is in the diagnosis. Blood. — In the strict sense of the term, haematuria should not include hemor- rhage from the walls of the urinary passages, following or preceding micturition ; but, for the sake of convenience, they are always considered together, and the blood may come either from the kidney, bladder, or urethra. The color depends partly upon the amount, partly upon the time that it has been mixed with the urine. If the hemorrhage is recent and profuse, as in a villous tumor of the bladder, or rupture of the kidney, the color is simply that of unaltered blood ; when it is poured out slowly in the tubules, or allowed to collect in the bladder, it gradually becomes more dusky, until the tint is a characteristic smoky brown. Tests. — The presence of blood in the urine may be recognized : — (i) By the color, red or smoky, as the case may be. Carbolic acid gives urine a brownish hue, and certain drugs (such as senna and rhubarb) and articles of diet (beet-root, sorrel, etc.) in quantity turn it red, but they can easily be distinguished. In hemoglobinuria the color is, of course, identical. (2) By the Spectroscope. — There is a broad, dark band between D and E, which, on dilution, gradually separates into two. Sometimes there is a band between C and D, near the former (acid haematin), or midway between the two (methaemoglobi n) . (3) By the Microscope. — Blood-corpuscles retain their appearance for some time in acid urine ; when it is alkaline, the coloring matter soon dissolves out. In haemoglobinuria they are absent. Hcemin crystals may be obtained in the ordinary way. (4) By CJiemical Reaction. — A drachm of tincture of guaiacum is placed in a test-tube ; a drop of the urine added, and then some ethereal solution of per- oxide of hydrogen floated upon the top. A blue ring develops at the junction if blood is present, but the same effect is produced by many other substances. The source may be conjectured from the color, reaction, the presence of clots or of casts, the uniformity of the mixture, and the presence of other symptoms, such as renal colic, suprapubic pain, etc. {a) Renal Hcsmaturia. — The blood may be bright red, but usually it is I020 DISEASES AND INJURIES OF SPECIAL STRUCTURES. smoky, and it is always uniformly diffused. The reaction is acid, unless the quan- tity is very large or there is a profuse secretion of pus ; tube casts may be present (they are of themselves distinctive) ; a long, worm-like coagulum may comedown from the ureter, and the attack may be accompanied by severe j^ain in the loins, renal colic, or retraction of the testicle. IMood corpuscles often cannot be detected. (/;) Vesica/ Ifu-matiiria. — The color is usually bright red, unless the urine has been retained some time in the bladder, and the mixture is rarely uniform ; the last drops, as a rule, contain most, whether the hemorrhage is still going on, or whether it has ceased and the sediment has gravitated to the bottom. The reaction may be acid or alkaline ; irregular shapeless clots may be present (they are best seen floated out in water), but too much reliance must not be placed upon this, for the blood may have poured down from the kidney and coagulated in the bladder. {/) Urethral Iiemo?-rhage is always bright red, the blood either j^receding or following the urine. Causes. — Hcematuria is due either to a morbid condition of the blood (pur- pura, scurvy, etc.) or to local affections, and these may be due to injury, inflam- mation, or new growths. («:) Renal Hcematuria. — Blows upon the loins and renal calculus; all forms of nephritis (even granular kidney) and hypergemia, whether active or passive ; carcinoma, sarcoma, and tubercle. {b) Vesical Hwmatiiria.— ^ o\.\Vi(\.^ {e. g., rupture of the bladder) and contu- sions caused by calculi, catheters, etc.; cystitis in all its forms and ulceration of the mucous membrane ; carcinoma, villous tumors, and tubercle. {c) Urethral Hemorrhage. — Injury, such as impacted calculus or the passage of a catheter ; inflammation, as in gonorrhoea; or new growths, such as tubercle. Treatment. — Perfect rest and opium (unless there is nephritis, or renal congestion) are the most important. Cold may be applied by Leiter's coils to the loins, the suprapubic region, or the penis and perineum, according to the seat of hemorrhage. Vesical hematuria may be checked by washing out the bladder with water of the temperature of 120° F., or, if the points can be .seen, by touch- ing them with a styptic. In urethral bleeding, a catheter may be passed, and the penis gently compressed around it with a bandage ; or, if it is in the region of the bulb, Otis's crutch may be employed. Tincture of hamamelis is said to check vesical hemorrhage when injected into the bladder. Infusion of matico has been used in the same way. Gallic and sulphuric acids, acetate of lead, and ergot may be given inter- nally, but if the hemorrhage comes from a vessel of any size they are of little service. Coagula occasionally give rise to severe pain, and, if the urine is septic and the bladder atonic, may require speedy removal for fear of decomposition and septic absorption. This may be done most easily by means of a soft catheter and a lithotrity evacuator, the clots gradually being broken up and sucked away. Sugar. — Glucose is probably always present in the urine in minute quantities, and in certain circumstances the amount increases without very special signifi- cance. Thus it may occur from excessive consumption, chronic congestion of the liver, prolonged narcosis, or the inhalation of amyl nitrite ; or it may be present for a time, without any cause being discovered, in members of diabetic families ; but, though this is always to be noted in a history, it is not of the same importance as ])ersistent diabetes. Temi)orary glycosuria is not uncommon after injuries of the head, concussion of the spine, fractures of the vertebrae, and injuries to the abdomen and kidneys. Sometimes, but much more rarely, when caused in this way, it is permanent. Many of the skin affections in diabetes are due to physical causes, such as the harsh, dry condition, merging into pruritus, and the eczema which is so com- mon about the genital organs in women. Others, however, are due to the mal- nutrition of the tissues. Boils and carbuncles, for example, are of frequent occur- SURGICAL ASPECT OF THE URINE. 102 1 rence, and the latter, in i)articular, are of very grave import ; cataract may occur in one eye or both ; amblyopia, sometimes varying according to the state of health, is not unfrequent, and, what is more serious than all, gangrene, esjjecially of the ex- posed parts, may be caused by the least injury. It resembles, in general character, the ordinary senile form, but it is usually moist and much more rapid. For fear of this, from the susceptibility to shock, and the tendency to hemorrhage, operations, unless absolutely essential, are rarely undertaken in diabetic patients. Chyle arid lymph are occasionally found, coming from varicose lacteals or lymphatics, in the wall of the bladder. In the case of the former, the urine is white, like milk ; when the latter is present, it remains clear ; usually it coagulates, forming a loose, soft clot, which gradually becomes li(iuid again. Chyluria is of especial interest from its connection with the filaria sanguinis hominum. Fat. — After extensive fractures, a delicate pellicle is often found floating on the surface of the urine, and the same thing has been known to occur in diabetes. Occasionally, smaller quantities, with cholesterin, etc., find their way in from the breaking down of caseous mas,ses. Mucus. — A slight amount is always present ; and, especially in women, it often forms a light, transparent, floating cloud, without having any pathological significance. In catarrh it increases very greatly, and is mixed with young epi- thelial cells detached from the walls. Pus may come either from an abscess bursting into one of the urinary pas- sages, or from the mucous surfaces, after prolonged irritation. If the urine is acid, it forms a thick, creamy layer ; as the reaction becomes alkaline, it collects into dense, stringy masses ; and if liquor potassse is added, it forms a viscid gela- tinous deposit, like white of egg. The corpuscles, as a rule, have more than one nucleus, but, unless the quantity is excessive, it is difficult to distinguish from mucus. If both are present, the best plan, as suggested by Ralfe, is to throw down the pyin with mercuric chloride, filter it off, and then add acetic acid to the filtrate to precipitate the mucin. Pus may come from any part of the urinary system, and in general the diag- nosis as to locality can only be made from other symptoms. If it is abundant, and the urine remains acid, it is probably derived from the pelvis of the kidney ; when it is ammoniacal, and contains crystals of triple phosphate, some of it, at least, comes from the bladder. Urinary Deposits. Some are derived from the urine ; others from the walls of the urinary pas- sages ; others again are living organisms. I. Deposits from the Urine, {a) From acid urine : oxalate of lime ; uric acid ; urates ; cystin and tyrosin. Fig. 421. — Urates. I02 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Fig. 422. — Uric Acid. Fig. 423. — Oxalate of Lime. (/^) From alkaline urine: oxalate of lime; phosphates of lime and mag- nesia ; ammonio-niagnesian phosphate ; acid urate of ammonium and carbonate of lime. Fi(;s. 424 and 425. — Phosphates. 2. Deposits from the Walls of the Urinary Passages. (a) Epithelium coming from the kidney ; from the pelvis and ureter ; from the bladder ; or from the urethra or vagina. The nucleus is usually visible under Fig. 426. — Epithelium from Urinary Passages. Fig. 427. — Spermatozoa and Vaginal Epithelium. the microscope, without the addition of any reagent, which is not the case with SURGICAL ASPECT OF THE URINE. either pus or mucus corpuscles. Ei)ithelial cells from the kidney are usually either rounded in shape or cubical ; those from the pelvis and ureter more columnar, but often they are triangular or cauilate ; blad- der ei)itheliuin, as a rule, is flatter; and that from the vagina squamous; but, with the excei)tion i)erhapsof the last, it is rare- ly ]iossible to be certain as to the source, unless the cells are aggregated together into masses — unless, that is to say, tube- casts are jiresent from the kidney or glandular casts from the prostatic follicles, or irregularly-shaped collections from the walls of the bladder. {J)) Blood, sometimes separate corpus- cles ; sometimes casts of clots. (0 Pus. (d) Mucus. {/) Spermatozoa. (/) Fragments of new growths, either villi or broken down epithelial masses, and sometimes cell-nests from epitheliomata. Fig. 428.— Urinary Casts. 4. Living Organisms. {(i) Animal Parasites. — The ova of Bilharzia h?ematobia — a trematode worm — are the most common ; but filaria are occasionally found, and booklets from broken down hydatid cysts. {b) Vegetable Organisms. — Penicillium and torulse are found growing in urine that has been allowed to stand, the latter only when there is sugar. The bacterium of ordinary putrefaction, and the micrococcus ureae, are of common occurrence. Tubercle bacilli may be found and recognized by proper staining, when ca.seous masses are breaking down and ulcerating. In addition to these, other substances occasionally find their way into the urine, either from ulceration opening up a passage between the alimentary canal and the urinary tract, or from accidental discharges from the rectum or vagina. 1024 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER XXI. INJURIES AND DISEASES OF THE BLADDER. Ectopia Vesicae. Defective development of the anterior wall of the abdomen and front of the bladder from the umbilicus down to the penis, involving the pubic symphysis. It is more common in males than in females, and is due to the deficient growth of the mesoblast in the embryo. At birth there is a thin membrane covering in the opening, but this soon dries up and is cast off, leaving a few shreds around the margin. It is known as extroversion of the bladder, from the way in which the posterior wall with the orifices of the ureters, being entirely unsupported in front, is pushed forward like a hernia by the pressure of the viscera behind. The appearance is characteristic at the first glance. In the pubic region, where the symphysis should be, there is a round, red, vascular projection of mucous membrane, which becomes more prominent whenever the child cries or strains. On the front of this are the ureters, with drops of urine falling from them at regular intervals. Above is the linea alba, generally very much widened, so that the two recti are far apart ; below is the flattened penis, with on its .surface the urethral groove and the openings of the prostatic follicles ; and on each side is a rounded projection, caused by the pubic bones, which do not meet in the middle line. The testes may be present in the scrotum, or they may still be in the inguinal canal ; i rci'^j' Fig. 429. — Ectopia Vesicae in the Male. Fig. 430. — Ectopia Vesicse in the Female. and there may be a hernia as well on either side. The thighs are widely separated from each other, so that the gait is waddling, and if the skeleton is examined the obturator foramina are smaller than natural, the iliac bones straighter, and the pubic ones separated by an interval of from two to four inches. In the female the appearances are so much the same that sometimes there is a little difficulty in determining the sex. The testes, however, or the body of the uterus, as the case may be, can usually be made out without much difficulty. In older cases the skin around becomes sodden and excoriated ; the surface of the projection becomes rough and granular from the constant friction and irri- tation to which it is subjected ; papillary growths spring up around the ureters, so as to cause a slight degree of obstruction : this leads to dilatation, and at length the pelves of the kidneys become involved, the secreting substance is absorbed, and interstitial nephritis sets in. Suppurative inflammation, however, is rare, owing ECTOPIA VESIC/E. 1025 to the very free drain that exists for the urine. Sometimes, when the nreters are dilated, the urine is ejected in small jets when any pressure is made upon the abdomen. Treatment. — Many attempts have been made by reflecting flaps of skin to cover in the opening and form an anterior wall for the bladder ; of the.se the most successful is Wood's, but even with this the greatest benefit that can be hoped for is the formation of a cavity which will retain urine for a short time with the aid of an appliance. In general, all that is possible is to cover in and j^rotect the surface, leaving at the lower part an orifice through which the urine can drain into a urinal. Some time beforehand the hair follicles must be destroyed by epilation and nitric acid ; if left, i)hosphatic concretions are liable to form upon the hairs and become the source of much annoyance. The flaps are arranged so that there is a double layer in front, one with its epidermis facing the bladder, the other laid over this, raw surface to raw surface, facing the other way. The former of these, if the opening is of any size, is reflected down from the abdominal wall above the umbilicus, giving it as wide a pedicle as possible, and making it sufficiently large to reach the soft tissues on either side, and come well down on to the root of the penis. Care must l^e taken in doing this that the abdominal cavity is not opened, for the aponeurosis beneath is very much stretched and thinned. The flaps to cover this in are taken from either side, the root of each being formed by the side of the scrotum and the urethral groove ; and they should be large enough when brought together and united in the middle line to cover in the whole of the vesical flap, and reach well on to the raw surface above it and at its sides. In dissecting up these the greatest care must be taken not to bruise the edges or score with the knife the under surface of the skin. Hemorrhage should be checked at once by torsion. The vesical flap is laid in position first, being turned down on itself so that the epidermic surface faces the bladder. The apex is secured by two stout wire sutures, one on either side, to the margins of the urethral groove, close to the roots of the lateral ones ; and the edges, if necessary, to the margins of the raw surface at the sides with catgut. Meanwhile, its surface, as well as that of the lateral flaps, is gradually becoming glazed over. When all oozing has ceased, a stream of some warm antiseptic is gently poured over to wash away any clot, and when they are thoroughly clean and dry the two side flaps are brought over the vesical one, pressed down firmly upon it by means of a sponge, and secured to each other and to the margins with wire. This covers in the whole of the bladder, leaving at its lower end an opening on the dorsum of the penis tightly embraced by the roots of the side flaps. The edges of the wounds from which the vesical flaps have been reflected should be brought together as far as pos- sible by means of harelip-pins ; the rest may be left to granulate, broad bands of strapping being fastened over the dressings to support the whole. After the operation the patient must be kept absolutely quiet, in a sitting position, with the knees well supported and secured by bandages, so that there is no strain upon the sutures ; and as this becomes very irksome, it may be necessary to keep him under the influence of some narcotic. If all goes well, the sutures may be removed at about the end of the week. Very often there is some yielding at the upper angles, especially if the flaps are rather short, and this may give rise to troublesome fistulae. Even in the most successful cases the orifice usually en- larges, owing to the pressure on the tissues behind it, and at length requires to be covered in by some operation similar to that practiced for epispadias. When the opening is not so large, Wood recommends that two lateral flaps only should be used, each having a pedicle springing from the scrotum and the side of the urethral groove. The size, of course, varies with the case, but they must be each of them sufficiently large to cover in the whole of the bladder. The same precautions are retjuired as in the previous case. When the surfaces are glazed one is twisted round and laid with its epidermis toward the cavity, and the other is laid upon this and secured to it and to the margins. I026 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Thiersch's method is simpler, and succeeds better, as some of the cases acquire a certain degree of control. A new urethra is formed first. In the region of the glans a deep groove is cut on either side of the mucous membrane, and the edges are l)rought over and united by twisted sutures. Behind, in the jienile i)art, a new roof is formed from rellecteil nai)s of skin. One of these is taken from each side, and they are so arranged that while the first is reflected toward the groove (so that, when it is in position, the epidermic surface faces the mucous one), the second, which should be considerably larger, is slid over the raw surface of the other. As soon as this is accomplished, and the parts are fairly firm, the front of the bladder is closed in. Two longitudinal flaps of skin are dissected up, one from each side, of sufficient length and breadth combined to cover the exposed mucous membrane. Each is separated at the sides and beneath, but left attached at the ends, so that the under surface may cover itself with granulations. At the end of a fortnight or three weeks, when they are thick and vascular, the ui)per end of the lower one is divided, so that it can be twisted on its lower attachment (which lies close by the root of the penis), and placed acro.ss the lowest part of the bladder, just above the new urethra (a groove is cut in the opposite side, by the border of the mucous membrane, to receive its upper end). Then, a short time later, the other one, which lies on a slightly higher level, is divided in the .same manner and carried over the upper half. By means of these two flaps the greater portion of the cavity is covered in ; the little angle above is patched up from the front of the abdomen, and the similar one below by means of a loop from the scrotum. More recently, Trendelenburg has advocated the division of the sacro-iliac synchondrosis from behind, and the gradual approximation of the pubic bones, by properly contrived splints, until the sides of the cleft are sufficiently close to be united. The operation is performed during infancy. The left fore-finger is kej^t in the rectum to ascertain the position of the sciatic notch and avoid the gluteal artery. An incision from two to three inches in length is made through the soft structures on the back of the joint, from the posterior superior spine downward ; the posterior ligaments are divided, and then the interosseous ones, until the joint can be forced open by lateral pressure, and the pubic bones brought together. The wounds behind are dressed and drained ; and the child is ])laced in a V-shaped splint, well padded, to protect the bony prominences, until the healing is complete. Afterward, the edges of the cleft are deeply pared and brought together. Unless the pubic bones can be placed in apposition and sutured together, the operation cannot be considered successful ; later, the cavity of the bladder must be dilated by continuous pressure with a rubber bag, and the urethra comi)leted. The same thing has been attempted by gradual pressure without division of thfe ligaments, the prominences being protected by means of rubber rings and the points varied as much as possible. Injuries of the Bladder. The bladder may be injured by stabs or gunshot wounds through the abdo- minal wall, the rectum, or the vagina ; it has been punctured through the sacro-sci- atic foramen ; it may be torn by one of the pubic bones in fracture of the pelvis, or wrenched from the triangular ligament by separation of the symphysis ; it may be bruised to such an extent in parturition, or by the presence of the retroverted uterus, that the wall sloughs and gives way ; and when it is distended it may be ruptured by compression. If the tissues are healthy, the force neces.sary to effect this must be considerable ; if, on the other hand, they are diseased in any way, it may be altogether insignificant : even muscular action is enough. Rupture of the bladder, therefore, is said to be either traumatic or idiopathic. In the former, the walls are sound, the force severe, and the rent in general runs along the posterior surface, vertically down from the urachus, for one or two inches. In the latter it takes the form of a ragged opening with thinned and INJURIES OF THE BLADDER. 1027 sloughing edges ; and the locahty depends upon pre-existing conditions. There may, for example, be a pouch i)rotniding from between the muscular fasciculi, formed only of mucous membrane and cellular tissue, and ready to give way with the least pressure ; or an ulcer caused by the pressure of a catheter, or by syphilis, tubercle, or carcinoma. In other ca.ses a calculus has been known to cause gradual thinning at one spot, until the wall broke down almost of itself; and in others, again, the tissues are so weakened from long continued distention and fatty degeneration as to yield simply t'rom the weight of the contents. The most frequent cause is a blow upon the lower })art of the alxlonien, but it may be produced by contraction of the abdominal muscles, as in lifting heavy weights ; and perhaps, for the same reason, by violence applied to the back. In one or two instances, in which it has been due to a fall in a sitting position, it was probably the result of the sudden impact of the fluid against the base. The blad- der must be distended, or it cannot be torn (though it maybe punctured) ; and partly for this reason, partly because in alcoholism the protecting influence of the muscles is in abeyance, it is peculiarly likely to occur in men when they are drunk. The rui)ture maybe either intra-peritoneal or extra-peritoneal. Occasionally it extends through the reflection of the ]:)eritoneum ; and a few instances are re- corded in which the rent has been really subperitoneal, involving only part of the thickness. The character of the opening depends upon the condition of the wall : if this is healthy, it resembles a lacerated wound, and the blood pours out freely into the peritoneal cavity, or behind the pubes ; when the rupture is due to ulcera- tion, the opening is either round or irregular, with everted and perhaps sloughing edges, and the bleeding is slight. Symptoms. — The typical symptoms are the feeling of something giving way ; collapse, severe pain, inability to stand upright or walk, and desire, but want of power, to micturate. Not one of these, however, is always present, and the only evidence that can be relied upon is that obtained by passing a catheter ; the bladder either contains only blood or a small quantity of blood-stained urine. Col- lapse may be wanting ; patients have walked to hospital, twenty-four hours after the accident, simply from anxiety at not having passed any urine. Inability to mictu- rate cannot be relied upon, for partial and even complete power has been retained, especially in extra-peritoneal cases. Sometimes there is no pain at all ; and par- ticularly when the accident has occurred during drunkenness, so that no history can be obtained, and it is merely a matter of conjecture whether the bladder was full at the time or not, the diagnosis may be a matter of the greatest difficulty, especially during the period when treatment is most valuable. Even the evidence given by the use of the catheter requires consideration. If it was known that the bladder was full, and if nothing but blood or a few drops of urine mixed with blood come away, there can be very little doubt ; and this little may be removed by the sensation conveyed by the instrument ; it is clearly not in a cavity ; it cannot be rotated or depressed ; the walls everywhere are in contact with it, and cling around it. The instrument, however, may slip through the rent in the wall and enter the peritoneal cavity, or there may be only a punc- ture, or simple leakage, such as is produced at first by the giving way of an ulcer. Occasionally the diagnosis is difficult for the opposite reason ; the bladder has been bruised, there is a certain amount of hemorrhage, and the secretion of urine is so diminished from shock that the cavity remains almost empty for hours. It has been suggested, under these circumstances, to inject the bladder with a warm antiseptic solution, to ascertain whether it can rise well up over the pulses. I. Intraperito7ieal Rupture. — Immediately after the accident the bladder col- lapses, and the urine enters the peritoneal cavity, collecting at first at the lower part, but soon becoming diffused by the movement of the intestines. Healthy urine does not give rise to peritonitis immediately ; the abdomen has been opened on several occasions, more than twenty-four hours after extravasation, without there being any evidence of inflammation. If, however, it is left, or if the urine comes I028 DISEASES AND INJURIES OF SPECIAL STRUCTURES. from a bladder already inflamed, as when the wall of a sacculous slough, or a cancerous ulcer gives way, peritonitis sets in within a very few hours, and becomes general, the abdomen becoming distended, the face pinched and drawn, and the pulse rapidly failing. 2. Extraperitoneal Rupture. — In this the urine is poured out either into the loose tissue that lies in front of the neck of the bladder, or behind, between the bladder and the rectum, or the uterus. Sometimes there is a free exit, the j>erineum, or the vagina, or rectum, being torn as well. If there is not, the ordinary symp- toms of extravasation of urine set in, and inflammation, followed by sloughing and septic poison, spreads rapidly into the iliac fossae, the front wall of the abdomen, and even into the scrotum, through the inguinal canal. Generally, the peritoneum becomes involved as well before the patient dies. Prognosis. — Gunshot injuries are not so fatal as might have been expected ; the urine escaji^s through the wound, and retention and decomposition are pre- vented. The same occurs when the bladder is wounded by foreign Ixidies pushed into it through the rectum or vagina, or when it sloughs in consequence of pressure during parturition. When there is no external wound, or easy exit for the urine, it accumulates, decomposes, and acts as a virulent poison. Treatment. — The first indication is to remove the urine that has already escaped, the second is to close the rent in the bladder so as to prevent further ex- travasation. Until within the last few years there was no certain case of recovery after rup- ture of the bladder into the peritoneum. Various methods had been attempted : the abdomen had been opened, thoroughly cleansed, and the wound in the bladder closed : but either leakage had taken place or the sutures had given way. The peritoneal cavity had been washed out through the rent. The bladder had been drained, not only by catheters, but by median and lateral cystotomy, to prevent the exit of any more, hoping that the peritoneum would be able to deal with that already present ; but all without avail. It was not until Lembert's fashion of suturing the intestines was applied to the bladder that there was any success, and then MacCormac's, Holmes's, and Walsham's cases followed rapidly one after the other. Now there is no doubt : the patient is placed under an anaesthetic ; a rub- ber bag introduced into the rectum to raise and fix the floor of the bladder ; and an incision made in the middle line, ending just below the upjjer border of the pubic symphysis. The extra-peritoneal portion of the bladder is examined first by gently pushing the folds of peritoneum upward. If there is no extravasation of blood there, or evidence of bruising, the peritoneal cavity itself is laid open and the rest of the bladder carefully felt. If there is a rupture, the edges are steadied and drawn forward by hooking up the nearer end with a blunt and rounded retractor (a suture is unnecessary and only inflicts further injury), and then a series of Lembert's sutures passed close together, commencing in the sound tissue beyond either end of the rent and carefully avoiding including any of the mucous mem- brane. Greig Smith recommends a double row, one to transfix the cut muscular surface, the other, Lembert's, outside this ; and that all should be passed before being tied. The intestines are held back out of the way, in the meantime, with a soft, flat sponge. Then the abdominal cavity is cleared of all blood-clot and urine that may have found its way in, and irrigated either with warm water (temp. ioo° F.), or with a dilute solution of some non-poisonous antiseptic. The wound should be closed in the usual way, introducing a drainage-tube only when there is already peritonitis. If there is any doubt as to the security of the sutures in the walls of the bladder, they can be tested first by distending the cavity through a catheter. Silk is the best material, and the sutures should not be more than one- eighth of an inch apart: catgut, even if it were so certain, is difficult to knot securely when the wound lies deep in the cavity of the pelvis. In one or twc cases the difficulty has been so great that it was necessary to make a short trans- verse incision through the peritoneum on either side. After the operation the bag in the rectum is emptied and withdrawn, a sup- ATONY OF THE BLADDER. 1029 positoryor a hypodermic injection of morphia given, and the patient kept warm and quiet in bed, with only a small quantity of ice to suck or a few teaspoonfuls of milk. At first there is very little urine secreted, and if the sutures are suffi- ciently close there is no need to pass a catheter, much less to tie one in, or jjerform cystotomy ; the bladder is able to empty itself without risk. Kxtra-i)eritoneal rupture must be treated on the .same jjrinciples. If the rent can be secured from the front, an ojiening should be made over the pubes, and Lembert's sutures passed as before ; only, as it is impossible to remove the urine from the loose cellular tissue around the bladder, the abdominal opening should not be closed and a large drainage tube should be inserted. Wounds involving the rectum or vagina, if not very large, may be left for a time ; very frequently they close in : or, if not, contract so that the resulting fistula is much smaller. Wounds in other parts are usually complicated by other injuries. DISEASES OF THE BLADDER. Atony. The bladder is said to be in a state of atony when the muscular power is im- paired, without there being any evidence that the nervous system is affected. Atony may occur when the walls are healthy, but it is much more likely if the strength of the muscles is enfeebled by old age or inflammation. In such cases, even passing a catheter or drawing off residual urine may abolish the small amount of power that still remains. Atony may be caused by a single act of retention ; the bladder becomes over- distended ; the muscular fibres over-stretched ; and all power is lost, perhaps for life. This may happen even in voluntary cases, although it is more likely if the obstruction is mechanical. More frequently the loss of power is gradual and slowly grows worse ; the bladder is imperfectly emptied ; some urine always re- mains behind ; the amount grows larger and larger; the muscular coat becomes accustomed to it ; and at length the bladder remains full, the urine falling out of it, drop by drop, as it enters from the ureters (overflow). Obstruction sometimes causes atony, sometimes hypertrophy. The difference depends, to some extent, upon the age and strength of the patient ; the effect of retention is different naturally in an old man of feeble health and in a younger one of vigorous life ; but the chief causes are the rapidity with which the obstruction is produced and the amount of irritation at the neck of the bladder. In cystitis, for example, and in cases of enlarged prostate in which there is much spasm, hypertrophy usually results. When, on the other hand, the prostate is tender and painful as the bladder contracts and presses upon it, the patient, perhaps uncon- sciously, tries to save himself and quietly stops before he has finished. If this happens constantly, the bladder at length loses the power of emptying itself, and atony sets in. The same thing happens from purely mechanical causes in enlarge- ment of the prostate : the bladder becomes accustomed to retain a certain amount of urine, and after a time is unable to expel it. The immediate result of atony is distention and dilatation, owing to the pressure of the urine : the bladder grows thinner ; the muscular fibres degenerate, and at length the ureters and the pelvis of the kidneys become affected. Cystitis and pyelonephritis nearly always follow, sooner or later : there is everything to favor their occurrence ; and if the urea decomposes the walls of the bladder may slough. Symptoms. — Increased frequency of micturition is the most prominent: if the bladder is over-full, the urine flows away without cessation ; if there is less, it escapes on coughing or laughing, or at night, giving rise to extreme annoyance ; and the patient either complains that he is passing too much water, or that he can- not retain it. In some cases the bladder is distended nearly up to the umbilicus, I030 DISEASES AND INJURIES OF SPECIAL STRUCTURES. forming a rounded, fluctuating swelling on the front of the abdomen ; in others, especially where chronic cystitis precedes the atony, the size is so small that it can scarcely l)e felt. The diagnosis can only be made by ]jassing a catheter, after the patient has, as he thinks, emptied his bladder ; if there is atony a variable amount flows away without any force, the stream rising and falling with the respiration. This proceeding, however, is not unattended with danger ; the patient must be lying down ; sudden evacuation of a bladder in a state of passive distention has before now caused fatal syncope ; and if the amount of urine withdrawn is over a few ounces, some of it must be replaced by a smaller quantity of some dilute anti- septic, so that the pressure in the bladder may be gradually reduced. Too sudden relief brings on passive congestion of the renal vessels; and this, if the kidneys are in the least diseased, may end in suppression. The treatment is very simple : in the first place, the cause of the retention, if it is practicable, must be removed ; then the bladder must be carefully emptied, at least four times in the twenty-four hours, so that there may be no further strain upon the muscular wall. If the amount of residual urine was large it may be some weeks before it is safe to remove it completely. A catheter should not be tied in, the danger of cystitis and urinary fever is much too great. Subcutaneous injections of strychnia are sometimes of benefit, and occasionally the walls may be stimulated by injecting cold water after the bladder is emptied. Galvanism, one pole in the rectum, the other on the surface of the body, and the current slowly interrupted from time to time, may effect some improvement even in ad- vanced cases. Irritability of the Bladder. Irritability of the bladder is a symptom, not a disease. It is present, to a greater or less extent, in all local affections, such as cystitis, calculus, tumor, fissure at the neck, atony, etc. ; in cases in which the urine contains an excess of uric acid or other irritating substances ; and sometimes in affections of other organs which apparently have nothing to do with the bladder. It may be only slight, giving rise to a certain amount of annoyance, or it may be so intense as to render life almost unendurable. In itself it is a matter of some imjjortance, as a constant contraction of the bladder leads in time to hypertrophy of its walls and dilatation of the ureters and of the pelvis of the kidneys. The most common cause is some affection of other parts of the urinary sys- tem. In many of these the neck of the bladder is involved directly. In con- gestion of the prostate, for example, after excessive coitus or masturbation, or in that form of slight irritation which is so frequent in gouty people of sedentary habits, and in women when the bladder is pressed upon or dragged out of its place in pregnancy, it is reasonable to refer the irritability to the congestion and in- creased sensibility at the neck. In other instances, however, it is probably reflex. All diseases of the kidney, for example, are liable to be attended by it ; in tuber- culous pyelitis, in particular, it is a most distressing symptom, as, unlike the irri- tation of tuberculous cystitis, it cannot be relieved by median cystotomy and drainage ; and it may be caused by phimosis, with accumulation of the secretion beneath the prepuce, by slight strictures near the orifice, or by vascular growths or superficial fissures around the meatus in women. Its reflex character is still more plain when it is excited by affections of other organs, such as disease of the uterus, fissure of the rectum and anus, piles, prolapse, intestinal worms, vari- cocele, etc. ; and this is not at all uncommon. Reflex irritability may occur even in the strongest and most healthy ; it is much more frequent, however, and more obstinate in those who are broken down by excesses or by prolonged residence in hot climates, or who, from inheritance or other causes, are especially prone to nervous disorders. In some instances, and they are often the worst, no immediate exciting cause can be found ; the de- sire to pass water is constant, or it invariably comes on under certain particular circumstances, and the patient lives in a state of continual apprehension, until, INCONTINENCE OF URINE. 1031 from constantly dwelling upon it, the condition becomes permanent and almost incurable. The prognosis and treatment in cases such as these must be guided by the cause. Where some definite source of irritation can be found and removed, the l^rognosis is good, especially in the early stages ; after it has lasted some length of time the difficulty becomes greater, partly because of the force of habit, partly from the changes that are induced in the condition of the bladder. Where nothing can be found, the chief reliance must l>e placed upon careful dieting and restor- ing the i)atient's strength and confidence in himself, paying special attention to any constitutional tendency that is present. In some cases steel sounds may be used with benefit ; at first they should be only of moderate size (No. 10 or 11 English) and withdrawn at once ; but as soon as the mucous membrane of the urethra has grown accustomed to them, larger and larger ones may be passed, and left in position until they are no longer grasped. In women dilatation of the urethra with the finger is sometimes attended with suc- cess. Tepid douches apjjlied to the loins and the hypogastric region for ten or fif- teen minutes, if the patient can stand it, may answer ; and, even when the condition is advanced, relief may be obtained by slowly injecting the bladder through the urethra, beginning with a small quantity, two or three ounces, and gradually in- creasing it day by day as the patient grows more accustomed to it. When all other measures fail, median cystotomy and drainage sometimes succeed. It is probable that in some instances at least the irritability of the bladder, whatever may have been the original cause, is maintained by the contracted and hy])ertrophied condi- tion of the walls, and that the ])rolonged rest obtained in this way allows time for a certain amount of relaxation and even wasting, so that when the artificial open- ing closes the bladder becomes more tolerant. Inxontinen'ce of Urine. Nocturnal Incontinence. — Closely allied to irritability is a condition, very common in children, especially boys, in which the bladder will only retain a certain amount of urine. As soon as it becomes filled to a certain point it contracts and expels its contents, without any j)ain, and without the child being able to prevent it. This is known as nocturnal incontinence of children, owing to its usually occurring at night. The least stimulus is sufficient to excite it Tthere may be a calculus, but generally, when there is one, micturition is more frequent while the child is running about) ; contracted prepuce with retained secretion ; polypus in the rectum ; oxyurides ; the pressure of the bedclothes on the penis ; excess of uric acid in the urine ; any slight irritant, in fact, is sufficient. The most common is the tension upon the walls and the pressure upon the neck, as the bladder becomes fiill. The real reason is the excitability of the reflex centres, which is always greater in children than in adults, even during health, and which sometimes, as at the period of teething, becomes immensely exaggerated ; and it occurs more frequently during sleep, because then the influence of the cerebrum is suspended, and the spinal cord is free to act for itself. Toward puberty it nearly always disappears. Treatment. — In most cases nocturnal incontinence may be cured by care and attention. All sources of irritation that can reasonably be suspected must, of course, be excluded, but unless it is exceedingly obstinate, or other symptoms are present, it is rarely advisable to explore the bladder for this only. Circumcision, however, may generally be performed with advantage. Careful attention must be paid to diet, especially if the urine deposits crystals of uric acid : the amount of liquid taken, particularly toward evening, must be restricted ; the child should be taken up the last thing at night ; the bed should be firm, the clothing light, and the patient made to sleep on his side, not his back. The old-fashioned plan of tying a handkerchief round the waist so that the knot comes over the vertebrge answers exceedingly well. In addition, the back should be sponged and rubbed well, night I032 DISEASES AND INJURIES OF SPECIAL STRUCTURES. and morning, the bowels made to act regularly, and qninine and tonics given in- ternally. If anything more is recjuired. belladonna rarely fails ; either the tincture or the extract may be given, commencing with small doses, and gradually increas- ing them until the drug produces some physiological effect, such as dryness of the mouth and fauces or dilatation of the pupil. The dose should then be diminished, and kept up for some weeks, leaving it off gradually. Nux vomica and cantharides are also said to be of service. In very inveterate cases a soft bougie may be passed, or a dilute solution of nitrate of silver (gr. ij ad .^j) (.12 ad 32 c.c.) applied to the neck of the bladder. Galvanism, one pole being placed in the rectum, the other over the sacral region, and the current occasionally reversed, sometimes succeeds where everything else has failed. True incontinence in men is very rare. It is common for patients to comjjlain that !hey are unable to hold their urine, or that it is constantly running away from them ; but it rarely happens that this is incontinence in the proper sense of the term. Either the bladder is over-distended, as sometimes in stricture or enlarged prostate, and a drop falls out for every one that enters, leaving it as full as ever \overflow) ; or they are suffering from atony and partial retention, and the bladder is irritable, and unable, owing to the presence of residual urine, to hold much more. True incontinence has, however, been known to occur after the median operation for lithotomy, even when the calculus was not of unusual size ; and it may follow belladonna poisoning and injury or disease of the lumbar portion of the cord. The bladder loses its power altogether ; it slowly shrinks and becomes smaller, merely acting as a mechanical receptacle, until its function is lost. It is also stated to have followed impaction of a calculus in the neck of the bladder, and in one or two instances to have been occasioned by a growth from the prostate of peculiar shape, projecting forward into the orifice so as to prevent the action of the sphincter. In women incontinence of urine is much more common from anatomical reasons. Sometimes it comes on gradually in old age, the sphincter losing its power, until urine is expelled with every cough ; and it may follow dilatation of the urethra for the extraction of calculi (it has been known to happen even when only the finger was used) ; but the most common cause is some injury to the urethra, either from the prolonged pressure of the child's head in parturition or the use of instruments. If the condition is incurable, the patient must be fitted with a suitable form of urinal. Retention. Retention of urine is either partial or complete. In the former a certain amount of urine is never expelled, and the capacity of the bladder is proportion- ately diminished ; in the latter it is distended until it can hold no more. Causes. — Either the expulsive power of the bladder is defective, or there is some obstruction to the exit of the urine ; or both may happen. 1 . The former may arise from failure of the muscular power, or of the nervous stimuli, or of both. Atony and peritonitis, spreading to the muscular coat, are instances of the former ; paralysis from disease or injury of the spinal cord or of the sacral nerves, hysteria, exhaustion (as in fevers), alcoholic excesses, shock, and, perhaps, belladonna poisoning, of the second. Railway accidents, ojjerations about the rectum, such as ligature of piles, and injuries in the region of the pelvis are especially likely to cause it ; but in old people, and those in whom the wall of the bladder is already in a condition of partial atony, retention may follow the slightest accident, even a fall on the trochanter or the passage of a catheter. 2. Obstruction to the flow of urine may be situated : — (a) In the interior of the canal : impacted calculus, for example. \F) Outside the urethra : such as a string tied around the penis by a child to check nocturnal incontinence ; or the pressure of the gravid or displaced uterus. (<:) In the wall itself. This is by far the most common. The affection may RETENTION OF URINE. 1033 be permanent, as stricture or enlar^'ed prostate, or temporary, as congestion and spasm. In most cases temporary and permanent act together. .\n imj)acted cal- culus, for instance, may occupy only a small part of the interior, but the spasmodic contraction that it causes prevents the i)assage of a drop of urine ; a stricture may admit a No. 7 or 9 French catheter the day before, and suddenly become clo.sed in the same way, owing to alcoholic excesses or exposure to cold ; and enlarged prostate may have existed for years without serious inconvenience, until suddenly congestion sets in, and the mucous membrane becomes so swollen that the weakened muscular fibre finds the task too great. Consequences. — As the bladder fills it rises up into the abdomen and j^ro- jects above the pubes as a rounded tumor, dull on ])ercussion, and most prominent when the patient is standing. Sometimes the outline can almost be seen through the abdominal wall. It may reach the umbilicus or even the ensiform cartilage in the middle line, sloping off on either side, so that the iliac fossae are resonant, and, especially when the walls are thin and soft, it has more than once been mistaken for ovarian tumor. In old cases of cystitis, however, in which there has been partial retention for years, and the walls are rigid and hypertrophied, and the cavity contracted, such distention is impossible, and retention with urgent symptoms may occur without the bladder being perceptible from the exterior. The effect depends upon whether the obstruction can or cannot be surmounted. In the former case the overflow commences ; the spasm and congestion give way before the increasing pressure, and the bladder remaining full, the urine flows away drop by drop. This condition the patient almost invariably describes as incontin- ence, exactly the opposite of what is correct. In the latter either the urethra gives way {extravasation of urine'), or the pressure in the renal tubules grows higher and higher, until the secretion is stopped {suppressio7i). Retention of urine is often followed by atony ; the unstriped muscular fibre of the wall is stretched until it loses its power of contracting ; in some cases this condition is permanent. Symptoms. — If obstruction is complete, so that no urine can escape, the symi)toms are very serious. The pain as the tension increases is extreme, espe- cially when the cavity is small, and the walls thickened and rigid, as in old cases of enlarged prostate ; the patient becomes delirious ; the tongue dry and brown ; the pulse small and frequent ; and typhoid symptoms, with extreme prostration, soon set in. When there is a means of escape, as in most cases of stricture, the urinary organs gradually adapt themselves, and the immediate symptoms are not so urgent. It is not uncommon to find that a patient suffering from stricture, with his bladder distended far above the pubes, complains of nothing more than the inconvenience caused by the incessant dribbling of urine. In this case there is no sudden check to the secretion, but the ultimate result is no less grave, for the ureters become dilated, the kidney substance is absorbed, and chronic pyelitis and nephritis inevitably follow. Treatment. — This depends upon the cause, but in all cases it is absolutely essential to relieve the bladder as soon as possible. 1. Diminished Power of Expulsion. — A soft catheter must be passed as often as required, with the utmost gentleness. If the condition is of long standing, and the bladder in a state of chronic distention, the amount of residual urine must be diminished gradually; sudden evacuation may cause congestion and sup- pression. 2. Mechanical Obstruction. — Any cause blocking the interior, or pressing on the outside, must, of course, be removed at once. Morbid conditions of the neck of the bladder, or the wall of the urethra, require further consideration ; the most important are acute inflammation, stricture, and enlargement of the prostate. {a) Acute Inflammation {such, for example, as Gonorrhceal Prostatitis'). — The symptoms are exceedingly severe ; the bladder soon becomes distended, and there is intense desire to pass water, with high fever and urgent distress. In many 66 I034 DISEASES AND INJURIES OF SPECIAL STRUCTURES. cases a catheter must be passed at once; if the ijaticnt can wait, relief can some- times be obtained by free leeching in the perineum and by hot baths, the tem- perature as high as can be borne, for at least half an hour. A full dose of opium should be given at the same time, and the bowels opened freely. Even if this is not successful it makes it easier to pass a catheter afterward, procures sleep and quiet, and tends to prevent the occurrence of rigors and other secondary troubles. Afterwards the patient must be kept in bed, on milk diet without any stimulants, and the urine rendered as unirritating as possible. In cases of gonorrhoja, or when there is a prostatic abscess, this may have to be repeated night and morning for several successive days. (J)) Stricture. — In this case the distention may be so gradual that the bladder rises as high as the umbilicus before the patient is in the least concerned about it. The urine flows away drop by drop, and this generally is the cause of complaint ; there is little or no pain, and no fever, although the health is sure to fail, from the interference with the action of the kidneys A moderate-sized catheter should be tried first, then smaller and smaller ones, but always with the utmost gentleness. The more soft and flexible the instrument, especially near the point, the more likely it is to be guided by the folds of the mucous membrane into the orifice of the stricture. Black ones, slightly bulbous at the tip, with a flexible neck, are the best ; small metal ones are excessively dangerous. If these fail, a catgut bougie will sometimes succeed, and, if it passes, the urine will find its way readily by the side ; but, in the majority of instances, when the constriction is so tight, it is not advisable to persist. Retention is seldom due solely to organic stricture ; the urethra is narrowed by this at one point, and rendered so sensitive that the slightest irritant will close it completely by the spasm and congestion it excites. Prolonged irritation with a catheter only makes this worse. Cocaine is of very great service ; a few drops of the ten per cent, solution, injected on to the face of the stricture, will frequently turn the scale ; but it is better, if the catheter does not pass after a very moderate trial, to place the patient at once in a hot bath and give him a full dose of opium. This nearly always succeeds ; and, generally, if he is kept in bed, on light food, without stimulants, if the bowels are kept freely open, and hot baths given night and morning, in a few days the spasm and con- gestion are relieved to such an extent that a catheter can be passed with ease. The only alternative is to give an annssthetic, try again, and, in case of failure, puncture the bladder. The result, so far as the stricture is concerned, is the same, but at the expense of an operation. [Median perineal cystotomy is always prefer- able to puncture.] {/) Enlarged Prostate. — This may cause retention, either by the third lobe falling over the orifice, like a valve ; or by sudden congestion, narrowing the elongated and tortuous passage to such a degree that the already enfeebled mus- cular coat is unable to overcome the resistance. The symptoms are usually very acute, the pain is exceedingly severe, and delirium and extreme prostration set in almost at once. For this, opium and hot baths can do no good, and often they are positively dangerous. A catheter must be passed at once, either a silver one with a long, sweeping curve ; a gum elastic, provided with a stilet, so that the end can be tilted up ; or a black one with the point bent at an angle {coiide), so that it can ride over the obstruction. Unless a stricture is jiresent as well, the largest catheter that will pass the meatus should always be selected, and, owing to the growth of the prostate, it should be of extra length. Violence is never jus- tifiable, but it is often necessary, when passing a catheter under these conditions, to make use of steady but firm pressure. The urine is nearly always blood-stained afterward, perhaps for several days, owing to rui)ture of the vessels in the congested mucous membrane and the blood finding its way back into the bladder. If this does not succeed, the choice lies between forcibly pushing the catheter through the substance of the prostate or tapping the bladder. TAPPING THE BLADDER. 1035 'I'ai'I'INc Tin; l>i.Ai)iii;u. 'I'his ma\- be rctiuirecl, either as a teni])orary measure, to give relief until the natural passage can he reopened, or as a permanent means of exit in impermeable stricture or enlargement of the prostate. It may be performed either over the pubic symphysis, through the perineum (going either through or behind the pros- tate), or through the rectum. In exceptional instances, where, as in cases of extravasation of urine or advanced cystitis, the object is rather to drain the bladder than to relieve retention, the prostatic portion of the urethra may be opened in the middle line, at the apex of the gland {^la boutonniere) ; and sometimes this is done in case of stricture (Cock's operation). Suprapubic Tapping. This may be performed either with an aspirator or with an ordinary but rather curved trocar and cannula. When the bladder is distended there is abundant room ; but especially in old cases of cystitis, the posterior surface of the symphysis must always be followed. If the relief required is only tempo- rary, the aspirator may be used, a small incision being made in the skin with a scalpel, and the trocar pushed through it into the bladder, downward and backward. No extravasation follows, as the mucous membrane glides upon the muscular coat when the bladder collapses, and the orifice becomes val- vular. If necessary this may be re- peated two or three times without much danger, and I have known it done night and morning, for more than a week, without any ill result ; but, if it is continued, there is always a risk, either of leakage taking place through the wall of the bladder, or without there being any direct opening, of an abscess forming in the loose cellular tissue, between the layers of the transversalis fascia, possibly due to the escape of irritating material from the end of the cannula as it is withdrawn. When a permanent opening is required a large trocar (with a linear, not a triangular, cutting edge) and cannula may be introduced in the same way. On withdrawing the trocar, a soft india-rubber tube is passed down the cannula and left when this is removed. The other end of the tube may be carried under the bed-clothes to a receptacle. After a few days the tissues become consolidated and form a short, straight canal, which can be fitted with a rubber tube and stop- cock. Owing to the contraction of the sinus there is no leakage, and I have known patients to go about with this arrangement, in perfect comfort, for years. In exceptional cases, after suprapubic cystotomy for enlargement of the pros- tate or tumor of the bladder, the opening has been allowed to contract to a sinus and the same arrangement made use of. Fig. 431 — Tapping the Bladder, (i) Suprapubic; (2) Perineal : (3) Rectal. 2. Pcritieal Tapping. Post-prostatic tapping through the perineum has recently been advocated by Howlett. The patient is placed in the lithotomy jwsition, the forefinger of the left hand passed into the rectum as a guide, and an incision made in the perineum behind the bulb ; a trocar and cannula is then pushed onward between the prostate and the rectum, until the bladder is entered. This is known by the cessation of the resistance. A tube is introduced afterward, and worn so long as the patient 1036 DISEASES AND INJURIES OE SPECIAL STRUCTURES. is in bed ; but it is only of service as a temporary measure, and the bladder, unless there is a large post-i)rostatic pouch, is entered at an unnecessary dejJth. Harrison (see Enlargement of the Prostate) advocates draining the bladder through the prostate, but this is different from simi)le tapping. 3. Tapping per Rfction. An enema having been administered, the patient is placed in the lithotomy position and brought down to the edge of the bed. The forefinger of the left hand is introduced into the anus, and the boundaries of the prostate examined. The finger should reach well above the ui)per border, and be able to feel the wave of fluctuation when the abdomen is percussed above the pubes. The bladder has often been entered through the prostate, but it is not advisable. A long curved trocar and cannula is taken, and the point, guarded by the finger, guided to the spot where fluctuation is felt, exactly in the middle line. This corresi)onds to the trigone. When it is adjusted the handle is slightly depressed and driven smartly upward and forward, as if for the umbilicus. 'Jnihilte Fig. 432. — Operation of Tapping the liladder through the Rectum. There is no doubt that in this way the bladder is drained more efficiently than by the other methods, but it is not suited to cases of enlarged prostate and is impossible for a permanency. In many patients there is great difficulty in main- taining the cannula or catheter in position, even for twenty-four hours, owing to the irritability of the rectum. I have known it stitched to the skin at the margin of the anus without avail. Sometimes, it is true, if the cannula is removed the two orifices face each other again as the bladder becomes distended, and the urine is discharged into the rectum ; but this cannot be relied upon, and is attended with some danger of urinary infiltration. The space available is so small that if the tapping is repeated there is considerable risk of inflammation and even of sloughing. In brief, where temporary relief is recpiired, the choice lies between supra- pubic aspiration and rectal tapping : neither may be repeated more than two or three times without running serious risk ; but the former has a slight advantage so far as this is concerned. Where the opening must be permanent the suprapubic operation is the only one ; whether it should be done with a trocar and cannula, or whether cystotomy should be performed first, must depend upon the cause of the retention and the condition of the bladder. Cystitis. Inflammation of the bladder may be acute or chronic. Nearly always it begins on the mucous surface and is of local origin. The chronic form may commence as such, or be the result of the acute. CYSTITIS. 1037 Causes. — i. Injury, mechanical or chemical. The former includes wounds and contusions trom calculi or instruments ; tension, as in stricture and enlarged prostate ; antl bruising or straining, as in i)arturition or disjjlacement of the uterus ; the latter, irritating conditions of the urine, due to uric acid, cantharides, and, more than anything else, carbonate of ammonia and other products of decom])osition. 2. Infective organisms, such as tubercle, and new growths, such as carcinoma. Even non-malignant tumors of the bladder are always attended with a slight degree of cystitis. 3. Extension from surrounding parts, especially in the case of gonorrhoea and stricture. It may occur in peritonitis, and, excei)tionally, in diseases of other neighboring structures. Pathological Appearances. — In the milder forms of acute cystitis, such as occur in gonorrhoea, the mucous membrane is thickened and swollen, the epi- thelium detached, leaving the surface raw and bleeding, or covered over with flakes of lymph and reddened in patches, owing to small extravasations. When it is more severe it may be lined with a slough, which can be peeled off like a diph- theritic membrane ; the color is dark crimson, or, if it is some time after dteath, even black ; the mucous membrane is sloughing and gangrenous ; the submucous tissue and even the muscular coat infiltrated with pus ; and sometimes the peritoneal surface involved as well, either covered with lymph from recent peri- tonitis, or, in the worst cases, perforated from ulceration. In chronic cystitis the bladder is either thin-walled and distended, or small, hard, and inelastic, so that it can neither expand nor collapse. In the former case the mucous membrane is thinned and stretched and generally slate-colored or dark from old hemorrhages, the submucous coat can hardly be found, and the muscular fibres are wasted until scarcely a trace of them is left. In the latter the interior is rough and uneven ; here and there it is bright red from extravasated blood, in other parts almost black, especially along the veins. The mucous membrane is thickened and velvety, or studded with superficial excoriations and even ulcers ; and it is smeared all over with a grayish, intensely offensive, tenacious mass of mucus and phosphates. The submucous tissue in some parts is hard and dense from long-continued inflammation, in others riddled with abscesses. The muscu- lar coat is thickened into great bands which extend around the bladder, dividing and joining again, so as to leave between them lozenge-shaped depressions. In old cases these grow out into thin-walled sacculi or pouches with very narrow necks, and once formed, they are permanent (Fig. 433) ; each time the bladder con- tracts more fluid is driven into them ; there is no mus- cular coat, so they cannot empty themselves ; and at length they become half- filled with mucus. Other pouches are sometimes due to the gradual yielding of the whole thickness of the wall ; but these seldom oc- cur unless there is a calculus (Fig. 437) or a great devel- opment of the inter-uretral bar. In some of these the wall is forced down behind the prostate until it is possi- ble to tap the bladder direct- ly through the perineum. When ammoniacal de- Kig. 433.— Hypenrophied and Fasciculated Bladder Consequent on Enlarge- rnmnncitinn r^f tli^ iiri"n>i ment of the Median Lobe of the Prostate. A large, ihin-walled sacculus COmpOSUlOn 01 ine urine with a very small orifice has been forced out on the left side. 1038 DISEASES AND INJURIES OF SPECIAL STRUCTURES. occurs in a blackler already the seat of chronic cystitis the changes are more exten- sive still. The walls are constantly bathed with an intense irritant ; the sarculi are filled with a most offensive mixture ; ulceration and sloughing follow ; the jnis spreads into the submucous coat and between the muscular fibres, even to the jjeri- toneum ; and at length the bladder is reduced to the condition of a sloughing abscess, filled with putrid fluid, under constantly increasing tension. When ulceration occurs at an early period it is usually due to injury fsuch as the pressure of the point of a catheter tied in) or to tubercle. In the latter case the trigone is chiefly affected, and the ulcers are multiple, slightly raised at the margin, circular in shape, and covered over with a yellow granular slough. Tuber- cle bacilli may l)e found on the surface and sometimes in the urine. In cystitis the inflammation never remains limited to the bladder for long; very soon it spreads to the ureters and involves the pelvis (pyelitis) ; thence it ex- tends into the substance of the kidney itself. So long as the nephritis is not very intense, there is merely an increase in the amount of connective tissue, with some diminution of the secreting power ; if, however, the urine decomposes, and the products gain the pelvis, suppuration and multiple abscesses occur very soon. Symptoms. — Pain. — When the inflammation is very acute, or when there is ulceration, this is described as agonizing, radiating to the groins, down the thighs, and all over the lower part of the body, with unceasing desire to pass water {stran- gury), and such an amount of spasm that only a few drops of blood-stained fluid are ejected at a time. In the gonorrhoeal form it is less severe ; and as the inflam- mation becomes chronic it may almost disappear. Generally, however, there is a dull aching over the pubes and in the perineum when the bladder is distended and as it begins to contract, when, that is to say, tension falls upon the inflamed mucous membrane ; and for the same reason there is tenderness on pressure over the .same regions, and on examination per rectum or with a catheter. Contrary to what occurs in calculus, the pain is less severe after the bladder is emptied. Increased frequency of micturition is never absent, unless there is some insur- mountable obstacle. If the cystitis is severe the urine is ejected every few minutes with violent spa.sm ; in milder ca.ses the intervals are longer, but the call scarcely less urgent. The character and frequently the amou?it of urine are altered. In very acute cases the quantity is greatly diminished, and it consists of little more than blood, mixed with shreds and flakes of lymph from the surface of the mucous membrane. In gonorrhoeal cystitis it is cloudy and turbid with mucus ; blood is usually present, especially toward the end of the micturition, when the muscles at the neck of the bladder are contracting upon the congested mucous meml)rane ; but the amount of urine generally remains the same. As the inflammation grows chronic the ha^ma- turia diminishes and may even disajjpear ; but blood corpuscles can generally be found in the sediment. In chronic cystitis, so long as the urine is acid, the deposit consists only of mucus mixed with minute organisms, detached epithelium, a few blood-corpuscles, urates, and oxalate of lime. When decomposition sets in the smell becomes ammo- niacal and intensely offensive, and the deposit is largely increased ; a thick, viscid, gelatinous mass gradually sinks down to the bottom whenever the urine is allowed to collect, and clings tenaciously to the sides. The constitutional disturbance in chronic cystitis is rarely severe, though the health always suffers from the irritation and want of rest and from the changes that are induced in the kidneys. Traumatic inflammation, if the bladder was healthy before the injury, may be attended with a certain amount of fever, some- times with shivering ; but, unless the cause is persistent, it soon subsides. In gon- orrhreal cystitis the temperature occasionally ranges very high, and there is for a time great anxiety, with distress. The worst cases are those in which, owing to injury or decomposition of the urine, an acute attack suddenly breaks out in a bladder which, from atony, enlarged prostate, or any other cause, cannot completely CYSTITIS. 1039 em|)ty itself. The urine ra];idly becomes i)utrid ; the tension grows higher and higher; the poison is absorljed through the inflamed and ulcerated walls ; and owing to the kidneys being nearly always involved as well, there is very grave danger of sujipression of urine. The tcmi)erature does not rise very high ; but the patient becomes delirious ; the most extreme exhaustion sets in ; the symptoms assume a typhoid character, and death may ensue in the course of a few days. Prognosis. — This depends upon the cause and the condition of the bladder, though naturally the secreting jjower of the kidneys is especially imj^ortant. In- flammation, excited in a healthy bladder by a transient agent that can be removed at once, soon gets well. On the other hand, if the irritant is persistent, as in the case of tubercle or carcinoma, or if the bladder is rough and irregular, with rigid walls that cannot collapse, or studded with pouches that cannot be emptied, or if there is any obstacle to complete evacuation, the attack may be stoi)ped for a time, but it is always ready to break out again. Treatment. — i. Acute Cystitis. — The first thing is to remove the cause ; the second, to give the bladder rest. If it was previously healthy and the irritant was a transient one (lithotrity, for example), active local measures are not required. The patient should be confined to bed, on milk diet, the bowels thoroughly opened, and a hot bath given night and morning. If there is much pain or throb- bing, leeches may be applied to the perineum ; and if the bladder is very irritable, morphia and belladonna may be given, either in the form of a suppository or as a pessary introduced into the bladder at night. Alkalies are not of much service, but if the urine contains an excess of uric acid, ten-grain doses of citrate of potash may be given with hyoscyamus. Iced barley-water and similar drinks may be taken freely if the patient is hot and feverish ; but buchu and triticum repens are of little use at this stage. If retention occurs from congestion of the mucous membrane at the neck, a soft or black catheter should be passed. 2. Chronic Cystitis. — In this again the cause must be ascertained, and, if possible, removed. Irritating conditions of the urine, for example, such as occur in gout and ill-fed strumous children, must be treated by attention to the digestive organs. Stricture must be dilated or divided ; calculi removed ; vascular growths about the urethra excised ; and displacement of the uterus rectified. {a) Constitutional. — In some cases — tubercular cystitis, for example — this is almost all that can be done ; in all it is very important. The clothing must be warm ; exposure to cold and over-exertion avoided ; diet regulated ; stimulants, coffee, etc., prohibited; and the bowels kept gently relaxed. If there is much mucus (mucus does not cause fermentation of urea, but it assists it, partly by lessening the acidity, partly by coating the urethra with a stagnant layer of alkaline fluid, in which the ferment growls with ease), quinine, boracic or salicylic acid may be given internally. Benzoate of ammonia helps to keep the urine acid ; triticum repens, pareira, and buchu check the catarrh, but the two last often dis- agree ; and copaiba, sandal oil, and other resins are of service in the same way, especially in chronic cystitis with abundant secretion. In most cases, however, when the stage is reached, local measures are required as well. (/') Local. — Washing the bladder is exceedingly useful in checking the for- mation of mucus, clearing out the adherent coating, and preventing decomposition ; but it must be distinctly recognized that, unless it is done with the greatest care, it may easily do more harm than good. The utmost gentleness must be used, and, unless there is some special condition, the amount injected should never exceed four ounces. The simplest contrivance, one which the patient can easily manage for himself, is a glass funnel attached by flexible tubing to a large-eyed soft catheter. As the funnel is raised, the fluid pours into the bladder by its own weight ; as it is lowered, it falls back again ; and if it is turbid, it can at once be replaced by fresh. When there is a large amount of phosphatic debris, or of thick, tenacious mucus, a modification of Higginson's syringe with a double-way tap or a lithotrity evacuator may be employed ; but the amount of force must be accurately gauged with the hand. Bladders with softened walls are easily ruptured. I040 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The most useful solutions are corrosive sublimate (i in 10,000, with a drop of hydrochloric acid) ; iodoform, gr. x ad 5J, susjiended in mucilage, especially for tubercular cystitis ; (juinine, with a drop of sulphuric acid ; boracic acid, gr. X ad 5j. ^^'ith glycerine, nitrate of silver, and acetate of lead. Hut hot salt and water, dilute nitric acid (especially if there is much phosphatic debris), perman- ganate of potash, sulphate of zinc or copper, and many others may be emj^loyed. It seems of some advantage, when there is much mucus, not to continue with the same one too long. Carbolic acid, unless very weak, is too irritating. Even when the urea has decomposed and the urine is ammoniacal, so that a fresh and very grave source of irritation is added, washing out the bladder, if it is done carefully, and if the condition of the walls and of the kidneys is not too far advanced, is very successful. The germ upon which the fermentation depends is killed ; the decomposition stopped ; the excess of mucus washed away ; and the inflammation of the mucous membrane gradually subdued. Exploration and Drainage. — If this fails, the interior of the bladder may be explored either with the cystoscope or with the finger. In some instances a piece of soft rubber tubing has been found, of course, without any history ; in others a pouch spreading out from the bladder ; or a new growth ; or sometimes, especially in young subjects, a deposit of tubercle breaking down. The cystoscope may be used at an early period. Digital exploration of the male bladder necessitates an opening in the perineum ; but the operation is an exceeding simple one, almost unattended with danger, and in nearly all the cases in which it is required for diagnosis it is equally valuable for drainage. A grooved staff is passed down the urethra into the bladder; the patient is jjlaced in the lithotomy position ; a small incision made exactly in the middle line, three-quarters of an inch in front of the anus, and deepened until the finger-nail can feel the groove. Then the membranous portion of the urethra is opened above the bulb, and a prol)e or gorget jnished along the groove into the bladder. The staff is now withdrawn and the forefinger gently pressed through the prostatic portion, dilating it as it goes. The further treatment depends upon what is found. If there is tubercular cystitis, and the disease is not too far advanced, iodoform or dilute lactic acid may be applied ; or suprapubic cystotomy performed and the ulcers scraped, though the cases in which such a proceeding is advisable are very few in number. If there is a foreign body or a tumor, it may be removed ; a sacculus may be drained ; and other conditions dealt with according to circumstances. When the cause is irremediable, as in advanced tubercle or carcinoma, simple drainage through a perineal opening gives more relief than anything else : the patient is freed from jiain ; he is able to obtain a certain amount of rest at night, and, for a time at least, he may gain a certain amount of strength. Even when no cause for the cystitis is found, and sometimes it will persist in a most inexplicable manner, draining the bladder through the perineum — giving it j^erfect rest for a month, and allowing all the urine to flow out through a tube — has in many in- stances effected a permanent cure. This oj^eration is imperatively required when chronic cystitis that has lasted perhaps for years, and has produced serious changes in the kidneys and in the wall of the bladder, suddenly becomes acute. This may be due to lithotrity, especially if the fragments are not thoroughly cleared away ; or to the use of instruments, or to decomposition of the urine in cases of atony and enlarged prostate. The symptoms are of the gravest description : the kidneys are already in a state of in- terstitial, sometimes of suppurative, inflammation ; there is i)artial sui)i)ression of urine ; the bladder is unable to expel its contents ; the walls are intensely inflamed, perhaps sloughing ; septic absorption is rapidly taking place, and the ])atient is in imminent danger of sinking into a state resembling typhoid. Under such con- ditions there is no alternative : the bladder must be opened at once and allowed to drain just like any other offensive abscess. In many cases the patient sinks from exhaustion ; but sometimes the mucous membrane clears itself with surj^rising rapidity ; the urine loses its offensive character ; the amount and the specific gravity both increase ; and the strength and health are gradually regained. VESICAL CALCULUS. 1041 Vf.suai. Calculus. Calculi mav be rorinctl from any of the sediments that occur in urine, but the tendency is much greater in the case of some, uric acitl for example, than in the case of others, such as phosphate of lime. The animal matter that holds the particles together is derived from the mucus of the urinary tract, which undergoes a process of fermentation, and either collects layer after layer of uric acid or leads to the formation of sparingly soluble oxalate of lime. Origin. — The nucleus of a calculus may be hollow, or consist of dried blood ; in most, however, it is formed of uric acid or oxalate of lime, held together by a colloid material. These are of renal origin, though they subsequently increa.se by the deposit of laminae, as they lie in the pelvis of the kidney or in the bladder. Those formed of triple phosphates are only thrown down when the urine becomes ammoniacal, and usually, therefore, originate in the bladder, though they are not confined to it. Nuclei of uric acid are most common in early childhood and in late adult life, especially if there is a tendency to gout. The starting-point is the deposit of crystals in the secreting tubules, and most likely in the actual cells ; infarcts of uric acid are often present in the renal tubules of infants shortly after birth ; and in gout all stages can be traced, from crystals in the cells and irregular masses in the tubules of the medullary i)art, to minute calculi i)rojecting from the orifices on the pyramids or lying loose in the cavity of the pelvis. The cause of the precipitation is probably some impairment in power of the cells, whether this arises from weak- ness, from exhausting illness, or from long-continued overwork, as in gout ; and it is assisted by everything that tends to check the flow of urine, whether it is the small size of the secreting passages, as in children, or an actual obstruction, such as enlarged prostate. When once the pelvis of the kidney or the bladder is reached, the nucleus increases by acting as a focus around which are deposited layers that differ according to the reaction and composition of the urine. Very little is known with regard to the formation of renal calculi, with the exception of those composed of triple phosphate, which may, of course, be formed round anything that causes decomposition of urea. It is notorious that in certain parts of England — the eastern counties, for example — they are much more com- mon than elsewhere, but though this has been assigned to climatic conditions, the prevalence of cold and damp, the nature of the soil, and the hardness of the drinking water, it is not conclusive, though the last mentioned cause is certainly of importance. In certain countries — India, for example — the proportion of oxalate of lime calculi is higher than in England, without any reason being known. In children of the poorer classes calculi are more common than among the well-to-do, and are nearly always composed of uric acid ; possibly this arises from a deficient supply of milk and improper diet. Gravel, too, is chiefly found among those who have a tendency to gout, or who consume large quantities of animal food, or are addicted to alcohol ; but though this points in a general way to increase in the tissue-waste, and to the effect of indigestion, acidity, and malassimilation, in causing the precipitation of sediments in the urine, something more is needed to explain the formation of calculi. There must be some condition of the urinary organs leading to the production of the colloid material necessary to cement the particles together. Calculus is more common in the male than the female ; and this cannot be altogether explained by anatomy, as the same holds good with regard to the kidneys, though to a less extent. Hereditary influence probably does exist, even after full allowance has been made for the efi'ects of locality and for similarity of habit. Physical Characters. — Calculi vary in size from minute bodies, only larger than gravel, to masses of more than a pound in weight. The smaller ones are frequently numerous, large ones single. In shape, unless they are formed upon some foreign body, such as the end of a bougie, they are more or less rounded ; I042 DISEASES AND INJURIES OF SPECIAL STRUCTURES. but sometimes they are llattened, and occasionally they are covered with facets from mutual friction. In rare cases where the bladtler is sacculated and the calculus lies ]jartly inside the i)ouch, it is moulded into the shape of an hour-glass. The surface varies according to the composition, those formed of oxalate of lime being peculiarly rough and characteristic. It rarely happens that a calculus is homogeneous throughout. \Vith the excep- tion of some formed of cystin, which have a peculiar radiated appearance, the surface of the cut section is made up of concentric layers, varying in character and structure according to the reaction and comi)osition of the urine. Laminae of oxalate of lime, more or less pure, alternate with those of uric acid ; or a soft earthy layer of urate of ammonia may be interposed between others of mixed com- position. Owing to the roughness of their surface and the amount of irritation they cause, nuclei of oxalate of lime are generally coated over with phosphates. Calculi sometimes suddenly undergo spontaneous disintegration, and break up. Probably the immediate cause is an alteration in the reaction or the specific gravity of the urine, so that the solubility of the different layers is no longer the same ; and sometimes, after this has happened, the irritation arising from the presence of numerous angular fragments brings on an attack of cystitis, and the isolated portions become welded together again with triple i)hosphate. Position. — For the most part calculi lie at the back of the bladder behind the prostate ; sometimes they are caught l)ehind the pubes in front ; and occasion- ally they lie in cysts, either large sacculi with very small openings, which are formed as hernial i)rotrusions of the mucous membrane between the fasciculi of the muscular wall in hyi)ertroi)hied bladders (Fig. 433), or little cavities which the calculi work out for themselves. These are most common on the right side at the base, close to the orifice of the ureter, and they fit so accurately round the stone that it may require considerable force to dislodge it (Fig. 437). All the layers of the bladder wall, very much thinned and stretched, enter into their structure, and when the calculus lies behind the prostate the orifice of the sac may be almost closed during life by the muscular bands contracting and pressing the stone deep into the substance of the gland. Phosphatic con- cretions are occasionally found upon growths i:)rojecting into the bladder ; and it is said tliat calculi are sometimes adherent to the mucous surface. Chemical Reactions of Calculi. — The calculus should be finely pounded and divided into four parts. T. One i)ortion is placed on platinum foil, and heated before a blow-j^ipe. {a) It disap])ears, or nearly so : uric acid or urate of ammonia. (J)) It clears to some extent : ])robably oxalate of lime ; if so, the residue effervesces, and dissolves with hydrochloric acid. {/) It fuses readily into a porcelain-like mass : triple jihosphate, mixed with phosphate of lime. 2. The second is moistened with hydrochloric acid. (rt) It dissolves : oxalate of lime, ])hosphate of lime, or ammonio-magnesian phosphate. Carbonate of lime, and oxalate that has been heated, effervesce as well. Xanthin also dissolves. {b) It remains unaltered : uric acid ; urates ; or cystin. 3. The third is Avarmed with liquor potassae. {a) It dissolves : uric acid ; urates ; cystin ; or xanthin. The two former give the murexide reaction ; the latter do not. If ammonia is present, it is given off when the solution in liquor potassK is heated. Fig. 434. — Uric Acid Calculus, with Nucleus of Oxalate of Lime. VESICAL CALCULUS. 1043 <« I'i .- rt i^c D." 3 >^ 3 ~ '^ 3 t/1 O «J C XL O^ g C rt W U . 13 D rt C U "^ 3 ^ in bo bo 4) C — -- 4J m 13 > C >-e o ;a ^ 3 (J . - I- "1 ■r.^ u ■^ t3 fcoii ci; c (D (U N u cn ^ g c 3 13 13 0) > s a, tn O « c a. 2 ° u I044 DISEASES AND INJURIES OF SPECIAL STRUCTURES. (J)) It remains unaltered : oxalate, i)hosphate, or carbonate of lime. 4. The fourth is moistened with acetic acid; if it dissolves, it is either car- bonate or i)hos])hate of lime. Besides these, concretions have been found in the urinary bladder, formed of fatty matter, with a certain amount of urates or phosphates (urostealith) ; of fibrin, blood, and even of indigo, derived from the indican ; but they are all extraordinarily rare. Symptoms. — The cardinal symptoms of stone are pain, increased frequency of micturition, ha^maturia, and sudden stoppage in the stream of urine. They are worse with small calculi than with large ones, because the latter remain stationary in the bladder, and do not roll about and irritate the mucous membrane ; they are more marked when the bladder is empty, because, so long as it is full, the calculus lies in a fluid of higher specific gravity than water, and, though it does not actually float, it cannot come into forcible contact with the walls ; they are worse with oxalate of lime calculi, because their surface is so rough ; and most severe of all when the mucous membrane is inflamed. Fig. 435. — Calculus composed of Oxalate of Lime : Surface and Section. Fig. 436. — Calculus com- posed of Cystin. Fig. 437. — Hypcrtrophied and Fascicu- lated Bladder, with Enlargement of Prostate. A calculus was buried in a deep pouch behind the gland, and the orifice was so firmly contracted around it that at the post-mortem \ there was some difficulty in dislodg- ing it. 1. Pain. — This is of two kinds. The one is a constant, dull, aching sensa- tion across the loins, in the groin, and running down the thighs ; worse on move- ment, especially riding, driving, or jumping. The other, which is more character- istic, is an intense cutting or shooting pain, felt at the end of the penis as the fluid leaves the bladder, and the sensitive mucous membrane at the neck is crushed down upon the rough and hard surface of the calculus. Children, toward the end of mic- turition, scream with pain, and pull upon the penis, until the prepuce is im- mensely elongated. Violent straining often occurs at the same time, the contents of the rectum are discharged involuntarily, and the mucous membrane, especially if any piles are present, often becomes prolapsed. 2. Increased Frequency of Micturition. — This is especially marked during the daytime, while the patient is moving about ; at night, contrary to what occurs when there is enlargement of the prostate, the bladder is at rest, because the stone is quiet. When cystitis sets in, this symptom is very troublesome. 3. Hiematuria. — Blood is frequently present in the urine after exertion ; but VESICAL CALCULUS. 1045 it is only characteristic if the urine itself is clear, and at the cw^X of micturition, when the pain is coming on, a few bright red drojw follow. 4. Sui/Jcn Stop/^agf of the Stream of Urine. — This is not so common ; it may occur, however, from the stone falling against the neck, especially in children, and setting up spasmodic contraction of the sphincter. Latent Calculus. — The symptoms of calculus are occasionally masked to such an extent that its i)resence is never even suspected. This may occur with very large, smooth, and rounded calculi. They remain perfectly quiet ; there is no hoematuria, pain, or spasm ; merely increa.sed frequency of micturition, owing to the diminished capacity of the bladder. Stones of over a pound in weight have been found post-mortem, \vithout the inconvenience ever having been sufficiently great to make the patient apply for treatment. It may also happen if the prostate is much enlarged, without there being any cystitis. The calculus remains behind the projection, and never comes into con- tact with the neck ; the symptoms never become urgent. Chronic inflammation of the bladder is always present in encysted calculus. Consequences of Calculus. — Inflammation always breaks out sooner or later ; at first the mucous membrane only is involved, but very soon it spreads to the submucous and muscular coats ; the cavity shrinks, the walls become rigid, inelastic, and irregularly thickened ; sometimes sacculi develoj) or ulceration sets in, and the mucous membrane becomes coated with an intensely offensive layer of putrid pus and triple phosphates. Dilatation of the ureter and of the pelvis of the kidney always follows ; the cortex is absorbed ; the connective tissue increases in quantity ; the secreting power is diminished ; the urine becomes ammoniacal, and the inflammation rapidly spreads upward, involving the pelvis and the sub- stance of the kidney, and causing suppurative pyelonephritis. R. A. YARN'ALL Co., Phila. Fig. 438. — Thompson's Metallic Sounder. Diagnosis. — The presence of a calculus can only be proved by exploring the bladder with a sound or a cystoscope. Sounds are made of steel, for the sake of the polish. The handle may be cylindrical or flattened and rougher on one surface than the other, so that there may be no mistake as to the direction of the beak. The shaft is round, nine inches in length, and about the size of a No. 7 English catheter ; the beak is an inch and a quarter in length, slightly bulbous at the end, and is bent up to an angle of 120°. For children, of course, they are smaller. Sometimes it is of advantage to have them hollow, so that the amount of fluid in the bladder can be varied. With children it is always advisable to give an anaesthetic; in an adult an injection of cocaine does a great deal toward diminishing the discomfort. The same precautions should be taken in passing a sound as in passing a catheter. Fatal consequences have occurred even in children with perfectly healthy kidneys. The patient should, if possible, be prepared beforehand, and should re- main quiet afterward. It is best if he will keep his room, and, if there is the least suspicion with regard to the kidneys, even his bed, for the rest of the day. A large cupful of hot tea with five grains of quinine and a few minims of lauda- num is an excellent precaution. If there is any retention afterward it may be relieved by a full dose of opium (provided the kidneys are not affected) and a hot bath. For choice, the bladder should contain four or five ounces of urine ; if there is more than this, a small calculus may easily elude the sound ; if less, the folds of the mucous membrane may collapse around it and cover it in. In children and young adults, in whom there is no reason to suspect chronic retention, it is suffi- cient if the bladder contains the secretion of the last hour or two ; but in older I046 DISEASES AND INJURIES OF SPECIAL STRUCTURES. men, with possible atony antl enlarged prostate, or where there is any difficulty, it is better to pass a soft catheter first, empty the l)ladder thoroughly, and then inject it with four or five ounces of warm boracic solution. The i)atient should be lying down, with the head comfortably supported upon a i)illow, the pelvis slightly raised, and the knees and hips flexed and rotated out- ward. The sound, of course, must be warmed and well lubricated, preferaljly with Lund's oil. In sounding a bladder a definite i)lan should be followed. The upper part and the sides are examined first, as the point emerges from the jjrostatic portion of the urethra, not forgetting that a calculus is sometimes held against the pubes, even when the patient is lying down ; then the handle is depressed, the beak inverted, and the floor and the pouch that exists in so many ca.ses behind the prostate care- fully felt all over. Rapid or rough movements must be strictly avoided : the former give rise to waves which may drive a light calculus away ; the latter may injure the wall of the bladder. Digital examination of the rectum at the same time should never be omitted, i)articularly with children. The contact of the sound with the stone must be heard as well as felt, and an attempt should be made to ascertain further details. Sometimes the material of which the stone is composed may be conjectured from the character of the sound it gives when struck. If it is oxalate of lime, the ring is clear, as against metal ; if uric acid, it is more dull, like stone; if the outer crust is composed of triple phosphates, there is merely a rough, grating sound. In the same way a general idea may be gathered with regard to the size and number ; but to obtain definite infor- mation, a lithotrite must be used, and even then, if, for example, the calculus is a very flat one, it is not always possible to be certain ; one stone must be grasped first, its measurement taken, if possible, in more than one diameter, and then the instrument used as a sound to detect the presence of others. Besides this, the posi- tion and mobility of the stone, whether it is encysted or not ; the state of the bladder as regards irritability, softness or hardness of the wall, whether it is smooth or covered over with xngx, ; the size and prominence of the prostate ; and the condition of the urethra, should all be noted. Very often the method of opera- tion is determined to a large extent by some detail of this description. Errors may arise in various ways. Not unfrequently a calculus is missed, even after repeated examination. There is too much fluid in the bladder, and the stone floats away before the sound ; or too little, and it is enveloped in folds of mucous membrane. Sometimes the sound never reaches the bladder at all, but stops in the prostatic portion of the urethra or in the enlarged and dilated prostatic sinus. More often the stone is missed just at the neck, because the sound is not rotated soon enough after entering the bladder. Calculi lying in cysts are always difficult, owing to the very small size of the opening ; and after lithotrity minute fragments covered over with a layer of coagulated blood may easily escape notice. The opposite error, imagining that a calculus is present, is more serious. In children, in whom the wall of the bladder is very thin, the sacral promontory and the spine of the ischium, if struck smartly with a sound, give something of the same sensation, though the ring is not clear. A rough and fasciculated condition of the wall of the bladder, especially if the rugoe are coated over with i^hosj^hates, and tumors encrusted in the same manner, sometimes raise a momentary doubt ; and the same thing may occur after lithotrity, when the bladder is being washed out, from the mucous membrane suddenly flapping with an audible click against the orifice of a large and straight evacuator. The other methods of examining the bladder can only be regarded as acces- sories to the sound. The cysto.scope, except in the case of a sacculated bladder, gives little or no further information. With very few exce])tions, calculi must be removed from the bladder by crush- ing or cutting ; solution is rarely worth the trial. As the former is more common, and has to a great extent superseded the latter, it will be taken first. LITHOTRITY. 1047 LnnoiRirY. The modern operation owes its position to Kigelow, who, in i Sy.S, recognizing the immense ])Ower of dilatation possessed by the urethra, and the ease with which the fragments of a calciihis can be extracted by suction, proved that a stone could be crushed and removed, once for all, with far less risk than when the o])eration was repeated many times successively, and the bladder in the meanwhile left full Full Size. Fig. 439. — Bigelow's Lithotrite. Fig. 440. — Thompson's Lithotrite. of sharp, angular fragments, any one of which might become impacted at any moment. Lithotrites for large calculi must be cut from a solid bar of steel ; those for finishing the fragments may be forged. The principle is the same in all ; a male blade gliding on a female one, and capable of being screwed down into it with immense force. The jaws are modified according to the kind of work ; in the I048 DISEASES AND INJURIES OF SPECIAL STRUCTURES. larger instruments the female is pierced at the base, so that it cannot become clogged with debris, while the male is deeply cut into sharp-edged notches, so that the calculus may not slip ; in the smaller ones both are solid and the surfaces are smoother. The male is narrower than the female, to avoid the risk of catch- ing the mucous membrane. In one of the latest jjatterns (Reli(|uet's) the teeth of the female blade are directed transversely and obli«iuely, so that the calculus cannot slij) toward the point when the male one comes clown upon it ; and the teeth of the latter, which act singly upon the stone, pass through the fenestras of the female so as even to project beyond. The handle varies a good deal, but in all it is so contrived that while the male blade can glide up and down freely in the female for the purpose of seizing the calculus, it can be fixed at any point by simply touching a catch, and then can only be moved by the screw. The largest instruments, the end of which is prolonged into a kind of beak, are about the size of No. 28, French ; the smallest. No. 15. The other instruments required are a set of steel sounds, highly polished, for the purpose of dilating the urethra ; evacuators. thin-walled metal tubes, straight, or curved like a catheter, varying in size from No. 15 or 18 to 32, French, each having a single large opening at or near the end, on the convexity or in the hollow of the bend, so as to suit all conditions, and an india-rubber aspirator (Fig. 443) which can be fitted on to the end of these by means of a short piece of flexible tubing. Various forms have been devised to prevent the entry of air, regulate the flow of liquid, and trap the frag- ments as they are sucked out. They are all filled from the top by means of a funnel closed with a stop-cock ; some are fitted with a wire valve, which, however, is liable to become clogged ; in others, the glass receiver, which should always be below the aspirator, is so placed that the frag- ments are conducted at once to the bottom, and the fluid drawn away from the top. Perhaps the most convenient, except that its connec- tion with the tube is rigid, is the one de.scribed by Bigelow in the Lancet (January 6, 1883), as it can be filled with clean water without discon- necting. The rectum should be emptied the morning of the operation by means of an enema, and the patient placed under an anaesthetic. Cocaine may be used for small calculi if the patient is accustomed to the use of instruments. The pelvis should be slightly raised, and care should be taken that the chest and limbs are well covered u]), as the operation may last a considerable time. A steel sound is passed first to dilate the urethra and to ascertain its size. As a rule, an evacuator equal to No. 28 can be passed without diftnculty, and some- times even No. 32, though it may be necessary to slit the meatus down by the side of the fraenum. If the patient's bladder is not irritable and is known to contain a certain amount of urine, it may be left : but in most cases it is advisable to withdraw the contents, and inject four or five ounces of a warm antiseptic solution. The choice of lithotrite must be guided by the size and composition of the calculus. If it is large the instrument should be of proportionate strength and the jaws deeply cut, the female being fenestrated ; if small or soft, such as a phosphatic concretion, a medium-sized one may be used from the first. If a sound passes KiG. 441. — Operation of Lithotrity. LITJIOTRJIY. 1049 Fk;. 442. — Operation of Lithotrity. easily, it rarely happens that there is any difficulty in the introduction ; tlie instrument must be warmed and oilctl, and then allowed to slip tlown by its own weight, not letting it pass beyond the perpendicular until the beak y has glided well below the ])ul)es. y There are two methods of seizing the calculus. In the first the closed lithotrite is allowed to rest with the convexity upon the fundus of the bladder, and the male blade withdrawn (Fig. 441) ; very often, on |nishing it down again, the stone is grasped at once, or, if not, is felt to slip to one side or the other, so that its position is known. In the other, the handle of the instru- ment is depressed until the beak occupies the centre of the blad- der, the blades reversed, and the stone picked up from the floor (Fig. 442). The former answers for the first crush- ing ; the other is the better when the prostate is enlarged, and when fragments have to be dealt with. The instrument, as it were, swings on a pi\ot formed by the fixed por- tion of the urethra ; if it is steadily held, the fragments, as the stone is crushed, drop ver- tically down, and can be picked up again one by one with the minimum of manipu- lation. With soft phosphatic concretions the crushing can be effected by the hand ; in other cases, as soon as the stone is grasped, the male blade is fixed with the catch, the instrument gently brought to the centre of the bladder so as to make certain that the mucous membrane is well out of the way, and the screw driven home until the calculus yields. If the fragments are large they may be crushed w'ith the same lithotrite, but as soon as the bigger ones are disposed of a lighter instrument is better. Great care must be taken before it is withdrawn, that the male blade is well home, and that no debris is entangled in the jaws. Dragging out fragments of the calculus, tearing the mucous membrane of the urethra, is a most dangerous proceeding. A smart tap on the handle, or working the blade backward and forward, nearly always releases it. If possible, before the second lithotrite is removed, the calculus should be thoroughly crushed, so as to reduce the number of occasions on w'hich an instru- ment is passed as much as possible. The evacuating tube should be the largest the urethra will admit without straining. Curved ones pass more easily, but Bigelow prefers them straight. If the fluid from the bladder does not at once rise up in the tube, it must be filled with a syringe, so that no air can enter ; but a careful record must be kept as to the quantity. The aspirator introduces from one to three ounces more, and though the total wnll not nearly fill a healthy bladder, it is quite possible to tear the walls if thev are thinned and softened from atrophy or fatty degeneration. On the ' 67 Fig. 443. — Bigeluw's Evacuator. I050 DISEASES AND INJURIES OF SPECIAL STRUCTURES. other hand, if there is too little (and occasionally a certain amount is lost when the instruments are changed), the mucous membrane may be sucked into the orifice of the tube and bruised. The injection should be slow, but the bulb quickly released, so that it expands rapidly, and the end of the tube should be moved gently about the fundus, especially if there is a posl-prostatic pouch, to search the fragments out. Sudden stoppage of the current is due to the tube being accident- ally withdrawn into the prostate, to the bladder becoming empty, or to the im- paction of a large fragment in the eye. This can be recognized by the sharp, clear sound, and the sensation as it strikes against the side of the tube. When the cal- culus is large it is often necessary to withdraw the evacuator after some has been removed and re-introduce the lithotrite, but this should be avoided if i)o.ssible. At the end of the operation the bladder should be washed out with some clear fluid to make sure that no fragment is left. In the case of small calculi there is no bleeding, but with large ones and prolonged manipulation, esjjecially where the veins are much dilated, it is scarcely possible to avoid it altogether. It is espe- cially desirable to avoid leaving any fragment behind. The opprobrium of lithot- rity is that the relief is not permanent — that recurrence takes place much more frequently than after lithotomy ; and there is no doubt that it is to a great extent true. Sometimes the reappearance of calculi, as in the case of phosphatic con- cretions in old men with enlargement of the i)rostate, is due to entirely independ- Fk;. 444. — Evacuating Tubes. ent causes ; but it must be admitted that occasionally small fragments are left (they may be passed subsequently by the patient) and form a fresh nucleus. After-treatment. — If the urine is acid and the bladder and kidneys sound, the after-treatment of the case is exceedingly simple. There is always a certain amount of irritation, owing to the prolonged manipulation ; but, as the cause is removed, this soon subsides. The patient should be kept in bed for a day or two ; a hot bath may be given at night ; the diet should be light and unstimulat- ing ; and if there is much pain or tenesmus, or if retention is threatened, a few drops of a solution of morphia may be introduced just inside the neck of the bladder, or an opium suppository placed in the rectum. Unfortunately, when the urine is alkaline and the calculus phosphatic, and still more when the kidneys are diseased, even though the stone is softer and the amount of manipulation less, the risk of complications setting in, and of after-troubles, is very much increased. Serious accidents may occur during the performance of lithotrity, without its being possible to allege undue violence. Hemorrhage is rarely of consequence, but in a few cases it has been excessive, probably from the rupture of a varicose vein filling the bladder with clot, and placing the patient in danger of septic decomposition and cystitis. The male blade may become so fixed that it is diffi- cult to dislodge the fragment, and in one or two instances it has been necessary to open the bladder and free it before it could be withdrawn. Rupture of the bladder into the peritoneal cavity has occurred ; and occasionally the urethra and the prostate are so bruised by the frequent passage and manipulation of very large instruments, that inflammation, and even suppuration, have followed. Impaction LITIIOTRITY. 1051 of a fragment at the neck of the bladder, which used to be not uncommon, is scarcely ever met with under the present system. Complications. — Lithotrity, like all other operations on the urinary organs, may be followed by consequences, some reflex, others inflammatory. (pression of urine, urinary fever, or diffuse inflammation and even sloughing ; and there is no doubt that lithotrity is esjjecially exposed to these dangers ; the only j)oint is whether, in this respect, it is in any degree worse than lithotomy. 7. Lithotrity may be impossible owing to the size and hardness of the stone. Calculi of over three ounces in weight have been removed by crushing, the sitting lasting as long as four hours ; but, as a rule, if composed of unmixed oxalate of lime, it is very difficult to crush one that measures an inch in diameter. The same thing may happen from the position of the stone. A calculus lying in a sacculus, or embedded in a cavity it has worked out for itself, often cannot be crushed. It is true that no operation can boast of much success under such conditions, but lithotrity is especially bad ; the wall of the cyst is exceedingly thin ; as the cavity cannot be emptied, it is left full of the debris ; septic cystitis is almost certain to follow, and peritonitis or even sloughing of the wall may occur. When the calculus is tightly grasped, so that it cannot be dislodged without using excessive force, if the patient is an old man it is better to leave it alone. Lithotomy. The bladder may be approached either through the perineum or above the pubes. In exceptional cases calculi have been removed through the vagina and the rectum. The patient should be prepared in the same way as for lithotrity — a purgative given the day before and an enema the morning of the operation. Perineal Lithotomy. Lateral Lithotomx. — The deep incision carried through the membranous and prostatic portions of the urethra into the left lobe of the prostate. The instru- ments required are a sound ; a grooved staff, either straight or curved ; lithotomy tapes, anklets, or Clover's crutch for fastening up the jjatient ; a lithotomy knife, or broad-bladed, straight-backed scalpel ; various kinds of forceps and a scoop. A catheter and a syringe for inject- ing the bladder, or washing it out after the operation ; a blunt-pointed gorget, when the perineum is too deep, or the prostrate too large for the finger to enter the bladder ; and a petticoated tube, or india-rub- ber tampon, in case of deep hemor- rhage, may be required as well. The table should be narrow and of a convenient height, so that the operator has not to raise his hands too much. If Clover's crutch is used, the anklets and the strap may be placed in position while the anaesthetic is being given. It con- sists of a metal bar tp place between the legs, with a semicircular padded crutch at either end. The legs are flexed upon the thighs ; the bar. which is provided with a sliding rod fixed by means of a screw at any required length, i)laced between them ; and the anklets fastened round the limbs, immediately below the knee. The thighs are bent upon the abdomen ; a soft leather strap passed behind the Key's Knife. Straight Probe-pointed Knife. Fig. 445. — Lithotomy Knives. LITHOTOMY. '053 shoulders, and the free ends buckled to the crutches, so that when it is tightened up the limbs are absolutely fixed. Then the knees are separated to any extent by the sliding rod. If bandages or tapes are used, the i)atient's hands must be made to grasj) the soles of the feet, the bandage being fixed first by a clove-hitch round the wrist, and carried round hand and foot together in a figure-of-eight. The staff may be intro- duced either before or after the patient is tied. The for- mer is the easier, but care must be taken in moving the limbs that the point is not driven through the wall. It is absolutely essential that the stone should be felt with it before the operation is com- menced, and it is a wi.se pre- caution for one of the assist- ants to feel it as well. If the patient has not passed water recently, and the bladder appears to contain sufficient, there is no need to pass a catheter ; but when there is any doubt it is as well to empty it. and replace the urine by six or eight ounces of some warm antiseptic fluid. Fig. 446. — Clover's Crutch. The patient is brought to the edge of the table, so that the nates project slightly over it, the limbs fixed in position, the perineum shaved, and the staff given to a third assistant to hold. If it is a curved one, it should at first be slanted a little toward the abdomen, and gently pressed down in the perineum, to bring the lergusson's Staff. Fig. 447- membranous portion of the urethra toward the surface ; as soon as the groove is felt, it should be raised to a vertical position, and pulled well up under the pubes for the deep incisions. The shaft should be grasped firmly with the fingers, and the ball of the thumb pressed against the flat part of the handle. If the staff is straight, it is held well up with the handle pointing slightly toward the operator, until he takes it himself. Before beginning, the forefinger is introduced into the rectum to feel the I054 DISEASES AND INJURIES OF SPECIAL STRUCTURES. prostate, to make sure the rectum is empty and the staff in its proper jjlace, and stimulate the gut to contract out of the way. Then, steadying the skin with the left hand, an incision is made from a point midway between the scrotum and the anus, commencing close to, but not at, the middle line, downward and out- ward for about three inches (in an adult) to a point nearer the ischial tub- erosity than the anus. This divides skin, superficial fascia, subcutaneous fat, external hemorrhoidal vessels (which may bleed freely for a moment), and perhaps the superficial {perineal vessels and nerves. The incision is then deepened by dividing the trans- versus perinei muscle, with the artery upon it and the lower border of the triangular ligament, the forefinger guarding the rectum in the wound. The bulb should not be touched, though the fibres of the accelerator urinae may be exposed and even divided. The finger is then pressed into the upper angle of the wound, to feel for the staff, and the knife passed along it until the point is lodged in the groove. The staff is then raised to the vertical position and hooked well uj) ; and the knife, with the edge turned toward the tuberosity, is carried forward in the groove until it is stopped at the end, dividing as it goes the compressor urethrre and the mem- branous portion of the urethra, the deep layer of the triangular ligament, the left lobe of the prostate, some of the fibres of the levator prostatae, and the ring at the neck of the bladder ; the incision, of course, not being deej^er than the blade. Fig. 448. — The Incision for Lateral Lithotomy. Fig. 449. — Lithotomy with the Curved Staff. It is then withdrawn, the edge still i)ointing toward the right, so that it faces the longest diameter of the prostate, and as it comes, being gently drawn downward and outward, to enlarge the incision on the under surface of the gland. The fibrous ring at the neck of the bladder is notched so that it yields readily ; in doing this the plexus of veins may be laid open, and in old people they are not unlikely to bleed profusely ; but, if the cut is not deeper than this, there is no fear of infiltration of urine. If the incision is too small, the tissues are so bruised in the process of extrac- LITHOTOMY. 1055 tion that diffuse inflammation is very likely to follow. If it is too large, passing through the jjlexus into the recto-vesical fascia and dividing the lateral true liga- ment of the l)ladder, urine is almost certain to be extravasated into the deep cellular tissue. The staff must be held well up against the j^ubes, the ])oint of the knife not allowed to leave the groove, and the blade ke})t in a line with the staff, except in withdrawing it quite at the end. If this is carried out, it is almost im- FiG. 450. — Lateral Lithotomv with Key's Straight Staff. possible to wound the floor of the bladder, and the incision is sufficiently large to admit the finger with a little gentle pressure. When the calculus is left, if it is thought that there is not sufficient space, it is easy to divide anything that resists with a probe-pointed bistoury. With a straight staff the process is slightly different ; the preliminary stejis are the same, but as soon as the point of the knife is placed well in the groove, the Fig. 451. — Blunt Gorget. operator takes the staff himself with the left hand, lowers it until it is nearly hori- zontal, holding the point of the knife meanwhile quite still, and then, turning staff and knife together on their long axis, so that the latter is in the proper plane, pushes it on until the resistance of the prostate is no longer felt. The extent to which the gland is divided depends upon the angle formed by the knife with the staff. With a straight instrument used in this wav as a director, it is much more Fig. 452. — Lithotomy Forceps. easy to keep the knife in the groove and to make an incision sufficiently free with- out being too wide. As soon as the knife is withdrawn the finger is gently worked down the groove without using force, dilating the tissues until it enters the bladder and feels the calculus. Then, and as a rule not till then, the staff may be removed. In the case of very deep perineum or very large prostate, where the finger is too short to reach the bladder, a blunt gorget may be passed along the groove to open up 1056 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the route for the forceps ; or a director may be used to keep the line of the urethra and act as a guide after the staff has been withdrawn. As soon as the finger feels the stone, a suitable pair of forcei)S, warmed, must be guided through the wound into the bladder, and the blades gently separated. Withdrawing the finger is followed by a gush of urine which may carry the calculus at once into the grasp of the forceps, or a slight movement of the blades may enable it to be seized ; but often this is the most difficult part of the operation. The blades should be oi>ened laterally, and the lower one made to sweep along the floor ; if this fails, the stone may be caught behind the prostate or above the pubes, and the forceps mu.st be withdrawn to the neck, and the handles raised or lowered. Sometimes the diffi- culty arises from the size of the calculus or from its sha|je, and it may be neces- sary to remove the forceps and introduce a larger pair, or to manipulate the stone with the finger so that it may be caught in another diameter. If it breaks up, it must be extracted with the finger and a scoop, washing the bladder out afterward to remove the debris. Everything must be done .slowly, gently, and methodi- cally ; the direction of the forceps must be in the axis of the pelvis ; the traction must be straight, without rotation ; if there is much resistance, the tissues in front of the stone must be felt with the finger ; sometimes they can be gently pushed off it ; or they may be notched with a scalpel ; or if the obstruction can be felt all round, and it is clear that the incision is too small, the forceps may be removed, the stone allowed to drop back, and the tissues that resist divided, as far as is prudent, with a probe-pointed bistoury, using the finger as a guide. By this means, in an adult, a stone an inch and a half in diameter maybe removed without divid- ing the lateral ligaments and without too much bruising; one two inches across may possibly be extracted by drawing it well down and carefully dividing the tissues that resist, or incising the other side of the prostate ; but in such a case it K. A. YaRNALL Co., Vhila. Fig. 453. — Liihotoiny Scoop and Director. is better either to perform the suprapubic of^eration, or to crush the calculus first and then extract the fragments. Under no conditions may the incision be made first, and then the stone broken up by instruments introduced through the wound. The fracture of a calculus, even when held in the forceps, adds mat-erially to the risk, owing to the necessity of washing out the bladder to get rid of the fragments. The last step in the operation is to explore the bladder with the finger, to make sure there is no other calculus present. Unless hemorrhage is feared, there is no need to leave a tube in the wound. If the bladder and kidneys are sound, it is quite possible, especially in children, to secure union by the first intention, which this, of course, would prevent. As a rule, the urine flows away through the opening for the first two days, and then, owing to the swelling about the prostate, some, and occasionally all, comes by the urethra. If suppuration begins it pours out of the wound, the amount gradually diminishing as healing jjrogresses. The patient should be jilaced in bed, on his back, on a divided mattre.ss protected by a waterproof. The hips and knees should be bent and the legs supported by pillows. Dry sponges wrung out of carbolic solution and frequently changed, or wood-wool, may be used to absorb the urine and the discharges of the wound. Every endeavor must be made to keep the skin dry and to prevent excoriations; especially in old people, and where the urine is ammoniacal, this sometimes gives a great deal of trouble. Occasionally the wound becomes coated over with phosphates, and it may recjuire to be washed out. The diet should be simple but good. The question of stimulants must be determined by the habits of the patient and the condition of the pulse. The bowels may be opened on the third or fourth day by a gentle aperient, aided by an enema ; and as soon as the wound is closing and there is no further risk of hem- orrhage, the patient should be allowed to sit up. LITHOTOMY. 1057 ACCIDKNIS. 1. //(-/norr/mi^i-. — The transverse perineal and external hemorrhoidal arteries are rarely of consecinence ; if they continue bleeding, pressure forceps may be placed upon them until the end of the operation. The artery to the bulb may be wounded either from its taking an abnormal course, or from the incision being commenced too far forward, but it seldom causes any difficulty. Sometimes the bulb itself is injured in the same way. Profuse arterial hemorrhage occasionally comes from some deep-seated trunk, possibly the internal pudic, though this is very well guarded under the lip of the tuberosity ; if the vessel cannot be found and tied, forcipressure, acupressure, or even digital compression by relays of dressers, must be kept uj) for twenty-four hours. Venous hemorrhage may be i)rofuse at the time, or may come on later, and the blood may collect in the bladder and distend it before the occurrence is known. The coagula must be washed out, the bleeding checked by cold and ex- posure to air ; and if this does not succeed, or if it recurs after a few hours, the wound must be plugged. The best instrument for this purpose is Buckston Browne's dilatable tampon — a central tube, so that the urine has free exit, sur- rounded with a soft india-rubber sac which can be introduced when collapsed, and distended with air or water. A fle.xible tube should be attached, to conduct the urine at once to a vessel beneath the bed ; but it must be recollected that plugging the wound assists absorption from the surface and exerts very injurious pressure upon the soft tissues. 2. Wound of the rectum may occur, especially in old people, in whom the lower end is often much dilated. It may be cut, owing to the knife not being sufficiently turned to one side, or it may slough from bruising. Generally the opening closes of itself, but it may leave a fistula. 3. The postej'ior tvall of the bladder has been punctured by the staff and by the knife leaving the groove and being carried in too far ; and the urethra has been missed altogether, the knife passing by the side of it or behind it, and entering the bladder through the floor, or even behind the prostate. 4. Tearing the urethra across may occur in children. It arises from the deep incision being too small. The tissues are very delicate and easily give way ; the bladder lies higher and is less flexed than it is later in life, and if an attempt is made to force the finger down the urethra, it is very easy to tear it across and push everything onward until a cavity that feels like the bladder is formed in the tissues at the neck. In some of these cases the deception has been increased by the stone being felt through the wall. If the accident is recognized in time, the finger should be withdrawn, and the knife carefully pushed along the groove until the bladder is really opened ; but if the bladder is pushed off the staff so far that it cannot be brought down again, either the operation must be abandoned, or, as this is practically fatal, the suprapubic operation must be performed, the stone ex- tracted, and a catheter passed through the orifice of the urethra from the interior into the perineal wound. To avoid this Heath recommends that, instead of trying to pass the finger along the staff, a director should be introduced into the bladder first, the staff withdrawn, and the finger then gently worked along the upper surface of the director. In other cases a pair of polypus forceps may be introduced to dilate the urethra ; but whatever plan is adopted, if there is much resistance, it is wiser to remove the finger and enlarge the incision. Fig. 454. — Buckston Browne's Dilatable Tampon. 1058 DISEASES AND INJURIES OF SPECIAL STRUCTURES. The prognosis in lateral lithotomy depends upon: — 1. Ai^e. — In children it is wonderfully successful, a series of seventy and eighty cases without a death having been published. As years advance it becomes steadily more and more fatal. 2. The Size of the Calculus. — Up to an inch in diameter this is not material ; over this, the mortality increases rapidly, and in very large calculi the operation is exceedingly dangerous. 3. The State of the Kidneys. — This is the most important of the three. Most of the fatal cases may be traced to urinary fever with suppression, or to diffuse inflammation and exliaustion, consequent on renal disease. Causes of Death. — i. Septicemia. — All the structures around the wound are torn and crushed ; there is a certain amount of decomposing urine, and the tissues, if the kidneys are diseased, break down and slough at once. It generally begins about the second or third day ; there may be a rigor with high fever, acute cellulitis, and distention of the abdomen ; or the beginning may be insidious with little or no pain, but with dryness of the mouth and tongue, hiccough, and extreme prostration. It is nearly always fatal, but recovery with the formation of pelvic abscesses has been known. 2. Urinary fever may be acute and fatal within forty-eight hours from sup- pression of urine ; more often it is chronic, and a.ssociated in such a way with septicaemia that it is impossible to assign to each its share. It rarely occurs when the kidneys are sound, but it is a common cause of death where they are only just able to hold their own, as in old cases of calculous disease and chronic cystitis. Suppurative pyelonephritis sets in from extension of the inflammation up the ureters ; multiple abscesses form in the cortex; the secretion of urine becomes still further diminished, and the patient dies with symptoms of low fever and prostration. 3. Extravasation of urine into the celhilar tissue at the base of the bladder, owing to the neck having been laid open and the recto-vesical fascia divided. Brodie saved one case in which this had occurred by laying the whole perineum open into the rectum. Usually it is fatal within the first few days from acute peritonitis. 4. Hemorrhage, not so much from the loss of blood at the time as from the weakened state in which the patient is left. 5. Phlebitis and pyeemia. 6. Peritonitis from wound of the posterior wall of the bladder, sloughing of a sacculus, or extension from the cellular tissue. 7. Shock and exhaustion. I)ifticulties may arise in lateral lithotomy, either from anatomical causes, or from the size, position, and shape of the calculus. The former include false passages in the urethra, enlargement of the prostate, unusual depth of perineum, contrac- tion of the pelvis from rickets, and such occasional obstacles as tumors growing from the bones, and ankylosis of the hip joint. These may usually be overcome by the exercise of a certain amount of ingenuity. The size and shai)e of the stone may, however, be such as to render the operation imprac- ticable. It is difficult to say what size of stone has not been removed through a lateral incision ; but at a LITHOTOMY. 1059 the present time no one would willingly attempt the extraction of one two inches in diameter, and it is better to ado|)t other methods for all over an inch. The position of the stone is scarcely less important. When it is deeply imbedded in a sac that it has worn for itself, it may be dislodged either by the finger in the rectum, or by inserting the nail beneath it, and gradually working it out, or even by very carefully notching the edges of the sphincter-like ring that holds it fixed ; and this, it must be admitted, cannot be done by lithotrity ; but when the stone is lying in a large thin-walled sacculus, the orifice of which is at some distance from the neck, and very likely is only sufficiently large to admit a quill pen, it cannot be removed. If a small tube can be introduced through the perineal wound, some relief may be obtained by draining the sacculus, but there is no means of extracting the stone. Median Lithotomy. — In this the deep incision extends only through the mem- branous portion of the urethra and the apex of the i)rostate. The patient is prepared for operation in the same way, and placed in the same position, but the staff used is rectangular, so as to bring the apex of the prostate as near the surface as possible. The forefinger of the left hand is placed in the rectum, and either an incision made in the middle line, or a straight-backed bis- toury, with the edge toward the pubes, pushed at once through the perineum to the angle of the staff. Whichever plan is adopted, the incision must be exactly median, commencing below the bulb, stopping short of the rectum, and laying open the membranous part of the urethra and the commencement of the prostatic. A director is then passed along the groove into the bladder, the staff withdrawn, and the forefinger insinuated along the urethra, following the upper surface, because the roof is more firmly fixed than the floor, and there is less danger of tearing it across. In this way the prostate is gradually dilated, until the finger gains the interior of the bladder. There is a certain amount of bruising, and pos- sibly rupture of the gland tissue and muscular fibre beneath the mucous membrane ; but, so far as the adult is concerned, there is no extensive laceration (a similar operation is often performed merely for exploration), and rupture of the capsule or of the recto-vesical fascia is impossible. The operation is then completed in the ordinary manner. Comparison of Lateral and Median Lithotomy. The chief advantages possessed by the median are — {a) Less risk of hemorrhage. Abnormal arteries cannot be divided, and the prostatic plexus is not opened. {J}) It is impossible to injure the recto-vesical fascia. In the lateral operation the knife runs along the groove of the staff, cutting the prostate and the neck of the bladder ; so long as the incision is only the depth of the blade, which is quite sufficient to allow the finger to pass into the bladder without forcing it in the least, the lateral true ligaments and the pelvic cellular tissue are entirely out of danger ; but if the knife is not kept parallel to the staff, especially when the deepest part of the incision is being made, or if the surgeon allows his hand to drop too much, it is very easy to carry the incision right through the gland and the prostatic plexus. In the median operation this is impossible ; the incision goes no further than the apex of the prostate, and the finger cannot tear the fascia. {/) After the operation the urine very soon ceases to flow out of the wound, and the patient is saved much discomfort. The disadvantages are — {a) Want of space, not only for the superficial, but for the deep incision ; so that a calculus more than an inch in diameter cannot be extracted. To obviate this Harrison recommends that an incision should be made with a probe-pointed bistoury along the floor of the prostatic urethra, from within outward ; and that then the two sides of the prostate should be torn asunder by the pressure of the index finger. io6o DISEASES AND INJURIES OF SPECIAL STRUCTURES. (J)) In children particularly there is the danger of tearing the urethra across. (r) The bull) and the rectum are both more likely to be wounded. Median lithotomy can only be performed when the calculus is small, and is seldom selected unless there is some condition which either precludes crushing or renders it inadvisable. The following are the chief: — 1. Dense cartilaginous stricture, involving the membranous or the posterior portion of the bulbous portion of the urethra. Tliis may l)e incised at the same time. 2. iMilargement of the prostate, in which it is thought that either a ])ortion of the gland mav be removed with advantage, or the post-prostatic jjouch drained. 3. When there is a foreign body of peculiar sha])e. 4. When there is a number of calculi, too large to come away in an ordinary evacuating tube, and too many to be crushed. 5. When there is a calculus or a fragment impacted at the neck of the bladder, or in the prostate, or in the orifice of one of the ureters, endangering the safety of the kidney. 6. As an adjunct to lithotrity, after the stone has been crushed, where it is desired to evacuate the fragments at once or to drain the bladder. onK SupRAPumc LiTHoxtoiv. In this the bladder is opened over the pubic symphysis, below the peritoneum. When the bladder is empty the fold of the peritoneum lies below the upper border of the pubic symphysis ; in moderate distention it rises to the same level, and in some people it may be half, or even three-quarters of an inch above, but it is only in cases of chronic retention that the space is of any size. According to (rarson this is mainly due to the bladder stretching backward into the hollow of the sacrum and compressing the rectum, instead of rising uj) out of the pelvis ; and if this is prevented by filling the intestine to a very moderate extent, the fold of the peritoneum may be raised (especially in fat people) sufficiently for all surgical purposes. There is no strain upon the wall of the bladder ; its anterior surface is well exposed ; and the floor is raised and fixed, so that it is much more easy to introduce sutures if they are required. In children the fold of the peritoneum is higher ; when the bladder is moder- ately full it is nearly always well above the level of the bone ; in distention there may be two inches, and even more. The preparation of the patient is the same, but the i)osition is the ordinary recumbent one, with the hips slightly flexed. A very thin cylindrical rubber bag, made without seams, and capable of holding twelve ounces, is introduced into the rectum well above the sphincter, and connected with an irrigating can filled with warm water. Distention in this way is more equable than with a syringe, and the tube can be clamped or undamped at any lime. Ten ounces are usually ample, even in an old person ; and le.ss than this is advisable for a young adult ; the mucous membrane of the rectum has been severely injured on several occasions by bags of unsuitable shape or size. A soft catheter should then be passed, the bladder washed out with a warm antiseptic solution, and the end of the catheter connected by a flexible tube with a vessel filled with the same. By raising or lowering this, as occasion requires, the bladder may be filled to any desired extent, or emptied, without the necessity of tying anything round the penis. This method of disten- tion is much to be preferred, both in the case of the rectum and bladder. It is gradual and perfectly even ; it can be regulated to a nicety, andean be relieved at once by lowering the vessel. The pubes must be shaved, and an incision three or four inches in length made exactly in the middle line, commencing just below the upi)er margin of the symphysis. The sheath of the rectus is exposed first, and carefiilly divided upon a director ; then the layer of the transversalis fascia that bounds the prevesical space in front ; the posterior one should prevent the peritoneum being seen, but if SUPRAPUBIC LITHOTMtFY. 1061 it comes into view it must be pushed up out of the way with the finger. In the case of very large calculi it may be necessary to divide the tendon on cither side, but this should be done as little as i)ossible. If the vessel connected with the catheter is raised a little, the bladder slowly presents itself covered over with a layer of soft, delicate fat (sometimes of consider- able thickness), containing numerous tortuous veins. It is essential to interfere with this as little as possible ; the handle of a scalpel, or an ivory separator, as Thompson recommends, may be used to push it to one side ; one of the chief risks is the infiltration of urine, and this is almost sure to follow if there is any rough handling or hemorrhage. In most cases there are two large veins running down the anterior surface of the bladder in a vertical direction ; and the greatest care is needed to avoid not only these but the smaller ones near the neck. One way of securing the bladder, so that it does not collapse when opened, is to pass two sutures through the muscular coat, one on either side ; but a sharp hook or toothed forceps is usually ju'cferred. The opening itself should be made with a scalpel (the edge pointing toward the pubes) in the middle line between Showing the Incision through the Skin. {Bardenheuer.) a. Plate showing the Bladder Stitched to the marginof the wound, b. Appearance on Section. Fig. 456. — Suprapubic Lithotrity. the veins, and it should be large enough to admit the finger. The calculus must be dealt with according to its size and position. Sometimes it can be extracted by the finger and a scoop, or with the two fore-fingers ; in other cases polypus forceps, or lithotomy forceps, may be used to lay hold of it ; even small mid- wifery forceps have been employed ; and in one instance it was necessary to break up the calculus with chisel and mallet. One disadvantage of rectal distention is that the stone, owing to the way in which the centre of the floor of the bladder is elevated, is apt to roll down to the sides. This, however, is of little importance, as the whole interior can be easily explored. The treatment of the wound must be guided by the condition of the urine and of the walls of the bladder. In children and young adults, if the kidneys are sound, and the muscular coat fairly healthy and not much bruised, an attempt should be made to secure union by the first intention. Two series of sutures may be used — one through the muscular coat to bring the edges together ; the other, Lembert's, outside this; but neither should touch the mucous membrane, and the latter should extend not only the whole length of the wound, but for a little dis- tance beyond at either end. Either silk or chromic catgut may be used. In any io62 DISEASES AND INJURIES OF SPECIAL STRUCTURES. case the sutures must not be more than an eiglith of an inch apart, or wlien the bladder becomes distended leakage will take place between them. Kven if they do give way after twenty-four or forty-eight hours, the risk of urinary extravasation is by that time much diminished, and in a fair proi)ortion of the cases the wound has healed up at once. If, however, the walls are thinned or fasciculated, if they have been bruised, if the urine is ammoniacal, or the kidneys diseased, union by the first intention is so problematical that it is wiser not to try. The wound in the bladder should be left entirely open, the abdominal one, if it is very long, being closed, so far at least as the ujiper extremity is concerned. If the wound of the bladder is sutured, morphia is usually advisable. Sup- positories may be used, but it is better injected directly into the tissues over the pubes. If there is any doubt about the condition of the sutures a catheter may be passed as often as required ; with cocaine there is rarely any objection, but, espe- cially in the case of children, it should be avoided if possible. Tying a catheter in it is not merely useless, but a constant source of irritation ; and draining through the perineum, though it may be sometimes advisable to prevent decomposition after the removal of tumors of the bladder, is rarely needed in lithotomy. If the wound is not secured, an attempt must be made to keep the bladder as dry as possible. In his earlier cases Thompson recommended that the patient should simply lie on his side, changing from one to the other every six hours so as to prevent excoriation. Trendelenburg tried the prone position, but this is scarcely practicable in the cases which recjuire it most. The simplest plan is to introduce a full-sized tube, and thread it with loosely-packed lampwick for about a foot of its length, so that it will act as a siphon. If this fails, an apparatus like a Higginson's syringe may be attached to it by a side branch, and the contents as- pirated at frequent intervals either by the patient or the nurse. Greig Smith does not consider a drainage tube necessary if absorbent dressings are used and changed at frequent intervals ; the bladder is kept empty by the pressure of the viscera above it. Compared with the perineal methods, the accidents that may occur in the course of suprapubic lithotomy are exceedingly few and easily avoided. The rec- tum and bladder have been ruptured from excessive dilatation, and inflammation of the mucous membrane of the former has been caused by the pressure. The peri- toneum has been opened, so that the operation had to be delayed : and free hemor- rhage may occur from the prevesical plexus. This, however, is important rather from the facility that it gives to subsequent suppuration and extrava.sation of urine than from actual loss of blood. Causes of Death. — In children this operation is as successful as lateral lithotomy. In adults the comparison is hardly fair, as many of the cases were such that the lateral operation was impossible. Suppurative pyelonephritis, with j^artial suppression, is the most common. It generally proves fatal in the course of a few days, with low muttering delirium and extreme prostration. Pericystitis, extending into the cavity of the pelvis and setting up pelvic cellulitis and peritonitis, may occur from injury to the soft tissues around the bladder or from extravasation of urine. Its course and severity depend largely upon the condition of the kidneys ; in children, for instance, it very rarely occurs. Besides these, death may occur from shock, exhaustion, pycemia, or other secjuelie common to all operations in such conditions. Choice of Method. Three things have to be taken into consideration in selecting a method : the patient, the urinary organs, and the calculus. I. The Patient. — Under six years of age, crushing is not advisable. It has been done in younger patients, and occasionally the urethra is sufficiently capa- cious ; but this is exceptional. LITJIOTRITY AND LirJIOl'OMY. 1063 Between six and puberty, crushing antl cutting (for all moderate-sized stones) are e they are really fibro-myomata : and "'■^'^^:~ pure myoma has been described. In , ^, . -. ■ . others (fibro-myxoma) some of the fibrous part has become converted ^^^- 457 — Fjbro-papiiioma of the Bladder, into mucous tissue. Sarcomata are more rare. In external appearance they resemble fibro-papil- lomata, but the fibrous tissue in the interior is replaced by sarcomatous elements, and their growth is much more rapid. In some instances, in which fibro-papillo- mata have recurred after removal, the secondary growths were softer and sprang up more quickly than the original, as if the fibrous part was giving way to a growth of less perfect type. In a few cases round-celled, spindle-celled, and even chondrifying sarcomata have been found. Mucous Polypi. Outgrowths from the mucous membrane, resembling those that are met with in the nasal passages and in the rectum, are not uncommon, especially in children. Often they are multiple, and the pedicles occasionally become stretched to such an extent that in females they may even protrude at the meatus. Carcinoma. Scirrhus and encephaloid are rare. Epithelioma, on the other hand, is the most common of all tumors. It is usually found after middle life, and it may occur at any part of the bladder. Nothing is known with regard to its cause ; there is no reason to connect it with the irritation of calculi, catheters, or any- thing else. In general the tumor is single, but sometimes there is more than one, and occasionally they are very numerous. In a few instances, in which the growths have been on opposite sides, it would seem as if the secondary ones had originated by a process of infection from the first. When there is a perineal wound it is not uncommon for the mass to protrude and fungate, as if it had spread along the granulation tissue ; but this may admit of other explanations. At first the mucous membrane is smooth and unaltered, merely raised and vascular ; but ulceration very soon sets in, and the tumor being, as it were, ma- cerated in the urine, the surface .soon becomes exceedingly irregular and covered over with sloughing shreds of tissue. The growth itself is never encapsuled or freely movable on the deeper strata ; it infiltrates the submucous and muscular coats with great rapidity, and spreads from them to the surrounding organs. 68 io66 DISEASES AND INJURIES OE SPECIAL STRUCTURES. Sometimes the converse is the case, and the bladder becomes secondarily involved from malij^nunt disease of the uterus or rectum. General Symptoms of Tumors of the Bladder. — Hemorrha^je and irritability of the bladder, usually amounting to cystitis, are the most prominent. The former varies in amount and frequency according to the nature of the growth. In i)ai)illomata it is j)rofuse, pouring out from the delicate villi, and very irregular in occurrence. Often the first thing noticed is a sudden gush of bright blood following micturition, and then there may be an interval of months. In carcinoma, on the other hand, hemorrhage is usually preceded by increa.sed frequency of micturition and dysuria, and the amount of l)lood, though small, is much more constant. In the later stages the difference becomes still more marked ; with })apillomata there is discomfort, sometimes pain ; severe cystitis may occur as a complication ; the urine may even become ammoniacal and the timior crusted over with a layer of phosphates ; but this is as nothing compared with the severity of the suffering in carcinoma, especially when ulceration sets in. Decomposition of the urine nearly always occurs : the pain is excruciating, radiat- FiG. 458.— Epithelioma of the Bladder. Two apparently distinct masses opposite to each other. ing all over the body ; the desire to pass water is unceasing, and gives no relief; there is constant burning at the neck of the bladder, rest or sleep is impossible, and the strength rapidly gives way. .All these symptoms are intensely aggravated when the growth is near the orifice of the ureters, so that renal troubles are present in addition. The diagnosis must be made from : {a) the age of the patient (papillomata and polypi may occur at any time of life, though they are more common in the young — carcinoma probably never before forty) ; (/') the character and order of the symptoms ; (r) examination of the urine ; and (lny and Keclus.) FOREIGN BODIES IN THE BLADDER. 1071 the distress is so great, esjiecially in men, and the risk of nephritis so much increased, that colotomy should be performed. ICxcision of a portion of the wall of the bladder has been practiced in a few instances. In Sonneburg's case, the upper two-thirds were removed with the peritoneum over it, the wound being closed by means of sutures, and the patient lived for six weeks. In Antal's a tumor the size of a child's fist, with that part of the bladder wall from which it sprang, was removed by a suprapubic incision, the peritoneum being stripped up without being opened. The vesical wound was closed, the abdominal one drained, and the patient recovered, and was able to hold his water for three or four hours. [FORKKiN HoiMKS IN 'JHF, BlADIjF.R. I'nder the name of foreign bodies in the bladder are included every species of solid sul)Stance introduced into the l>ladder from without. Renal and vesical calculi are not included. They are more common than at first glance would seem possible. Among them are included : i. Various surgical instruments, such as portions of catheters, sounds, bougies, or portions of any of the ordinary instruments used in operations within the bladder; 2, substances introduced by onanism or perverted sexual instinct into the bladder by way of the urethra ; 3, projectiles thrown from firearms or cannon ; and, 4, foreign bodies entering the bladder by means of a fistulous open- ing from adjacent tissues or organs. Among the first-named class, the editor remembers a case, where a practitioner in attempting to catheterize a female patient allowed a short metallic catheter to slip entirely within the bladder. Among the second class hair pins occupy a leading place, although the variety is very great. The third class frequently includes por- tions of clothing with gunshot wounds, spicula^ of bone chipped from the pelvic walls, and occasionally the projectile itself. The fourth class may include substances from the intestine, debris of dermoid cysts, and even pessaries have been reported to have penetrated the bladder by ulceration. These foreign substances rarely become encysted, but usually soon become incrusted with the urinary salts, and thus form the centre of a vesical calculus. The symptoms depend somewhat upon the mode of entrance, but if external or fistulous wounds are closed, they in no particular differ from those of ordinary calculus. The diagnosis is greatly facilitated by the use of the cystoscope, but their presence may be detected by the sound. The treatment necessarily depends on the manner of introduction of the foreign body and the sex of the patient. In the female the urethra may usually be dilated sufficiently to allow' the removal of the foreign body through the natural channels. In the male, extraction is performed as in case of vesical calculus.] * Fig. 463. — Small Polyp as seen by Cystoscope. (After Duplay and Rectus.) * See the section on Wounds of the Bladder, for method of treatment in case of projectiles. I072 DISEASES AND INJURIES OF SPECIAL SI'RUCTURES. CHAPTER XXII. DISEASES Of THE PROSTATE. Atrophy of the Prostate. This has been described both in old age and in young adults ; probably it is rather defective development at puberty. It does not give rise to any symptoms. Hypertrophy ok thk Prostate. The prostate is liable to a peculiar form of enlargement which produces very serious effects upon the other urinary organs. It is rarely met with in men under fifty-five, for there are no symptoms until the size is very considerable ; but it begins long before that, and I have known it well marked as early as forty-two. Some en- largement is present in about one-third of those who reach middle life, but it is only in a small proportion of these that there is any interference with the working of the bladder. Pathology. — The nature of the growth is not always the same. In some cases it is a true hypertrophy, all the tissues of the gland enlarging ecpially, and the normal shape is retained ; but this is the exception. The fibrous and muscular elements generally form by far the larger portion ; the acini may dilate and become cystic, but there is rarely much adenoid growth. Not unfrequenily tumors, resem- bling the fibro-myomata of the uterus, are found in the interior ; they are round and hard, formed of concentric layers, lighter in color than the tissues near them, and surrounded by a kind of capsule, so that they can often be shelled out. As a nile, they consist mainly of fibrous tissue, with someunstriped muscular fibre ; occa- sionally acini and ducts are present as well, and in a few instances they deserve the name of adenoma. They may be single, but more often multiple ; in some cases they are as large as a walnut, in others so small that they can scarcely be seen, and they maybe buried in the substance of the gland, or project on the e.\terior as dis- tinct nodules. The size the prostate may attain under these conditions is enor- mous, and the shape most irregular. Sometimes the lateral lobes are enlarged equally, or one is in great excess over the other ; sometimes the median grows out and projects under the mucous membrane of the bladder, until it hangs over the orifice like a valve ; in other cases again the enlargement is toward the rectum. The effect on the prostatic urethra is e(iually variable ; it maybe merely stretched until it is four inches in length, or it maybe so tortuous and displaced that an in- strument can hardly pass through it. In a few very rare cases it has been held open in such a way as to cause true incontinence, the urine flowing away from the blad- der as it entered, leaving it always empty ; much more often the walls are firmly pressed together, so that on transverse section it takes the form of a narrow vertical slit lying between the dense and solid lateral lobes. Changes in the Bladder. — i. The Neck. — Owing to the ai>ex of the prostate being fixed by the triangular ligament, the orifice of the bladder, which normally is the lowest point when the body is erect, becomes displaced. If the elongation is uniform it is simply raised, so that the bladder drops as it were into a pouch in front and behind (Fig. 464). More frequently, owing to the greater amount of the growth behind, it is not only raised, but tilted forward so that it faces toward the pubes (Fig. 465), and instead of the mucous surface shelving smoothly down to the urethra, the margins of the orifice are raised up into irregular lips and bosses. The anterior pouch is never very large, unless a calculus is impacted in it ; the posterior, on the other hand, owing to the comparative thinness of the mus- cular coat above the inter-uretral bar, and the yielding nature of the tissues outside. HYPERTROPHY OF TlIE PROSTATE. 1073 may be expanded by the forcing of the urine down into it until it projects behind the prostate, between it and the rectum, and sometimes even reaches the perineum. ■■=---a««aat«!?- FiG. 464. — Enlargement of the Whole Prostate, with the Formation of Ante- and Post-prostatic Pouches. Fig. 465.— Enlargement of Median Lobe of Prostate, showing its Valve-like Action. 2. The Fundus. — The alteration in the shape of the neck soon produces changes in the rest. For mechanical reasons, the difficulty of emptying the blad- der becomes greater. It may be the third lobe hanging over the orifice like a valve, or the increased length of the neck, forcing the bladder to act at a disadvantage, I074 DISEASES AND INJURIES OF SPECIAL STRUCTURES. and increasing the resistance. If the obstruction is suddenly developed the muscu- lar coat becomes stretched until it can no longer contract, and the bladder dis- tended until it may reach as hij^'h as the umbilicus. If, on the other hand, it is slow and gradual, and if the neck of the bladder becomes irritaljle, so that the calls to micturition are more frequent than natural, the opposite effect is produced : the muscular coat, under the combined effect of increased work and increased fre- quency, becomes hypertrophied ; the capacity diminishes, the walls grow thick and hard, and the bladder can neither collaj^se nor expand as it ought. So long as the whole bladder is equally affected and there is no inflammation, the effect is similar to that produced by any other obstructing cause ; the uterus and the pelvis of the kidney become dilated, the renal substance is absorbed, the interstitial connective tissue increases, the muscular coat of the bladder becomes fasciculated ; and, in advanced cases, hernial protrusions of the mucous membrane make their way between the bands and enlarge into sacculi. The effect, however, is very seldom uniform. Partly owing to the natural weakness of the posterior wall, partly to the direction of the pressure when the bladder contracts, the urine is driven down into the space behind the prostate, the tissues stretch more and more, and the post-prostatic pouch grows until it becomes a receptacle for urine, which is known as " residual," becau.se it cannot be exi)elled by the bladder. Unhappily, this is not all. If inflammation appears all the symptoms are in- tensely aggravated, the bladder becomes irritable, micturition is more frequent, the lining membrane is swollen and congested and pours out an abundance of mucus which collects behind the prostate ; the walls grow thicker, and the irrita- tion spreads up the ureters, so that catarrhal pyelitis and interstitial nephritis soon follow. If, in such a condition as this, decomposition of urea takes place, and the urine becomes ammoniacal, the effect is infinitely more severe. The patient is already broken down by suffering and want of rest ; the tissues are badly nourished ; the bladder is fasciculated, perhaps sacculated ; the mucous membrane is in a state of chronic inflammation : the pelvis of the kidney is enlarged ;. its secreting power is diminished ; a certain amount of urine, loaded with mucus, is constantly re- tained in the post-prostatic pouch, and though some of this maybe changed when the bladder becomes full, the urine in the sacculi (if there is any) is not ; if, in such a condition as this, decomposition of urea once sets in, every drop of urine as it falls from the ureters becomes changed at once, and the bladder in its already diseased state is filled with a most intense irritant which it cannot expel. The result is not difficult to imagine ; phosphatic concretions form in all the depres- sions : the walls are covered with decomposing mucus mixed with salts of lime ; the surface is eaten out by ulceration ; the pus spreads in the submucous tissue, extending between the fasciculi of the muscular coat ; the membrane that lines the ureters and pelvis of the kidneys is almost destroyed, and all the renal substance that the absorption and interstitial nephritis have left is riddled with abscesses. Etiology. — The cause of the hypertrophy is unknown, though it may be compared with the formation of fibroid tumors in the uterus. The muscular system of the prostate is a continuation of that of the bladder, but the gland itself is con- nected with the sexual rather than the urinary organs. It scarcely exists in infancy and does not attain any size until puberty ; in adult life its muscular coat forms, as it were, a funnel-shaped prolongation of the neck of the bladder ; a line of separation can be seen on section, but there is nothing on the mucous surface to point to it. For some reason, possibly connected with the condition of the sexual organs, it begins to enlarge as they begin to wane, and the larger and more com- plex it becomes the more it acquires the appearance of a distinct and independent structure. Harrison considers the prostate essentially muscle, and holds that the presence of residual urine precedes, and is indirectly the cause of, the hypertrophy. For various reasons, in old age the floor of the bladder has a tendency to sink, so that HYPERTROPHY OF THE PROSTATE. '075 there is difficulty in emptying it ; the continued effort causes the prostate and the muscular band that passes between the ureters to increase until they coalesce and form a sufficiently powerful floor. The irregularities of growth, and the hyper- trophy of the non-muscular tissues, are secondary to this. The effect, if this is the case, is most unfortunate, for the hypertrophy, which is intended to jirocure the expulsion of the residunl urine, makes matters tenfold worse by the changes it induces in the shape of the neck. \Vith more jirobability it has been argued that the enlargement is the result of persistent congestion. It is well known that old men with enlarged prostates are subject to the most extraordinary libidinous desires, and it is usual to assign this as the cause. That they are connected is almost certain, but it is not impos- sible that the cause has been mistaken for the effect, and that the latent erotic desires are manife.sted because at that time of life the control that was formerly exercised over them has become feeble. Chronic congestion is certainly present in enlargement of the prostate in a degree that would not be susi)ected from post- mortem examination ; and though this disease is met with in all classes, it is of some significance that it occurs most frequently in those who are of full or gouty habit, especially if they are compelled to lead sedentary lives. \^^J^^,\i^ Fig. 466. — Section of Hypertrophied Prostate. (From Duplay and Rectus.) U. Urethra. E. Ejaculatory ducts. T. Fibrous trabeciilae. C. Prostatic nodules. Z. Fibro-muscular capsule. V. Periprostatic veins. F. F'ibro-glandular tissue. S. Section of seminal vesicles. The relation between atony of the bladder and enlargement of the prostate is another question. Harrison regards the former as the origin of the latter ; the primary cause is the inability of the bladder to empty itself. Others consider that the two occur together as a result of senile degeneration ; while others believe the atony to be entirely the consequence of the obstruction, compensative hyper- trophy failing from age. Whatever the primary cause may be, there is no doubt, so far as the later stages are concerned, the last-mentioned view is the correct one. Symptoms. — The symptoms directly due to the enlargement are so indefi- nite and gradual that in most cases the disease is already advanced before the patient thinks of applying for relief. Exceptionally, retention occurs at an early period. Frequency of micturition is one of the first symptoms ; different positions of the body, various kinds of movement, especially rising from the recumbent posi- tion, excite a desire to micturate at once, and the call must be obeyed. In the daytime it may not be severe, or perhaps is not much noticed ; but, especially if much fluid is taken late in the evening, the patient has to get out of bed several times toward morning, or while dressing finds that he is constantly desiring to pass 1076 DISEASES AND INJURIES OF SPECIAL STRUCTURES. water. In other words, the muscular coat is beginning to fail, and though it may still be capable of emptying a blatlder thoroughly when not too full, it cannot deal effectually with an accumulation ; a certain amount only isexf)elled before it is tired out, then it must rest for a time ; and the difficulty becomes greater every day, until at length a small but constantly increasing amount is left permanently as residual urine. For the same rea.son the stream fails in strength ; it is slow in coming and has no force — the urine flows away rather than is driven out : there is hesitation at the commencement, and the last few drops fall without control. Slight hemorrhage is not unfrecpient, especially when the call is urgent ; oc- casionally it is rather profuse ; obscure aches and pains are often felt in the loins or down the thighs ; erections of the penis and sexual irritation may occur and be very annoying. The rectum becomes affected by the constant straining ; prolapse or hemorrhoids may follow ; there is a teasing sense of fullness about the anus, and in advanced cases defecation is very liable to take place simultaneously with micturition. Retention may occur at any time. It may be complete, no drop escaping from the urethra : either the median lobe suddenly blocks the orifice like a valve, or the congestion becomes so great that the obstruction is too much for the weak- ened muscle. More often it is gradual ; the residual urine increases, the strength of the bladder diminishes, and at length it becomes so full that it can contain no more — the urine flows out from it drop by drop as it enters from the ureters. This is overflow, and must be clearly distinguished from incontinence, in which the bladder is empty. The other symptoms depend not so much upon the enlargement as upon its complications — cystitis and pyelonephritis. Even when the inflammation is slight the irritability of the bladder is most distressing ; micturition is no sooner ended than the burning begins again ; rest at night is impossible ; the jiain never ceases ; the appetite is lost ; the bowels are disordered ; the health is broken down com- pletely by the ceaseless suffering, and the patient becomes worn out and emaciated. But when the urine becomes amraoniacal and suppurative pyelonephritis is added to the rest, the results are infinitely more severe. The urine is offensive, it is loaded with albumin and throws down a gelatinous deposit of pus mixed with blood and phosphates, the specific gravity is lowered, the quantity fails. There is partial sup- pression, and partly from this, partly from the constant suffering and the septic absorption from the ulcerated mucous membrane of the bladder, the constitution becomes utterly broken down. The temperature may not rise, sometimes it is even subnormal, but the tongue becomes dry and brown ; the pulse small and quick ; low muttering delirium sets in ; the restlessness is extreme, the patient wants inces- santly to get out of bed ; the strength fails completely, and exhaustion or urasmia and coma speedily follow. Diagnosis. — Enlargement of the prostate can only be proved by an e.xamina- tion of the urethra or rectum, or the two together. If the rectum only is examined, the patient may either stand with the feet slightly separated and stoop forward over the end of a sofa, or, more comfortably, lie on his side close to the edge of a firm couch with the knees drawn well up. The central portion of a healthy prostate is soft and yielding, the sides are more firm, but shade off gradu- ally into the tissues around ; when it is enlarged it feels dense and resistant, or the consistence is uneven, and the outline more sharply marked and irregular. In extreme cases a shapeless mass projects into the rectum, extending far beyond the reach of the finger, both above and on either side. The degree of obstruction can only be ascertained by pa.ssing a catheter ; if the growth extends toward the rectum, the power of the bladder may not be much impaired ; on the other hand, a very slight enlargement of the middle lobe may cause complete retention. A sound may be used, but as instruments are always an evil, it is better to take a catheter, and to direct the patient to empty the bladder first, so that not only the shape of the gland but the amount of the residual urine in PERTROrJIY 01' yj/K J'/W state. 1077 may l>e ascertained. Tlic lcnj,^th of the enlargement may be judged by the distance the catheter passes before entering the bhidder ; the height to which the middle lobe rises by the depth to which tlie handle of the instrument uuist be depressed between the patient's legs. 'I'he most accurate information is obtained by con- joined rectal and urethral examination ; the distance between the catheter and the finger can be estimated, and the jiresence of irregular nodules or uneven enlarge- ^ment of one lobe better made out. Enlargement due to inflammation is distinguished by the pain and the sensa- tion of heat in the rectum, but it must not be forgotten that a certain amount of chronic intlammation is not uncommon in enlargement of the j^rostate, even when instruments have not been used. How far the increase is due to passive congestion is much more difficult ; but if the mucous meml^rane bleeds very readily when a large instrument is passed, and the hemorrhoidal veins are much enlarged, it is probable that some at least is caused by this. In malignant disea.se of the prostate the growth is more rapid and the i)ain more intense, radiating from the perineum down the thighs. (Generally the prostate is softer ; and profuse hematuria, toward the end of micturition, is the rule. . It is not sufficient, however, to make out that the prostate is enlarged, or even that the median lobe has grown out and obstructs the flow ; the condition of the bladder must be ascertained as well, how far it is already in a state of atony, and what amount of residual urine is left. This can only be done by passing a catheter ; but as this is a proceeding which is sometimes followed by very serious consequences, especially when done for the first time, or when there is residual urine, certain pre- cautions should always be adopted. The patient should be directed to lie down and keep warm and quiet for the rest of the day ; it is best for him to remain in bed, but at any rate he should not go out or expose himself to cold. Before the catheter is passed the bladder should be emptied as thoroughly as possible ; the object is to find out the quantity that cannot be expelled ; not unfrequently this must be done on more than one occasion before the amount can be definitely fixed, as from nervousness or other causes it often happens that the bladder does not act so well as usual. The best instrument is a soft rubber catheter of moderate size ; or, if this will not find its way in, a black one wnth the i)oint well bent up {coude), or a gum-elastic fitted with a stylet, so that if its progress is stopped abruptly the end may be tilted up. If a large amount of residual urine has been drawn off (more than five or six ounces) a smaller quantity of a warm antiseptic solution should be introduced and left ; the bladder cannot readily accustom itself to such altered conditions, and must be gradually educated, the quantity being reduced every second or third day. In all such cases the patient should be cautioned that there is almost certain to be some slight fever after the operation, and that rest in bed until the temperature is normal and the bladder has grown accustomed to its new condition is absolutely essential. Treatment. — 1. Palliative. — (a) General. — The treatment of enlargement of the prostate depends upon the condition of the bladder. If the patient's rest is not seriously disturbed at night, and if there is only a small amount of residual urine, every effort must be made to maintain the strength of the muscular coat and prevent it being strained. The bowels must be opened regularly ; micturition per- formed at stated times ; a regular amount of fluid taken, anything late at night especially being avoided ; and wines and spirits consumed very sparingly. The clothing should be warm, so that there is no sudden chill or congestion of internal organs ; and, especially if there is any tendency to gout, the diet should be light and without much meat, so that the urine may be as little irritating as possible. {b) Catheters. — If, however, as generally happens, the atony of the muscular coat is already advanced, and if two or three ounces of residual urine are found in the bladder on more than one occasion, showing that it is habitual, means must be taken to remove it thoroughly, at least once in the twenty-four hours. It is true that the passage of a catheter, under these conditions, is liable to cause urinary fever, even when every precaution is adopted ; and that, if no other treatment than I078 DISEASES AND INJURIES OF SPECIAL STRUCTURES. that already described is employed, the patient may go on for some years, though with great inconvenience ; but, all that time, the amount of residual urine is increasing, the muscular coat of the bladder is becoming weaker, its recuperative power more feeble, and the kidneys more and more diseased, so that, when at length, after years of suffering and ai)prehension, the catheter becomes absolutely necessary, urinary fever of the worst sort is almost certain to follow. There is abundance of evidence to show that the ill results which are occasionally met with after catheter- ism in cases of enlarged prostate not complicated by cystitis, are proportionate in their severity to the amount of residual urine, and postponing the commencement of catheter-life until it cannot be avoided merely means running a far greater risk of urinary fever, without having, in the meantime, increased in any way the patient's comfort. The instrument should be the softest and most flexible that can be introduced ; and the greatest care must be taken that it is thoroughly cleansed inside as well as out, before as well as after using. It is not a bad plan to keep it in a solution of carbolic, frequently changed, though the catheter itself soon becomes spoiled. The best time for beginning is when the patient is warm in bed, and, if he is not already accustomed to the use of instruments, he should be recommended to keep in bed for a couple of days, and to remain in his room for a week, even if all goes well. A week is none too long to give up altogether in such a case. The bowels should be kept open ; a warm hip bath taken every night ; and, if the kidneys are sound, and the urine of fair specific gravity, a small dose of opium may be given an hour or two before the catheter is passed. The temi)erature should be watched, and, if there is the least shivering, a full dose of quinine given in a cupful of hot tea. Unfortunately, the form of urethral fever that occurs in these cases is not that characterized by a single severe rigor, with temporary renal congestion, and which, though exceedingly alarming, is rarely followed by serious results. Much more frequently the fever is continued and commences insidiously, the temperature not rising for some hours, and then rarely reaching 102° or 103° F. When this occurs the most prominent feature is the prostration ; the pulse becomes quick and small ; the tongue brown and furred, and the eyes sunken ; there is constant delirium, especially. at night ; the patient is incessantly trying to get out of bed ; the quantity of urine is deficient ; its specific gravity is below normal and it always contains mucus and generally albumin. Symptoms of this kind seldom occur unless the kidneys are already in a state of advanced interstitial nephritis — the secreting power is already diminished ; the additional irritation, setting up congestion, leads to partial suppression ; typhoid symptoms follow, and unless there is a rapid change, uraemia and coma are inevitable. As soon as the bladder has become accustomed to the sensation of being emp- tied, and the urethra to the passage of a catheter, the patient may be taught to pass one for himself. The best time is the last thing at night, before retiring to rest, so that some hours' sound sleep may be secured ; but if the amount of residual urine is constantlv above three ounces, the instrument should be passed night and morning ; and if between three and six, three times a day. It is better to do it too often than too seldom ; if distention is avoided, the muscular coat may regain some of its power, and though the residual urine never disappears altogether, it diminishes considerably in quantity. One single instance of over-distention, how- ever, is sufficient to undo all the good. When once the commencement of cathe- ter-life has been pa.ssed, there is no reason why, if only reasonable j^recautions are taken, especially against the occurrence of cystitis, the patient should not resume active habits of life again. When there is cystitis, more active measures are required. It may be due to the catheter, or to an irritating condition of the urine, or possibly to the obstruc- tion cau-sed by the projecting masses of the prostate ; whatever the cause, if left to itself, it can only grow worse and spread to the ureters and kidneys. The blad- der is unable to empty itself, the irritability of the mucous membrane is so intense that the contraction never ceases ; the muscular coat becomes hypertrophied ; the HYPERTROrilV OF THE PROSTATE. 1079 alkaline mucus collects in the post-prostatic pouch, from which it cannot be evacu- ated ; the urine becomes peculiarly offensive ; at length ammoniacal decomposi- tion sets in. and the inflammation, which at first was simply catarrhal, runs on rapidly to ulceration and sloughing. As soon as it begins the bladder must be thoroughly washed out, so that the post-jjrostatic pouch may be completely cleared. If there is a j^rofuse secretion of mucus (catarrh), hot salt and water (a teaspoonful to the pint) may be used first, and then a mild astringent, acetate of lead (.06 ad 32 c. c), nitrate of silver, or, better, bichloride of mercury (.03 ad 32 c. c), on account of its powerful antiseptic qualities. Permanganate of potash, borax with glycerine, quinine, tannin, and many other substances have also been used. If there is much phosjjhatic deposit, dilute nitric (gtt. j vel ij ad 32 c. c), or phosjjhoric (gtt. iij ad 32 c. c.) acid is of ser- vice. Meantime the jjatient should be kept warm, if jjossible in bed, on light or even milk diet ; baths should be given every night, the bowels kept well open, and the state of the urine carefully watched. Stimulants do no good, but sometimes they must be given. If the irritability is very great, morphia suppositories may be tried, or a few drops of tincture of opium injected into the bladder after it has been washed out. Quinine appears of service when given internally, possibly be- cause some of it is excreted in the urine ; and, if it does not upset the patient, benzoate of ammonia helps to keep the urine acid ; but the cause and the treat- ment are both mainly local. (r) Drairiage. — Patients with enlargement of the prostate have been known to live for thirty years in comparative comfort, using a catheter two or three times a day ; but not unfrequently, as age advances, the bladder becomes more irritable, and the necessity for passing an instrument more frequent, until at length it has to be done every hour, night and day, rendering existence a burden. The prostate is swollen and tender ; sometimes there is ulceration at the neck of the bladder, causing extreme tenesmus ; or there are pouches which cannot be drained and \vhich are constantly infecting the rest of the urine ; or the bladder has become so rigid and contracted that it can only retain a few ounces ; and sometimes there are calculi. At length the suffering becomes extreme ; day and night there is most agonizing pain ; the catheter is wanted every minute, and every time it is passed only makes the condition worse. Temporary relief in these cases may always be obtained by draining the blad- der. This is easily done by the operation known as " la boutonniere." The patient is anaesthetized, placed in the lithotomy position, and a grooved staff passed into the bladder. The left forefinger is placed in the rectum to fix the apex of the prostate, and an incision three-quarters of an inch in length made exactly in the middle line of the perineum, an inch in front of the anus. This is deepened until the membranous portion of the urethra is opened behind the bulb. A direc- tor is then passed along the staff into the bladder, the staff withdrawn, and the fore- finger of the right hand gently pressed through the prostatic urethra, dilating it as it goes. If no calculus is found, and there is nothing about the shape of the prostate or in the cavity of the bladder to account for the persistence of the symptoms, a large rubber tube is passed through the perineal wound into the blad- der, and connected with a receptacle under the bed, so that every drop of urine flows out at once. The effect of this is most striking: the need for the catheter ceases entirely, the night's rest is uninterrupted, the pain disappears, and the patient can sit up comfortably in bed. The mucous membrane, being no longer in con- stant contact with foul, decomposing urine, begins to throw off its coating of mucus and phosphates, the ulcers heal, the absorption of septic material from the bladder ceases, the reaction of the urine becomes acid again, the blood disappears, and the deposit begins to diminish. As soon as the condition of the bladder is thoroughly restored, the tube may be withdrawn and the opening allowed to close. Harrison adopts a simple process. A straight trocar and cannula is intro- duced in the middle line of the perineum an inch in front of the anus and pushed loSo DISEASES AND INJURIES OF SPECIAL STRUCTURES. through the substance of the prostate until the bladder is tapped ; then the trocar is withdrawn, a self-retaining catheter introduced in its place, and the cannula re- moved. As soon as the urine begins to improve, the patient is allowed to get up and move about ; and, if it is thought desirable, the apparatus may be permanently retained, the catheter being connected by means of a rubber tube with a urinal strap])ed on to the leg. The amount of leakage by the side is very slight. In most ca.ses, after a few weeks the urine begins to come through the urethra again ; and this may be taken as a signal that the drain is no longer needed. Harrison has noted the curious fact that in several of these cases the prostate has shrunk to such an extent after the operation that the enlargement can hardly be detected through the rectum, and the patient experiences little or no difficulty with his urine afterward. In extreme ca.ses, in which, owing to the enormous size of the prostate or to other special complications, a permanent opening affords a better chance of relief, sui)rapubic puncture may be i)erformed ; or the bladder may be deliberately opened in the same region and cleared of all adhering mucus and phosphates, a properly arranged tube and urinal being worn afterward, as in cases of im]>erme- able stricture. Other complications that occur in the course of enlargement of the i)rostate may require special treatment. Retention of urine must be relieved by catheter as Fig. 467. — Watson's Cannula in Position. soon as possible. The muscular coat is already in a state of partial atony, and a slight degree of over-distention is sufficient to increase it until the power of con- traction is permanently lost. If the catheter cannot be passed, hot baths and similar remedies are useless ; an opening must be made in the bladder at once, but the necessity for this is very rare. Hemorrhage is seldom serious ; sometimes it ai)pears to give relief, especially the slight amount which in some patients is so constant as almost to deserve to be called periodic. When it follows the use of a catheter it may either be due to rupture of the engorged veins, or to the effect of suddenly relieving the pressure upon the wall of the bladder. In either ca.se the blood and the urine are inti- mately mixed, and though the color may be bright red just at first, it soon becomes smoky and brown. The patient should be kept quiet in bed, and the urine drawn off as occasion requires with a soft catheter; special treatment is seldom needed. If it persists, the bladder may be washed out with an iced infusion of matico or tincture of hamamelis, and opium with garlic and sulphuric acids given in- ternally. Clots, as a rule, disintegrate of themselves, but they may require an evacuator. If there is extreme jiain at the neck of the bladder when the catheter touches a certain spot, and ulceration or fissure can be diagnosed by the endosco])e, a solution of nitrate of silver (gr. v ad 3J) may be brushed over it with a properly HYPERrROPHY OF THE PROSTATE. 1081 arranged injector. Sacculi in the walls should be drained and washed out like the rest of the bladder, but the openings are so small that it is seldom possible to find them without the aid of a cystoscope. The ordinary method of washing out the bladder merely tends to make them larger, as it fills them under pressure with fluid which they cannot expel again. On the other hand, there are .several cases on record in which regular drainage has led, if not to their disappearance, at least to their causing no further trouble. They may sometimes be susjjected from the peculiar character of the urine, or from the way in which a catheter, after passing the normal distance and drawing off one kind of urine, suddenly slips in further and draws off something different. Phosphatic calculi are not at all uncommon, but fortunately they are so soft that they can be crushed and washed out without prolonged instrumentation. It is always advisable, however, not to allow them to attain too large a size. Recur- rence is very common, as the same conditions persist. 2. Operative Treatment. — In i)erforniing lateral lithotomy portions of the prostate have often been removed without ill consequence of any kind. Some of these were pedunculated mas.ses projecting into the urethra or the bladder, so that they were caught (occasionally by accident) in the blades of the forceps ; others were growths in the substance of the gland itself, which shelled out from the pressure of the finger as soon as the tissues around them were incised. Moreover, the gland has been repeatedly punctured from the perineum, and by means of catheters through the urethra. Occasionally there has been hemorrhage, and sup- puration and sloughing have been known to follow, though rarely ; as a rule, the wound heals without difficulty, sometimes relieving the condition of the bladder by making a direct channel to the pouch behind. In a few instances it has been noticed that after these partial operations the prostate has imdergone a kind of subinvolution, and diminishes to an extent that cannot be accounted for even when allowance is made for the cessation of the congestion and for cicatrization. Whether in this there is a further analogy to the fibromyomata of the uterus remains to be proved. Unfortunately, it does not happen with sufficient frequency to enable any reliance to be placed upon it. In some of the cases in which the residual urine has been drained in this way, even when the amount was large, the bladder has recovered its tone, the irritability has subsided, and catheters have been dispensed with. The question, therefore, arises whether it is not possible, without running too much risk, to pro- duce the same result at an earlier period, before the bladder and the kidneys are irretrievably ruined. There are three ways in which the prostate may be approached : through the urethra, through the perineum, and, after suprapubic cystotomy, through the bladder. {a) Urethral Operations. — Of these the best known are Mercier's and Bot- tini's. In the former an instrument shaped like a short-beaked lithotrite, with tolerably sharp edges, is used to punch out portions of the floor. In the latter a fresh urethra is bored through the sub.stance of the gland by means of the galvano- cautery. This has been done on several occasions (once on a medical man without an anaesthetic) with very distinct benefit. In the first case the residual urine amounted to thirteen ounces, and the dysuria was so great that a catheter had to be passed every two hours, night and day ; the operation only lasted forty-five seconds ; there was no fever afterward, and the bladder regained a great deal of its power. In others, however, there has been severe vesical tenesmus after the operation, and sloughs have continued to come away through the urethra for up- ward of three weeks. (b) Perineal Operation. — In this an incision is made in the middle line, in front of the anus, and the membranous portion of the urethra opened as in the operation for draining the bladder. The finger is then passed into the prostatic portion and the obstruction dealt with according to its shape and position. A 69 ioS2 DISEASES AND INJURIES OF SPECIAI STRUCTURES. median outgrowth, if sufficiently pedunculated, may be excised or removed by .means of a snare ; if it is sessile it may be punched out with a modification of Mercier's prostatome, or incised with a straight probe-pointed knife, and then torn with the finger until the passage into the jjouch is straight. Sometimes it answers better to pass a curved bistoury through the substance of the gland into the post-prostatir pouch, and cut into the urethras© as to ensure that division is complete. Afterward a full-sized drainage tube is introduced and retained until the urine begins to come by the natural route. When it is withdrawn the perineal wound usually closes rapidly. If the section is sufficiently deep a catheter is not recjuired afterward, but it should still be ^ i:)assed occasionally as a precaution. {/) Sitprapiibic Operation. — This was first performed after the removal of calculi, and sub.sequently as an independent opera- tion. The rectum must be distended, as in suprai)ubic cystotomy, and the incisions through the abdominal wall and into the bladder made with the usual precautions. The finger is then introduced to ascertain the size and shape of the mass. There are, according to McGill, three chief varieties admitting of surgical relief: in the first there is a uniform circular projection sur- rounding the internal orifice of the urethra ; in the second a se.ssile enlargement of the median lobe situated partly in the prostatic urethra and partly in the position of the uvula vesicae ; in the third a pedunculated outgrowth. Of these the last can be re- moved easily with scissors, and the second may be treated in the same way by dividing the mucous membrane over it freely and tearing it with forceps. The scissors should have long handles with short blades, curved in various directions. The collar enlargement is more difficult. McGill divides it longitudinally, first in front and then behind, by inserting one blade of the scissors into the urethra, and cutting in each direction. By this the projecting part is divided into two halves, which can be removed by enucleation with the finger. The whole of the projecting valve must be excised, and after the operation the forefinger must be pa.ssed down the urethra, to make certain that it is free. Hemorrhage is checked by a hot antiseptic solution ; and the bladder drained with a tube through the lower angle of the wound for forty-eight hours. It is impossible at the present time to give a definite opinion as to the relative or absolute merits of these operations. The last is the most complete, but at the same time by far the most serious. Mercier's is certainly insufficient, and shares with Bottini's the grave disadvantage of uncertainty. It is scarcely possible, even with the aid of the .sound and the cystoscope (when this can be used) to obtain sufficiently definite information concerning the relations of the prostate and the bladder under their altered conditions. The choice between the suprapubic and perineal operations rests on different grounds. There are three chief factors upon which the selection depends ; of these two can be a.scertained before anything is done ; the third cannot. One is the distance of the bladder from the perineum ; if this is more than three inches and a half the finger cannot reach it, and the operation becomes exceedingly difficult. Possibly the urethroscope with a very wide tube, used through the perineal opening, might prove of assistance, but the view would soon be obscured by the bleeding. The second is the condition of the bladder ; if it is small, rigid, and degenerate from chronic cystitis, the sujjrapubic operation is out of the question. The third is the shape of the obtruding mass. In a small ])roportion of cases this is such as Fig. 468. — Neck of the Bladder seen from within, in a case of Enlarged Prostate. The orifice of the urethra lies in the angle between the two projections. PA'OSTAT/r/S. 1083 to preclude effectual removal through a perineal opening, but this can only be as- certained by actual exploration. The perineal operation is the more simple : it gives much jjetter drainage, and these cases nearly always retiuire it, owing to the presence of cystitis, and perhaps ammoniacal urine. I have performed prostatotomy through it on several occasions with very great benefit ; prostatectomy, sufficient to remove the median obstruc- tion and relieve the bladder, is possible in a large ])roportion of cases ; and finally, in the few instances in which jjrostatectomy cannot be managed in this way, and is possible by the suprapubic method, the j)erineal opening does not add materially to the gravity of the operation, and is of the greatest assistance for draining the bladder and preventing septic absorption afterward. Malignant Disease of the Prostatf.. Carcinoma and sarcoma both occur, but the former is the more common. It is usually of the glandular or spheroidal-celled tyjje, and is more often soft than hard. Colloid carcinoma has also been described. Symptoms. — Carcinoma is generally met with after middle life ; sarcoma may occur earlier. The symptoms at the first are the same as those of simple enlargement or chronic inflammation, but they soon become more intense and acute. The obstruction to the flow of urine comes on more quickly ; the uneasi- ness and frequency of micturition are more marked, and the pain is more severe, radiating from the perineum down the thigh and to the end of the penis. Later, as the disease advances, it may become agonizing. Hemorrhages are common, often profuse, occurring with or without micturition, and tending greatly to reduce the patient's strength. Cystitis and decomposition of the urine follow ; the glands in the iliac region become involved, and death usually occurs in a comparatively short time from exhaustion, interference with the urinary secretion, want of rest, and pain. Operative treatment is practically out of the question, though in one or two instances obstructing portions have been removed with a certain amount of benefit. Suprapubic puncture at an early period is more effectual, though this cannot relieve the pain. The bowels must be kept gently relaxed, a soft catheter used when required, the interior of the bladder washed out with weak antiseptics, and the pain controlled, as far as possible, by means of morphia. Prostatitis. Inflammation of the prostate may be either follicular or parenchymatous. In the former, the mucous membrane and the follicles opening upon it are chiefly concerned ; abscesses may form, but they are rarely large, and they always burst into the urethra. In the latter, the whole substance of the gland is involved ; and, if suppuration occurs, the pus may spread into the tissues around, and point in the perineum, or even in the groin. I . FoUicula)- Prostatitis. This may be either acute or chronic. The former is usually due to gonorrhoea, but it may be caused by injury (impaction of calculi, the passage of large instru- ments, or the use of caustics), especially if the gland is already in a state of con- gestion from excessive sexual excitement, advanced stricture, or other causes, pjicycle riding is said to produce the same effect. It is very doubtful if simi)le irritation by the urine is sufficient to bring it on, though it may prevent its getting well. The chronic form is either the result of the acute, or commences as such, from similar causes acting with less energy. {a) Acute. — This usually occurs during the acute stage of gonorrhoea, liut it may be brought on later by the use of injections or the passage of instruments. There is intense burning at the neck of the bladder ; the desire to pass water io84 DISEASES AND INJURIES OF SPECIAL S'IRUCTURES. never ceases ; the stream from the first is small ; a few drops only are ejected, without the least relief, and even this may be im|)ossible. There is violent throb- bing in the perineum ; the pain extends down the thighs and into the loins; in the rectum there is a constant sense of fullness and tenesmus, with great suffering as soon as the bowels begin to act; and, if the finger is introduced, the prostate feels swollen and burning hot. The temperature rises from the first ; the pulse becomes full and quick ; the distress is very great, and not unfrecjuently there is high fever. Suppuration is usually, but not always, indicated by a chill. When the inflammation is due to other causes the course is generally less severe; and occasionally large chronic abscesses form in the substance of the gland, without any marked symptoms other than those of irritation about the neck of the bladder and obstruction to the jjassage of urine. If the treatment is active and early, the sym])toms usually subside. Occasion- ally the inflammation becomes chronic ; the irritability and pain persist, though with less severity ; there is a certain amount of discharge washed down by the first few drops of urine ; and whenever there is the least indiscretion, all the old trouble threatens to return. Treatment. — The patient should be confined to bed and placed upon milk diet ; a hip-bath, as hot as can be borne, should be given twice a day, and the bowels should be freely opened once; after that it is better to leave them alone, owing to the pain and need for local rest. The rectum may be washed out with hot enemata, leeches applied to the perineum, and the bleeding encouraged by fomentations. The pain must be relieved by suppositories or hypodermic injections of morphia. Sometimes the inflammation can be cut short by full doses of vinum antimoniale every hour, until nausea is i)roduced. If retention occurs, the urine must be drawn off with a catheter, either a soft rubber one of medium size or a black one, coude, so that it can ride easily over the obstruction. If suppuration is suspected, and there is any redness or fullness in the peri- neum, a free median incision should be made : if pus is not found, the hemorrhage will give relief; but, though this is not uncommon when the suppuration is in connection with the membranous portion of the urethra or Cowper's glands, it rarely occurs in prostatitis. Generally the abscess bursts into the urethra, either of itself or when a catheter is passed : there is a profuse discharge, and at once a sensation of intense relief. Owing to the extreme tension, the cavity contracts immediately, and, so long as the abscess is acute, fistula and extravasation of urine rarely follow. (Ji) Chronic Follicular Prostatitis. — This may be the relic of an acute attack, or it may result directly from gonorrhcea, stricture, or prolonged masturbation. The symptoms are the same, but of less severity ; and the affection is often mistaken for calculus. There is increased frecpiency of micturition ; the stream flows away, especially the last few drops, without any force ; almost always there is pain and scalding toward the end, and sometimes a few drops of blood escape at the same time. Shreds of mucus and casts of the jjrostatic follicles accumulate in the urethra, and are either washed down with the first few drops, or exude from the meatus during defecation. In the latter case, they are often mistaken for the secretion of the testes, and the patients are convinced that they are suffering from spermatorrha;a. Oleet is not present unless the i)enile portion of the urethra is involved as well. Kxamined through the rectum, the gland feels enlarged and tender. There is constant aching in the jjerineum, extending down the thighs and across the loins, much more severe during defecation and micturition, because then the prostate is compre.ssed. The constant straining usually brings on hemorrhoids as well ; the irritation spreads to the bladder, and cystitis follows ; at first it may be slight, but by degrees the walls become hypertrophied and lose their flexibility ; and then, often it is not properly emi)tied, even though the patient may pass water every hour. At last the health breaks down altogether, and mental as well as bodily vigor is seriously impaired. INFLAMMATION OI< II/i: PROSIAJK. 1085 Treatment. — This affection is generally of a most obstinate character, and requires prolonged anil careful attention. Fresh air and change of scene are often necessary ; the food must be good, but not rich ; stimulants, especially beer, sherry, and champagne, must be prohibited, and tonics, iron, nux vomica, cod-liver oil, and phosphoric acid, given according to the condition of the i)atient. The bowels should be kept slightly relaxed, so that there may be no straining at stool, and excessive exercise, especially on horseback, or on a bicycle, and sexual indulgence must be avoided. In most cases local treatment is e.ssential. Lightly blistering the perineum is .sometimes of service ; small patches should be painted over with blistering fluid on successive days, taking care to avoid the skin of the .scrotum, and, if po.ssible, not raising actual vesicles, or a little dry mustard may be rubbed in. Astringent injections ai)|)lied to the part itself are of great advantage, using either an injector or a i)rostatic syringe. (Glycerine and tannic acid, or five minims of a two per cent, solution of nitrate of silver, or nitrate of bismuth may be applied without fear ; stronger applications (even twenty grains of nitrate of silver to the ounce) are emjiloyed by some, but the pain they cause is very severe (though this may be prevented by cocaine), and their use is often followed by vesical tenesmus and a blood-stained discharge. The urethra should be washed out with hot salt and water first, to clear away adherent mucus, and the i)atient kept in the recumbent l)osition for the rest of the day, as a precaution against epididymitis. If these fail, tannic acid, eucaly])tus oil, and other astringents, made into bougies, may suc- ceed, but they must be introduced with a proper instrument, as they are too soft to pass of themselves. They soon become liquid, and the mucous membrane remains for some time bathed with the products of their solution. ParciicJiymatoiis Prostatitis. Gout, tubercle, and injury are the chief causes. Occasionally it is due to syphilis, and it is said that sometimes inflammation arises from exposure. Gouty prostatitis is not uncommon toward middle life in men who live rather freely, and whose urine is loaded with uric acid. The commencement is tolerably acute, and is often assigned to cold ; the fever is not so high as in the acute follic- ular form ; there is very rarely retention of urine, and probably never actual suppuration. The irritability of the bladder is even more intense ; the urine is ejected spasmodically, almost without the patient having any control, and the pain is very severe, especially at night. Per rectum, the prostate is distinctly enlarged, hardened, and exceedingly tender. Sometimes there is oedema of the prej)uce, or partial erection from obstruction of the veins of the penis. (Generally the attack subsides readily under colchicum and the alkaline carbonates ; the bowels should be freely opened with blue pill, the diet carefully restricted, and a regular amount of fluid (hot water is the best) taken at stated times, to diminish the acidity of the urine and prevent any concentration. Gouty prostatitis may in some cases lead to the accumulation of residual urine; the gland is very sensitive, and, to avoid squeezing it, the patient never thoroughly empties the bladder ; after a time a certain amount is constantly retained, the walls become atonied, and the power of complete evacuation is lost. Tubercular prostatitis usually occurs in young adults, in association with tubercular disease of the bladder or kidneys ; sometimes it appears to follow an attack of gonorrhoea, but it is rarely as a primary affection. In the earlier stages the symptoms are almost the same as those of calculus ; micturition is much too frequent, the patient wanting to pass water every hour ; haematuria is often present, especially as the neck of the bladder is beginning to contract, and, at the same time, there is a sharp, cutting pain at the end of the penis. Per rectum, the prostate is seldom much enlarged ; at first it is rather harder than natural, and perhaps nodular, but, as the caseous masses break down and disappear, it may become abnormally soft. In the later stages the urine brings away with it pus io86 DISEASES AND INJURIES OF SPECIAL STRUCTURES. and caseating debris, full of tubercle bacilli, the gland itself is completely exca- vated, the irritability and pain become unbearable, and the patient grows weaker and weaker. Generally speaking, there are dejiosits in other organs as well. The diagnosis in the early stages, when there is some hope of removing, or at least arresting the disease, can only be made with the endosco])e. If this is not £/a(7(/r, Prostate Fig. 469. — Prostato-vesical Calculus. .used, neighboring organs, such as the bladder or vesicuhc seniinales, are nearly sure to be involved before there is any definite evidence. Constitutional treatment is of great importance, but it does not seem to have the same influence over tuber- culosis of the genito-urinary tract as when it occurs in other parts — the bones, for example. Locally, iodoform, applied in an emulsion or as a pessary, is of some < f ^** ^^^ ■■*"\. / >. f ■^^S*; ^"^V.A '.'u-^^ '\7--''. KiG. 470. — Prostatic Calculi with some Enlargement, causing Prolapse of the Ureter. (Section a little to the left of the middle line ) service ; but i)ossibly, if the diagnosis were confirmed by microscopic examination, and it was fairly certain that the other organs were sound, it would be better, if speedy improvement did not take place with ordinary measures, to open the pros- tatic urethra from the perineum, and try free scraping and the application of lactic acid. In the later stages morphia is the only drug that relieves the pain. If the PROSTATIC CAJ.CULI. 1087 disease is limited to the jjrostatc tlic bladder may be drained thrcjiigh the peri- neum ; but, unfortunately, this often fails to give relief, owinj^to the other organs being involved as well. Suppurative Prostatitis. — Suppuration in and around the [)rostate is occa- sionally the immediate cause of death after lithotrity, operations about the neck of the bladder, or the passage of very large instruments, especially when there is old-standing disease of the kidneys. It may commence in the prostate itself, the gland being destroyed, the capsule giving way and the pus spreading in the loose tissue around the neck of the bladder, until, if the patient live sufficiently long, it points in the iliac fossa; or it may be periprostatic from the first, originating in tissues that have been saturated with septic material by absorption from the bladder. There may or may not be a rigor ; as a rule, the symptoms are exceed- ingly vague, being masked entirely by the vesical and renal trouble, and in the majority of instances the diagnosis is not made until the patient is sinking from septicaemia and suppression of urine. Prostatic Calculi. Calculi occasionally leave the bladder and become impacted in the prostatic portion of the urethra : under these circumstances they may sink into the sub- stance of the gland, and become, as it were, encysted, with a portion of their surface projecting. True prostatic calculi, however, are not uncommon, originat- ing in the follicles, and gradually growing larger and larger until the intervening tissue is absorbed, and they come into contact with each other. They are always multiple, rarely very large, and usually faceted from pressure; as a rule they con- tain about 85 per cent, of phosphate of lime with a trace of carbonate, and about 15 per cent, of animal matter, but the proportion of the latter is sometimes higher toward the centre. In one or two cases they have coalesced into large masses. So long as they are small they do not give rise to any symptoms ; as they grow larger they may cause inflammation and even suppuration. In one case under my care, admitted for extravasation of urine consequent on this, there was, in addition to the prostatic calculi, a much larger one in the bladder, composed of bone earth with a little carbonate of lime. io88 DISEASES AND INJURIES OE SPECIAL STRUCTURES. CHAPTER XXIII. INJURIES AND DISEASES OF THE URETHRA. Injuries of thk Urethra. The mucous lining of the urethra may be torn by calculi, or perforated with catheters, or bruised from blows upon the i)erineum, or from attempts at forcibly straightening out chordee ; but serious consequences rarely follow. There is a small amount of hemorrhage, perhaps sufficient to drip from the orifice ; micturi- tion is attended with scalding, and there is soreness about the part with a slight mucous discharge, but extravasation of urine seldom follows a superficial injury unless there is an obstruction as well. False passages escape from their direction. They start in most cases from the floor, in front of the bulb, very often on the left side, and run from there between the bladder and the rectum, but the opening lies toward the meatus, so that urine does not enter. Rupture of the urethra may be caused by a kick or violent blow in the [peri- neum, or by fracture of the pelvis.* In the former case the urethra is torn at the junction of the membranous and bulbous parts, the anterior layer of the triangular ligament giving way as well ; sometimes the whole circumference is ruptured, and the ends are widely separated ; sometimes there is only a rent on the floor, the roof remaining intact. Hemor- rhage is usually profuse, forming a swelling in the perineum and scrotum, and often dripping freely from the meatus, but no urine is extravasated until an attempt is made to relieve the bladder. In the latter, when the rupture is the result of fracture of the pelvis or sepa- ration of the symphysis, the deeper part of the urethra and the neck of the bladder generally suffer ; blood does not escape externally until an attempt is made to pass urine ; but this, from the moment of the accident, begins to leak out from the bladder and infiltrate the tissues around, setting up the most intense inflam- mation. The symptoms depend upon the seat of injury. If the rujiture is in front of the triangular ligament, or involves the anterior layer of it, a swelling rapidly forms in the perineum ; blood drips slowly from the meatus, and either the patient is unable to pass any urine, or, if he makes the attempt, it pours into the loose cellular tissue of the perineum, causing the most intense burning. If an attempt is made to pa.ss a catheter, either it stops abruptly at the seat of injury, the point rubbing against the lacerated tissues, or it suddenly slips onward, entering the bladder and drawing off clear urine. This accident is nearly always followed by a stricture, the severity of which de])ends upon the amount of suppuration. If the rupture is complete, and there is the least infiltration of urine, the cicatricial tissue becomes so hard and dense that practically the urethra is closed (unless steps are taken to jjrevent it) ; if the mucous membrane is partly intact and there is no supjjuration, there may be some obstruction, but the tendency to contraction is not nearly so severe. On the other hand, when the deeper i)art of the urethra is torn, external hemorrhage and swelling are rarely present, but the pain and the shock are much more severe, and, owing to the urine soaking at once into the cellular tissue, inflammation and fever soon set in. If a catheter is passed there is no difficulty until it begins to wind under the pubic symphysis; then it either stops altogether, [* The editor has seen a case of rupture of the membranous portion produced by a fall from the fourth story of a building. The patient bad a full bladder at the time of the accident.] RL'P I'i'RK OF /•///•: URETHRA. 1089 or if it can be introcliRctl into the bUicUlcr, tlic urine that it draws off is loaded with blood. This injury usually proves fatal from infiltration of urine into the cellular tissue of the pelvis, in the same way as extra-peritoneal rujjture of the bladder. Treatment. — In every case of severe injury to the jjelvis or iierineum a catheter should be passed as a matter of routine, to ascertain if there is any injury to the bladder or urethra. If it slips in at once, without any grating, or perhaps with a sensation of roughness of the mucous surface just at one spot, it may be withdrawn again ; there is merely an abrasion or contusion of the mucous mem- brane, and, if the bladder is emptied and urine is not passed for some hours, the surface will glaze over. If, on the other hand, the catheter is brought to a sudden stoj), or if the i)roximal orifice of the torn urethra is only found with difficulty, and perhaps after more than one instrument has been tried, steps must be taken to prevent infiltration. {a) Rupture of the Anterior Part of the Urethra. — If there is the least diffi- culty in passing an instrument into the bladder, or if it is clear from other evidence that the urethra is badly torn, the patient should be placed in the lithotomy posi- tion, a catheter passed down to the rupture, or through it, and a median incision made of sufficient length and depth to allow the extravasated blood to escape and l^revent infiltration of urine. Tying a catheter in will not do this ; urine always trickles by the side of it, no matter how large it is, and if the wall of the urethra is torn at any point, infiltration and urinary abscess are sure to follow. The blood collecting in the wound and in the cellular tissue around seems to encourage it, by the readiness with which it undergoes decomposition and the way in which it opens up the tissues for the urine. Various methods have been tried to provide additional security against this. I have on several occasions sutured the two ends together; there is no difficulty, especially in young subjects, in whom the perineum is yielding. The finger placed in the rectum, forcing the tissues out through the wound, brings the proximal end of the torn urethra quite to the surface, so that sutures can be readily passed ; but I have never succeeded in obtaining union by the first intention, and it has seemed to me that not only is the additional bruising which this entails injurious, but that there is a great tendency for the two parts of the urethra to unite at an angle with a spur between. Tying a catheter in after the incision has been made might pre- vent this, but in many cases it is a very serious irritant, causing grave reflex dis- turbance, and of itself tends to prevent union, so that it would do more harm than good. There is no difficulty, four or five days after the injury, in finding the proximal end and guiding into it a catheter passed down the penis. Draining the bladder directly through the perineum or the rectum, so that no drop can flow down the urethra until the wound is healed, has been recommended ; but in the slighter cases it is not required, and in the more severe ones the extrava- sation of blood is so great that an abscess is almost sure to follow at the seat of injury. In any case, a soft catheter must be passed every second day at least, com- mencing not later than the end of the week ; for although there are cases on record which prove that rupture of the urethra treated by early incision does not of necessity lead to traumatic stricture, there is no doubt that it is liable to.* {b) Rupture of the deeper part of the urethra does not admit of this, or of suture. All that can be done is to drain the bladder as efficiently as possible through the perineum, in the hope that if urine has already been extravasated, the suppuration that follows may be kept within bounds. Unhappily, in nearly all these cases there is a fracture of the pelvis, which, in this way, becomes com- pounded into an ill-drained suppurating cavity. [* In three cases of urethral rupture under the care of the Editor, the first was treated by repeated aspiration of the bladder, until the rent healed ; the others by perineal section and tubal drainage. All recovered without unfavorable symptoms,] loyo DISEASES AND INJURIES OE SPECIAL STRUCTURES. Calculus in the U'rhihra. Calculi are occasionally formed in the urethra in the dilated and fasciculated pouch that develops behind a stricture ; but nearly always the nucleus is carried down from the bladder. The symptoms depend upon the degree of obstruction ; if the calculus is large enough to block the urethra of itself, or so sharp and angu- lar as to bring about the same result by the spasm that it excites, retention occurs ; and if sj)eedy relief is not given, ulceration and extravasation follow. If, on the other hand, it is small and lodged in a diverticulum, it may continue to increase from the deposit of phosphates on its surface and wear its way into the tissues, until at length it forms an enormous mass, lying in the substance of the penis, alongside the urethra, almost buried under the mucous membrane. Impacted Calculus. — This is more common in children than in adults, owing to the greater frecpiency of stone in them and the small size of their urinary pas- sages ; the calculus is washed down from the bladder during the act of micturition and suddenly arrested, generally in the membranous part or at the meatus. The stream stops suddenly, there is a sharp cutting pain at the end of the penis with violent straining, and i)erhai)S a few drops of blood exude from the urethra, especially if the calculus is sharp and angular. For a time the straining continues, the bladder becomes more and more distended, and then either sudden extravasa- tion occurs, or, if a small (juantity of urine can escape by the side, so that there is not such immediate tension, inflammation sets in, ending in urinary abscess and fistula. There is seldom difficulty in the diagnosis. The history of the case, the way in which the child keeps screaming and pulling at the end of its penis, the retention of urine, which is so rare in children from any other cause, and the few drops of blood are distinctive. Very often the calculus can be felt from the outside. If this cannot be done, a small catheter may be passed down the urethra ; sometimes it comes to an abrupt stop against the stone, sometimes it slips by the side of it with a rough, grating sensation, and, entering the bladder, gives relief for the moment. If any time has elapsed since the accident, the bladder may be distended up to the pubes ; or there may already be a swelling in the perineum due to inflam- mation and commencing extravasation. .\ calculus in the penile part can generally be worked forward with the fingers until it reaches the orifice, when a small incision may be necessary to extract it. If this does not answer, a scoop or a pair of urethral [" alligator "] forceps may be passed down the urethra, and an attempt made to draw it forward ; but this may inflict serious injury upon the mucous membrane. If it is fixed or too far back for this, the patient should be placed in the lithotomy position, the skin over the pro- jection stretched with the finger and thumb of the left hand, and a small median incision made down on to it. Generally the calculus springs out at once, and the wound can be left to granulate. The bulb should, if possible, not be incised. If the calculus is near the neck of the bladder it should either be removed by the median operation, or, if there is a suitable instrument handy, jjushed fiirther back and crushed with a lithotrite. Foreign bodies introduced into the urethra may re(iuire extraction. Crethral forcejjs should be avoided as far as possible ; sometimes, by placing the patient in a hot bath, giving him plenty of licjuid to drink, and directing him to hold his water, sufficient head can be obtained to drive out such an obstruction, for example, as the end of a catheter broken off in a stricture ; but this should not be tried too long. Hair-pins, on the other hand, and such like structures, nearly always require incision. The cases in which the obstruction is slight and the stone lies out of the way are much more rare, and as a rule are only met with in elderly men. In a few instances huge cylindrical calculi have been found, three or four inches in length and one and a half in circumference. These generally lie in the tissues by the side of the urethra, occupying a cavity which they have worn out for themselves, THE PASSAGE OF CATHETERS. 1 09 1 ami sometimes are so invested by the mucous membrane that a sound passed down the uretlira slips by them without any of the characteristic grating. TlIK I'ASSAdK OF CArilF/l'KkS, AND Till; (JkNKRAI. lOl'FKC I Ol ( )l'KRA IIONS ri'ON THK Urk'ihka. Catheters are made of various materials, some rigid, others flexible in various degrees. Metal ones have a fixed curve, occupying a quarter of a circle of a radius of three and a half inches. (Prostatic ones should be fifteen inches long, and the radius of the curve barely three.) The handle should be bent a little downward, so that if the jiatient is lying down the urine may not be ejected all over the bed ; the other end should be solid, with a smooth eye on the side about a ([uarter of an inch liack. If it is hollow to the end the space beyond the eye is never cleaned. a b c d Fig. 471. — Various Forms of Catheters : a. coiide : h, bi-coude ; t',"olivary : d, prostatic. Gum-elastic catheters are made of webbing coated with copal varnish. Like the former, they follow the roof, but their flexibility depends upon temperature, and they can be bent to any shape. In cases of enlarged prostate, for example, if the point of the catheter is arrested by the median lobe, it can be tilted over it by withdrawing the stylet. Black catheters are much more flexible, and follow the floor. The shape dif- fers according to the requirements of the case ; some have a minute bulb at the end, mounted on a slender neck, so that it can follow the most devious route; others are rigid and bent upward at an angle {coudc), so as to ride over an ob- struction ; others, again, are bent up twice in the same way {l)i-coiide). log 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Vulcanized india-rubber catheters are mere nibber tubes, closed at the end and provided with a lateral opening ; they are esi>ecially useful for j)atients who have to pass instruments for themselves, or where, as in cases of fracture of the spine, the urethra is absolutely insensitive. Celluloid instruments are too brittle to be of general use, but they are particularly suited for tying in the bladder, as they are much less affected by urine than the others. The sizes of English instruments are arbitrary ;^^ the smallest (^) is about one-fifth of an inch in circumference; the largest (12), nearly seven-eighths. French ones are accurately graduated from one millimetre circumference up to forty. Flexible instruments should always be preferred to metal ones. If there is a very tight stricture, and it is impossible to introduce a soft one, a small metal one may be tried, but, owing to the fineness of their points, they are exceedingly dangerous. An exception to this rule may be made in the case of an enlarged pros- tate of many years' standing, in which, after perhaps years of self-catheterization, retention has occurred at last. A full-sized, silver, prostatic one, with a very long curve, will, as a rule, ride over the obstruction, and squeeze its way between the swollen and congested walls of the urethra more easily than any other. Great care must be taken with the smaller black ones, as the varnish soon becomes cracked at the eye, and then the bulb is very likely to break off and be left behind. Unless the state of the urethra is known, a moderate-sized instrument, 15 mm. to 17 mm., French, should be used to commence with. A larger one gives more pain, a smaller one may catch in a fold of the mucous membrane. The patient should be in a recumbent position, with the umbilicus exposed, and the thighs slightly flexed and abducted. The instrument is sterilized and lubricated, preferably with Lund's oil falmond oil c.c. 32, castor oil c.c. 32, and pure carbolic acid c.c. 4) ; or, if there is a stricture, 4 c.c. of oil may be injected first. The operator stands on the left, and, holding the penis with his left hand, draws it well over the point of the instrument, putting the mucous membrane on the stretch, so as to obliterate its folds. The point of the instrument should follow the floor of the urethra for the first inch, to avoid a diverticulum occasionally left during development, after that the roof for the rest of its course. In a normal urethra, either the catheter experiences no resistance at all, but merely sinks down of its own weight, or, after passing two or three inches, is quietly and slowly gripped, and held by the unstriped muscular fibre in the wall. There is no sudden stop (so that there is no resemblance to the resistance of stric- ture), and in a minute or two the instrument becomes free again ; the fibres have tired themselves out. As the bulb is reached, owing to the dilatation on the floor and the softness of the mucous membrane, the point of the catheter may catch against the lower edge of the oj^ening in the triangular ligament. Ver}' little force, then, at the end of a long lever, will drive it through the mucous membrane and make a false passage. The instrument must be withdrawn a little, and the handle gently lowered. If there is the least difficulty, the forefinger placed in the rectum will find the cause at once ; but the utmost gentleness is required, or the point may slip over the edge in the right direction, but with a ])ainful jerk. Withdrawing the stylet in a gum-elastic catheter has the same effect. Well-made black ones, with a sufficiently flexible neck, rarely cause this trouble. The last obstacle is the neck of the bladder ; very often the point catches on the floor again, even when the median lobe of the prostate is not enlarged, and the obstruction must be surmounted in the same way. The best time for passing a catheter is in the morning, an hour or two before the patient gets up, so that he may remain warm. If this is not practicable, care at least should be taken that there is no exposure to cold afterward, and that mic- turition is not performed until it is absolutely necessary. With many patients, [* Little used in America.] THE PASSAGE OF CATHETERS. 1093 especially those who have suffered from ague, or who have lived in the tropics, it is advisable to give quinine for several days previously, and, if the kidneys are sound, one small dose of oi)iuni ; but care should be taken that the bowels are not confined. A sixth of a grain of mori)hia, hypodermically, a few minutes before the operation, diminishes the irritability of the urethra, especially if the injection is made in the region of the perineum. In all cases, excei)t, of course, where there is urgency, a previous examination of the urine, both as to quantity and (piality, should be made. The passage of a catheter, esi)ecially for the first time, is a very painful pro- ceeding, and may be followed by serious consequences. '^\\t pain is always worst as the instrument is passing through the membranous part ; it is usually described as cutting or burning, and it may cause syncope. If it is very severe before this point is reached, there is probably some morbid condition of the mucous mem- brane. Fortunately, it can be prevented by injecting a few drops of a ten per cent, solution of cocaine down the urethra. Other consequences arise from the effect upon the nerve-centres. Thus shock may affect the wall of the bladder, causing retention (especially if atony is already present) ; it may paralyze the vasomotor nerves of the kidneys, leading, according to its severity, to hcematuria, or siippressio7i of urine (particularly in cases in which the kidneys are already diseased) ; or it may involve the central nervous system ; for syncope (probably from dilatation of the abdominal vessels) and sudden death have been known to follow. Others, again, of which urethral fever is the most important, are of more doubtful origin. There are two chief forms of this : in the one there is intense shivering, with headache, depression, and vomiting; the temperature rises rapidly to 104° or 105°, and then begins to fall almost as tjuickly as it rose, while the patient lies in a state of utter prostration, sweating profusely ; in the other, the temperature falls at first, then rises slowly until it reaches 102° or 103° F. , some- times with a rigor, but rarely a severe one, and, after a few hours, if the kidneys are sound, gradually sinks again. This may occur after the operation, or more frequently after the first subsequent act of micturition, especially if it takes place soon. Those who have suffered from ague, or have lived in malarial districts, are particularly liable to it ; exposure to cold is especially likely to bring it on, and there is no doubt that, though it does occur in those whose kidneys are perfectly healthy, it is more likely to happen, and much more likely to be followed by serious consequences, when they are diseased. In fatal cases intense renal congestion is usually found, but it is not improbable that this is a coincidence due to the effect upon the vasomotor nerves, and that rigors may occur independently of it. Opinions differ with regard to its etiology. Harrison considers it due to the absorption from the urine of toxic alkaloids, which undoubtedly are produced in considerable quantities in the alimentary canal, and are excreted by the kidneys ; but, on this theory, it is difficult to explain the non-occurrence of rigors after lith- otomy and other operations. More probably it is a pathological exaggeration of the normal shiver which is so frequent during and immediately after micturition, and which is so strongly marked in infants, female as well as male, in whom it may be conjectured the spinal cord is, relatively to the brain, more active than it is in adults. This would bring it into the class of neurotic fevers; audits more fre- quent occurrence, and its greater severity when a catheter is passed for the first time, and when a stricture is still young and irritable, would admit of easy expla- nation. [It is significant of the origin of urethral fever that it seldom, if ever, follows the careful introduction of jr/'en with them, the instruments should never be left longer than three days without being changed. Many patients cannot stand the continued irritation ; the catheter acts as a foreign body, inllannnation soon commences, and in a very short time the urea decomposes, and the end of the instrument ])ecomes coated over with a layer of phosphates. The simplest method is to pass two threads through the metal loops, one on either side, and fix them to the skin of the penis by a piece of strap|)ing woimd round it near its root. Or, as this plan has certain objections, and is not too secure, the threads (which must be double) may be knotted on either side about an inch and a half from the catheter ; then, taking the two threads of one side, the one is carried over, the other under the |)enis, and knotted together on the opposite side so as to enclose in a loop ; the ends are tied to the pubic hair. The other pair is then to be treated in the same way. A better plan still is to fasten a band- age arovmd the abdomen, and to attach a long tape to it on either side ; these are to loop round the thigh. The end of each is carried across the abdomen, round the outer side of the opposite limb, and then brought up by the side of the scrotum, so as to be fastened to the waist-belt again. The tapes from the catheter are tied, one on each side, to the band in the groin, just opjiosite the root of the penis, so that it can assume any position that is con- venient, without allowing the unstriped muscular fibre of the urethra to push the catheter out. Arnold's elastic holder is simpler and ecpially effective (Fig. 473). Fig. 473. — Arnolil's Elastic Holder DISEASES OF THE URETHRA. Inflammation. Acute inflammation of the mucous membrane of the urethra is not common except as a result of gonorrhoia ; mild forms of it, however, may be produced by other causes. Chronic inflammation may commence as such (as in the case of tubercular urethritis) ; or follow an acute attack which is prevented from subsiding by some constitutional or local cause, such as gout or stricture. Causes. — i. Mrchanicalinjiiry : the passage of sounds, for example, or the impaction of a calculus. 2. Chemical Irritants. — These maybe the product of a specific germ (gono- coccus) ; or they may be present in foul septic discharge ; or they may be excreted by the kidneys in the urine — e.^^., cantharides and uric acid. 3. Syphilis and tubercle. Acute Urethritis. The most intense form is gonorrhoea, an acute suppurative inflammation of the mucous membrane due to contagion, and probably to the presence of a specific germ. It always begins as a local disease, but sometimes the constitution becomes affected, and secondary troubles, peculiar to itself, make their appearance in distant parts of the body. GonorrJioea. — The germ (gonococcus) is [a diplococcus] found upon the surface of the epithelial cells in gonorrhcjeal pus, each individual coccus being 1096 DISEASES AND INJURIES OF SPECIAL STRUCTURES. placed at a distance equal to its own diameter from its fellows. It is stated to be always present, and to be found in the discharge of ophthalmia neonatorum, as well as in the fluid of gonorrhteal arthritis and conjunctivitis. Cultivations of it have been made in gelatine, and these are equally active. Vaginal discharges [containing other pyogenic organisms] can infect the urethra and even the con- junctiva, and cause inflammation. There is no doubt that the action of the germ is greatly favored by different conditions. Certain people seem to enjoy immunity, or, if they are attacked, the inflammation is of the most transitory character. The first attack is usually by far the worst and, so far at least as out-patient practice is concerned, it is rare to see it very severe in any one over five-and-twenty. Intense and prolonged sexual excitement, too frequent intercourse, and irritating conditions of the urine, such, for example, as that produced by the free use of alcohol, of themselves some- times cause a muco-purulent discharge, and certainly they render the mucous mem- brane more sensitive. Asparagus and new sherry are stated to have a peculiarly strong influence in this direction. Symptoms. — The period of incubation is short, from four days to a week. The first sign is a slight redness at the meatus with an increased secretion of mucus, a sense of soreness or itching, and a certain amount of smarting during micturition. In the course of the next two days these symptoms become more marked, and more and more of the urethra is involved, until the whole mucous membrane is in a state of the most intense inflammation. The meatus is swollen, IS e«6 ^ ^ *t Fig. 474. — Gonococcus. (Bumra.) a, from a pure culture, b, from a blennorrhceic conjunctival secretion ; an epithelial cell covered with cocci : a pus cell completely filled with cocci ; a free mass of cocci in close proximity to a pus cell (Seibert). Oc. 2. c, scheme of development cf gonococci. (From Senn.) red, and pouting, the prepuce oederaatous, the glands turgid and shining, the whole penis enlarged and soft, with the veins congested and prominent. Sometimes red lines, due to the inflamed lymphatics, can be seen in the skin, and the glands in the groin, especially those just below Poupart's ligament at the inner end, are swollen and tender. At the same time the discharge increases until it flows away continuously, and its character changes from glairy mucus to thick, cream-colored, yellow, and even, in severe cases, greenish pus. Increased frequency of micturition occurs very early ; at first it is probably reflex, but later it is due to extension of the inflammation toward the neck of the bladder ; and each act is attended by a scalding, burning i)ain, partly caused by the tension on the mucous membrane, partly by the irritation of the acid urine. Sometimes, as the swelling and congestion increase, the stream is obstructed, and if the prostate is attacked, retention is almost sure to occur. Malaise and fever are usually present during the acute stage, and at night, even when the penile part only is involved, rest may be disturbed by chordee. As the patient grows warm in his bed the penis is liable to become erect ; owing to the infiltration in the corpus spongiosum, it cannot expand evenly, and the inflamed and tender fibrous tissue is stretched until it causes the most intense suffering. If the inflammation extends to the deeper part of the urethra, where it is fixed and surrounded by fibrous tissue, the pain is even more severe, and there may be high fever ; the perineum throbs and burns ; there is a sense of weight in the pelvis, and a constant aching across the loins ; and the skin over the scrotum and testes is sometimes so tender that the patient can scarcely endure being touched. The acute stage lasts a week or ten days. As it begins to subside, the scald- ACUTE URETHRITIS. 1097 ing becomes less intense ; the throbbing ceases ; the frequency of micturition dis- appears, and the discharge diminishes in quantity, loses its greenish color, and becomes less thick. If no complication is present it may cease altogether in about six weeks ; more frequently it i)ersists for some time, not more than a few drops of glairy mucus in the twenty-four hours, or perhaps merely sufficient to glue the sides of the meatus together in the morning ; but with every indiscretion, irregularity of diet, sexual excitement, undue exercise, or alcoholic indulgence, returning and becoming muco-purulent for a few days. Sometimes it becomes chronic. The mucous membrane becomes rough and granular, covered with hypertrophied papilla ; or the loose and vascular tissue that surrounds it becomes dense and hard, as the lymph that fills its meshes is organ- ized ; in either ca.se the change, slight as it is, is sufficient to maintain a certain degree of irritation ; there is a constant discharge of thin mucus from the meatus (gleet), and more and more lymph is poured out until the diameter of the urethra is narrowed, and a stricture is formed which, itself an irritant, keeps up the inflam- mation, and continues to get firmer and firmer the longer it lasts. Complications. — {a) Hemorrhage is not uncommon, owing to the over- loaded condition of the thin-walled vessels in the mucous membrane, but, unless very profuse, it need not excite alarm ; the green color of the pus is* due to haemo- globin. Chordce and retention have been already mentioned. (J)) The most common are caused by extension of the inflammation to struc- tures near. Balanitis, posthitis, phimosis, z.nA paraphimosis are of frequent occur- rence ; 7iiarts rarely occur until the irritation has lasted some length of time. Abscesses are not so often met with, but they occasionally originate in the mucous follicles, especially those of the fossa navicularis ; or they may occur independ- ently of the mucous membrane, in the lymph that is poured out around it. If the suppuration is in the region of the bulb, or on one side of it, in connection with Cowper's gland, it often spreads a considerable distance before coming to the surface. Prostatitis, with complete retention, and cystitis often follow ; occasion- ally even the pelvis of the kidney and the peritoneum are involved. Epididy- mitis, from extension down the vas deferens, is not so common in the acute stage as later, when gleet sets in. Bubo and inflammation of the lymphatics may occur at any time, especially if the patient will not rest quiet ; and even pyaemia may break out and prove fatal, starting, in all probability, from some ulceration of the mucous membrane. (r) Others are caused by direct infection. Of these, conjunctivitis h the best known and the most serious {gonon-hceal ophthalmia and ophthalmia ?ieonatorum~); and the mucous membrane of the nose and of the rectum may be also infected. [Rectal gonorrhoea is very common in women, from overflowing gonorrheal dis- charge from the vagina.] (d) Another variety is the result of constitutional infection, and does not occur, so it is said, in simple urethritis, however severe it may be. The fibrous tis- sues (particularly the joints) are the parts most liable to be attacked, but sometimes the sclerotic, the plantar fascia, the tunica albuginea of the testis, and the sheets of fibrous tissue in the loins suffer as well. Its connection with gonorrhoea is shown by the fact that not only does it return with each fresh attack, but that, if from any indiscretion there is a relapse or an increase in the amount of discharge, there is frequently at the same time a fresh outbreak of the secondary inflammation. When it is acute and attacks several joints, it maybe distinguished from rheumatic fever by the absence of the sweating and the thick, white furred tongue, and by the rarity with which cardiac complications occur ; but the relation that it bears to gout, particularly to the chronic rheumatic form, is much more uncertain. There is no doubt that it is more likely to break out in those who are subject to this com- plaint ; or in whose families there is a well-marked history of it ; and I have seen several cases which strongly bear out Hutchinson's contention that, in patients who are distinctly gouty or rheumatic, any urethral discharge, specific or not, may give rise to symptoms similar to those of gonorrhoeal rheumatism. Suppuration rarely 70 1098 DISEASES AND INJURIES OF SPECIAL STRUCTURES. occurs ; but, if it does, it is impossible to draw a definite line between gonorrh(jeal arthritis and jiyasmia. A similar affection occurs not unfrequently in women who are suffering from chronic leucorrhtjea ; and ophthalmia neonatorum, according to Lucas, may give rise to something of the same character. For a further descrijj- tion see Diseases of Joints. [Bacteriologists are now generally agreed that arth- ritis complicating gonorrhoea is caused by metastatic infection.] Acute //;r///r///>, of a similar description, but much less intense, mav be caused by infection from leucorrhceal or menstrual discharges. When due to mechanical irritation, such as the passage of a catheter or the impaction of a calculus, it rarely lasts more than a day or two. If there is a stricture the discharge may be profuse at first, but it is rarely purulent ; and if the cause is removed, the symptoms soon subside. Occasionally, however, the inflammation extends, and epididymitis and other complications occur, as in gonorrhoea. Gouty urethritis, like inflammation of the bladder, is not uncommon when the urine is loaded with uric acid. Usually it is an extension of the inflammation from the neck of the bladder, and the discharge is preceded for some days by irritability, increased fre(iuency of micturition, and sharp, cutting pain at the end of the penis. It is most common in stoutly-built, middle-aged men, addicted to alcohol, but it is met with in women also; and a somewhat similar form, dependent upon mal- assimilation, and attended with a deposit of uric acid crystals, is not uncommon among poorly-fed children, and often gives rise to the suspicion of calculus. Un- less it is the residue of a gonorrhcea kept up by the condition of the urine, it rarely happens that there is much discharge, or that it is purulent. l>erkeley Hill has described a very obstinate form analogous to this, eczematous urethritis, occurring under much the same conditions, but associated with eczema of the skin. The surface of the glans is reddened and tender, and the anterior part of the urethra appears to be affected in the same way ; the mucous membrane is bright red in color, though it does not bleed easily, and the discharge is scanty and milk-white. Epididymitis, prostatitis, and other complications may occur in gouty urethritis as well as in the rest; but, in addition, inflammation may attack the joints, the eye, the testis, the fibrous tissue of the back, the sheaths of nerves, and the plantar fascia, just as in gonorrhcea ; and unless the history, the condition of the patient, and the state of the urine are carefully investigated, it is very difficult to distinguish one from the other. Tubercular uretliritis is generally secondary to inflammation of the bladder, and the urethral symptoms are completely overshadowed by the intense irritability and the fearful burning pain at the neck when it contracts. The discharge is gen- erally scanty in amount, and unless the anterior part of the urethra is involved, is only seen when the urine washes it down, but it is often stained with blood coming from the surface of the ulcers when the muscles are contracting. The sense of smarting during micturition is sometimes very severe ; and, owing to muscular spasm, is apt to continue for a long time after the act is finished ; and the passage of a sound or catheter gives the most intense pain when the ulcers are reached. Cicatrization sometimes occurs, and gives rise to stricture ; but, as a rule, the bladder and other organs are involved, and the patient rarely lives long. Syphilitic Urethritis. — A scanty discharge, with a certain amount of soreness along the urethra, is not infrequent in early secondary syphilis, caused, in all prob- ability, by the eruption of a few roseolous spots upon the mucous lining. As a rule it disappears very rapidly under specific treatment. Treatment. — As gonorrhfjea commences by infection at the meatus, it has often been proposed to cut short the attack as soon as the redness first makes its appearance by the use of a strong astringent, limited to the anterior i)art of the urethra. Tannin or nitrate of silver (gramme .30 ad c.c. 32) is generally re- commended ; and so long as the penis is carefiilly compressed immediately behind they may be used without danger, but it is doubtful whether they are of much ser- vice. I. The Acute Stage. — Local applications are better avoided so long as the SVrmi.lTIC URETHRIJIS. ,099 intense hyperaMiiiu with iirol'use punilciit discharge and the severe i)ain continue. The patient should, if possible, be kept in bed ; the absolute rest obtained in this way is better than anything else. The bowels should be kept freely open, the diet carefully regulated, all forms of highly sea.soned food and sauces, pepper, vinegar, tea, coffee, rhubarb, and asparagus being forbidden, and as much fluid (barley water, milk, etc.) allowed as the patient wishes ; but no alcohol. Claret and very weak gin and water are perhaps the least injurious ; champagne, sherry, and beer will often bring back a temjjorary gleet months after its last ajjpearance. If the urine is acid and irritating, alkalies maybe given with sedatives, such as hyoscyamus ; but if the l)icarbonates are used they should always be taken during digestion, not while the stomach is empty. The dressing of the i)enis itself should be light and frequently changed ; anything that prevents evaporation, or that absorbs the pus and dries upon the meatus so that the discharge cannot escape, is injurious. A soft linen bag in which it can hang freely, with some wood-wool at the bottom to soak up the discharge, is as convenient as anything. Dressings retained under the prepuce are liable to be very irritating ; if the glans cannot be exposed it is better to introduce a soft rubber tube by the side of it as far as it will go, and irrigate its surface thoroughly several times a day with lead lotion. The antiseptic treatment by means of bougies, though it promises well, is not so successful in practice. If the hyperaimia is so great as to threaten retention of urine it may some- times be checked by free leeching in the perineum, or by the application of Leiter's coil, with ice-cold water. If it come on in spite of this, a soft rubber catheter of moderate size must be passed, and, if necessary, this must be repeated three times a day. A morphia and belladonna suppository the last thing at night, or a hypodermic injection in the perineum, will usually stop chordee. Bromide of potash in full doses is also very useful, and camphor is said to be of value. The' l)atient should be directed to take a warm (not hot) sponge bath, at night, to avoid late meals, to cause the bowels to act freely before retiring to rest, and to have only the lightest clothing on while in bed. Abscesses around or in connection with the urethra should be opened freely and as soon as possible, or they may de- generate into troublesome sinuses. They are most common near the meatus, start- ing from the follicles in the fossa navicularis, or else forming by the side of the frsenum ; sometimes, however, they occur further back in connection with Cowper's glands. They may burst into the urethra, but unless there is a stricture present it seldom happens that the fistulous opening persists. 2. The Subacute Stage. — When the active hypertemia and scalding have sub- sided, or if the inflammation is only subacute from the first, more active measures may be adopted. Copaiba and cubebs may now be given with advantage ; or if they do not agree with the patient, gurjun, sandal-wood, or eucalyptus oil. These all appear to act locally, the resin being excreted by the walls of the urinary pas- sages. Copaiba, when it can be tolerated, is perhaps the most efficacious ; 2 c.c. doses may be given, rubbed up with burnt magnesia in the form of a bolus, or with sulphuric acid, or better still, if the patient will take it, with liquor potassoe, with which it forms a kind of soap. Harrison has shown that it is much more effectual when given with an alkali than in the form of capsules. Cubebs are more stimulating, and may be taken with it. The best time for administration is either an hour before meals or three hours after. In some patients, however, copaiba produces a characteristic roseolous and even papular eruption upon the skin (copaiba rash) ; in others it disturbs digestion to such an extent that it can- not be endured ; and it even has the credit of causing hematuria. Few can stand it for any length of time, and if it does not produce a definite improvement in the course of a fortnight, it is better to stop it altogether. Such patients are often more benefited by tonics. In the majority of instances, gonorrhcea will cease without the use of injec- tions ; but in the subacute stage, when the discharge shows no signs of abating, and still more when a chronic gleet has set in, they may be used with advantage. iioo DISEASES AND INJURIES OF SPECIAL STRUCTURES. So long as there is extreme hyperaemia they are positively harmful. The ordinary glass syringe is useless, unless the mischief is confined to the fossa navicularis ; the object is to wash out the discharge from off the mucous membrane, so that it may not remain stagnant in its folds or recesses, and to ai)ply a very mild astrin- gent to the surface. Durham's tube, which can be introduced as far as the bulb, and which is provided with openings so that there shall be a recurrent stream, is the best, but in its absence a small flexible rubber catheter may be employed. This should be introduced as far as necessary, and then connected with a Hig- ginson's syringe. Hot water may be used first to wash out the urethra and then a very mild astringent. There is no fear of any injection penetrating as far as the bladder, if ordinary precautions are taken, and it should never be sufficiently strong to do any harm if it does. Chloride of zinc (.03 ad 32 c.c), sulj)hate of zinc (.06 ad 32 c.c), acetate of lead (.12 ad 32 c.c), tannin, mercuric chloride, subnitrate of bismuth (not suspended in mucilage), and many others are of use; and very often it is of advantage to change from one to the other. The bulb and the fossa navicularis may be thoroughly douched in this way every night, or, if no progress is made, night and morning; the application cau.ses a certain amount of smarting, but if it is really painful, either the injection is too strong or the inflam- mation still too acute. In tubercular urethritis everything must be done to maintain the strength of the patient and assuage, as far as possible, by morphia and belladonna, the irrita- bility of the bladder. If the urine becomes ammoniacal, relief may be obtained by opening the bladder in the perineum and draining it. Iodoform seems to be the best local application, as in tubercular cystitis. Local applications are rarely of service when urethritis is due to gout ; the urine must be rendered as unirri- tating as possible, the bowels kept open with mercurial purges, and careful atten- tion paid to diet and exercise. When the urethritis is simply caused by the irritation of the urine it can easily be cured ; but if there is gouty inflammation of the corpus spongiosum or of the prostate, the condition is exceedingly obstinate, and epididymitis and other se(iuelse are not unlikely. Chronic Urethritis. Chronic urethritis rarely occurs unless there has been an acute attack ; the inflammation subsides up to a certain point, and then from some cause, local or constitutional, becomes stationary, the discharge persisting as a gleet, sometimes disappearing for a few days, and then returning again almost as bad as ever. Even in healthy persons, the mucous membrane of the urethra is always peculiarly sensitive after an acute attack ; the least indiscretion for months after brings back a certain amount of gleet ; and a very slight cause is sufficient to keep the irritation up permanently. Chronic inflammation of this descrii)tion is the main cause of stricture; for months, and even years, minute quantities of lymph are constantly Vjeing poured out into the mucous and submucous tissues ; as it becomes organized, it gradually renders them so dense and hard that at length a definite organic obstruction is developed. The reason is often difficult to find. Sometimes it appears to be due to general debility rather than anything else ; the patient's health gives way ; the mucous membrane remains soft and relaxed, without any great local change, and the catarrh becomes chronic, as it occasionally does in other parts of the body. In other cases it may be traced to errors in diet or to faulty modes of living. More frequently it is dependent upon some local affection, very slight, perhaps, but quite sufficient to keep up irritation. Small warts, similar to those on the prepuce and behind the glans, gan be seen sometimes just inside the meatus. Pouches and dilatations of the mucous membrane, possibly originating from in- flamed follicles, are found occasionally, especially in the fossa navicularis and in the region of the bulb. These serve to collect a small quantity of urine, which begins to decompose and act as an irritant before it is washed away. Chronic CHRONIC URETHRITIS. iioi inflammation of Cowper's glands sometimes occurs in the same way. A granular condition of the surface is still more common, es[jecially in the region of the bulb. It closely resembles in appearance that which is left after rejjeated attacks of con- junctivitis ; the mucous membrane is rough and tender when touched ; the color is bright red ; and it is covered with small pai)ilh\i. Slight strictures, again, are occasionally the cause ; the exudation of lymj)!! is not sufficient to affect the stream, but for all that it renders the mucous membrane hard and unyielding, so that it cannot unfold itself as the urine is i)assing. Finally, in some cases the whole of the urethra in front of the triangular ligament continues to secrete a profuse muco- purulent fluid, without its being possible to find any local or constitutional cause to account for it. Harrison has described several such in which the passage ap- pears to have degenerated into a chronic suppurating sinus, which could not be drained, and which, in spite of injections, and in one case of internal urethrotomy. Fig. 475 — Leiter's Panelectroscope. Z, Lamp ; .S/. Mirror; ^', Lens for correcting any defect in the observer's vision. declined to improve in any way. At last they were cured by giving the urethra perfect rest for a month, opening it behind in the perineum, and draining off all the urine from the bladder, so that no drop should flow along it. An absolute diagnosis in such cases can only be made by means of an endo- scope. Leiter's panelectroscope is perhaps the most convenient ; it carries a small incandescent lamp in the vertical portion, so arranged that its rays are concen- trated by a mirror and reflected down the tube, while the observer's eye looks over the upper edge. It is an additional advantage that, with this instrument, appli- cations may be made to any part of the urethra that requires them, without with- drawing the tube. Constitutional treatment should be thoroughly tried. If the patient is broken down in health and strength, tonics and sea-air often prove efficacious; or, if there is evidence of gout, alkalies may be given, or the patient may be sent for a II02 DISEASES AND INJURIES OF SPECIAL STRUCTURES. time to a suitable watering place, so that the mode of life may undergo a complete change. The diet should, in all cases, be carefully regulated, especially as regards the amount of alcohol ; and, according to some, smoking is particularly injurious. At the same time, the deeper part of the urethra should be thoroughly washed out with some mild astringent, as in chronic gonorrhoia, only this should be done, not once a day, but after each act of micturition. It is no use injecting the meatus unless it is known there is a tender spot in the fossa navicularis ; the only method is to pass a soft rubber tube down as far as the bulb, and with Higginson's syringe gently douche the whole length from behind, varying the nature of the application every week or ten days. If this does not succeed, a full-sized bulbous instrument should be slowly and carefully passed, and then, after the spasm has subsided, withdrawn again. Sometimes this of itself is sufficient: the muscular fibre of the urethra is stretched ; the spasm ceases for a time ; the mucous mem- brane gets a certain amount of rest, and the irritation has a chance of subsiding. The same treatment is often successful in obstinate cases of neuralgia, which per- sist without anything being found to account for them. Most frequently, however, the persistence of the symptoms is due to some local change in the mucous membrane which requires special treatment. The method, of course, must vary with the lesion ; small warts in the meatus may be snipped off or touched with mild caustics ; if the mucous membrane is rough and granular, a moderately strong astringent may be applied to the surface by means of a syringe, as in chronic prostatitis. Glycerine and tannic acid I have found very useful to commence with ; if this fails, nitrate of silver (.30 ad 32 c.c.) may be tried. Sinuses should be distended with a similar injection, after each act of micturition, or, if near the meatus, they may sometimes be laid open. There is a congenital diver- ticulum occasionally present in the fossa navicularis, which rarely gets well until it is treated in this way. Its existence may be sus])ected when there is a feeling of pain in the glans at the commencement of micturition, or when squeezing the glans suddenly sometimes causes a iew drops of discharge to make their appear- ance ; but, as its opening lies toward the bladder, it can only be detected with the endoscope, or with a probe, the point of which is bent back upon itself. Finally, if there is any resistance to the passage of a sound, especially as it is being with- drawn, suggesting the presence of a commencing stricture, a full-sized instrument should be passed once a week, until it is no longer grasped. Stricture. Stricture of the urethra may be congenital or acquired. The former is very rare and only occurs at the meatus, or within a short distance of it ; the latter is met with in every part except the prostatic, and is always the result of inflammation. Stricture, in the true sense of the term, must be a structural alteration in the wall of the urethra; there may be only a certain degree of roughness and uneven- ness, so that the mucous membrane does not unfold itself smoothly when urine is passing ; or thickening and exudation in the submucous tissue, leaving the surface smooth ; but in every case there is a definite and persisting change. S])asm and congestion are always present in addition, owing to the vascularity of the part and to the amount of unstriped muscular fibre, es])ecially in the region of the bulb ; and in certain conditions (such as congestion of the prostate) these of themselves are sufificient to cause obstruction and retention ; but they are in reality symptoms, not diseases, and it is better to reserve the term stricture for an organic change. Causes. — Gonorrha'a is by far the most common. A slight attack merely leaves the surface tender with enlarged hypertrophied papillae ; when it is more severe and long continued, a large amount of exudation is poured out into the submucous tissue ; and gradually, as it becomes organized, it constricts the canal more and more. Ulceration of the surface and cicatrization are rare. Injury. — Rupture of the urethra may cause stricture of a very obstinate char- acter if suppuration occurs, owing to the dense mass of cicatricial tissue formed. STRICTURE OF THE URETHRA. 1103 Impaction of a calculus, median lithotomy, when the urethra is torn, and caustics, are occasional causes. Syphilis. — Primary sores not unfrequently cause stricture at the orifice ; and occasionally, in the later stages, ulceration of the mucous membrane or gumma- tous exudation into the corpus spongiosum, leads to the same result. A few in- stances are on record in which stricture has followed tubercular ulceration. Many different terms are used to describe strictures, according to the prom- inence of sjjecial features. If there is a band of lymph stretching across the canal from side to side, it is called a bridle ; when there is a thickening round the whole circumference, as if a piece of string were tied around it, it is annular ,- and if the base is much infiltrated, indurated. Sometimes, especially in old cases where there are fistulre, this is so hard and extensive that the stricture is said to be car- tilaginous. Those are irritable where rigors occur whenever a catheter is passed ; and resilient or elastic if the constriction returns at once after dilatation. Very often they are tortuous ; and sometimes, l)ut probably only when the wall of the urethra has sloughed, they are impermeable. So far as concerns the question of treatment, the most important distinctions are the locality (whether near the meatus or deep down in the bulbous part;, the length of time the stricture has been there, and the amount of induration. If re- cent, the infdtration is slight, and the lymph to a great extent is still soft and cellular ; in older cases, those, for instance, of some years' duration, an inch or more of the wall of the urethi:a may be converted into a dense cicatricial ma.ss, ex- tending into the corpus spongiosum, and feeling from the outside as hard and resistant as cartilage. Locality. — Stricture never occurs in the prostatic portion of the urethra. The most common situation is said to be at the bulb, though in a very large number of instances it is really in front of this, ^'arious reasons have been offered in ex- planation. Some consider it due to this portion of the urethra being horizontal when the body is erect ; the discharge does not flow away, and, acting as an irritant to the mucous membrane, causes a greater amount of lymph to be poured out here than elsewhere. Others have assigned it to the angle that the penis forms in front of this spot, so that the walls are pressed closely together. Probably the real reason is the unusual amount and the looseness of the mucous and submucous tissues allowing a larger quantity of lymph to collect. The urethra is only patent for the moment that the urine is passing along it ; except at this instant, its walls are in contact and thrown into longitudinal or spiral folds. If it becomes in- flamed, these are thickened, swollen, and pressed together ; and if the lymph that is poured out is allowed to become organized, the canal is permanently narrowed. When traumatic, the seat of the stricture depends naturally upon the injury. Usually the urethra is torn a little in front of the membranous part or just where this joins the bulb. Those due to venereal sores are nearly always at or close to the meatus. In most instances stricture is single, but it is not uncommon to find two or even more,(^and in a few cases as many as six distinct ones have been described as existing at the .same time.?) Pathology. — Post-mortem a stricture appears as a contraction of part of the urethra. Sometimes, especially when near the meatus, there is a band stretching across from one wall to the other, or a distinct cicatrix on the sides ; more fre- quently there is an opaque white constriction, extending around the whole cir- cumference, dense and indurated, and varying in thickness in different parts, so that the canal is narrowed, tortuous, and irregular. In many cases the mucous membrane is affected ecpially with the submucous tissue, its elasticity is entirely gone, and it is fixed firmly ; but sometimes it can be dissected off, and opened out to its full extent, almost unaltered. On the other hand, in old cases, especially in the region of the bulb, the mucous and submucous coats, the corpus spongiosum, and even the areolar tissue outside, are converted into a gristly cartilaginous mass, in which scarcely a trace of any of the original structures can be found. II04 DISEASES AND INJURIES OF SPECIAL STRUCTURES. In front of the stricture the mucous membrane is swollen, reddened, and hypereemic, ready to bleed at the least touch, and the unstriped muscular fibre is in a state of tonic contraction, but this, of course, disappears /(^j-Z-wc/Vf^w. The surface, however, is rough and irregular, with small granulations ; usually it is dis- colored from old hemorrhages, or it is excoriated or covered over with mucus, and the normal folds of the urethra are confused and sometimes altogether lost. Behind, the effect upon the other organs is soon apjxirent. Owing to the increase in the pressure the urethra becomes dilated, the orifices of the small ducts enlarge, some of the bands of muscular fibre increase in size, leaving between them depressions in the thinned and stretched mucous membrane, similar to those found in the bladder, only ori a much smaller scale, and at length the interior may become reticulated or studded with little pouches, which act as receptacles for decomposing urine. Then the bladder becomes affected. If the obstruction is sudden and extreme from the first, too great for the muscular coat to overcome, it yields and becomes atrophied, the cavity enlarges, and the walls become thin and soft. If, on the other hand, the resistance is of slow formation, so that the work increases gradually, and if there is any irritation, so that the bladder is constantly contracting, the opposite effect is produced — at first, at any rate; the walls grow thick and rigid, the cavity diminishes in size, the muscular coat hypertrophies, and the fasciculi stand out under the mucous mem- brane in ridges, like the musculi pectinati of an auricle, leaving between them deep depressions. As time passes, these changes become more and more marked ; each time the bladder contracts the urine is driven into the depression between the ridges, until they become deep enough to jiroject on the outside under the serous covering, md then they soon enlarge mto ttinii a ry her nice r sacculi. There is no muscular filire in their \\ all ; they cannot resist or empty themselves ; with each contraction the urine is driven into them, distending them in all directions, and not unfrequently they become almost as large as the bladder itself, with which they communicate by a very narrow opening (Fig. 433). The same influence is felt by the ureters and the pelvis of the kidneys ; there is no regurgitation, but. owing to the great increase in the pressure, they be- come more and more distended, at the expense of the glandular part, until, in the case of the kidneys, the secreting power is seriously im- paired. The effect, however, is rarely limited to mechanical dilatation. I have known ca.ses in which, though the bladder was distended to the umbilicus, and though it had been in that con- dition for months, and even years, the urine on being drawn off was normal and acid, but this is the exception. Inflammation nearly always breaks out sooner or later, probably extending upward from the stricture. Ulceration may cies; Ulceration above the Stricture, and f^gn Set in behind, in the dilated i)art of the orifice of false passage below. , , , , . ^- c • urethra, and lead to extravasation of urine ; an abscess may form in the substance of the stricture tissue and burst in the perineum, leaving behind it a fistulous opening; suppuration may occur around the prostate, or the inflammation may sj^read down the vas deferens to the testes. The bladder is usually the first involved, but the ureters and kidneys follow Fig. 476. — Stricture of Urethra showing Fas- ciculated and Contracted Bladder ; Dilated Prostatic Urethra with Reticulations conse- quent upon Distention of the Prostatic Folli- STRICTURE OF THE URETHRA. 1105 suit very soon. At first there is merely catarrhal cystitis and pyelitis, but when the urine becomes more irritating, and especially when it decomposes, the effect is much more marked. 'J'he mucous membrane becomes ulcerated and coated with phosphatic debris, the pus spreads along the connective tissue in the sul)stance of the kidney, numbers of minute abscesses form under the capsule and in the cortex, the apices of the pyramids are destroyed, and at length the kidney is almost dis- organized ; it is reduced in size, hard, and irregular on the smface, from old inter- stitial intlammation ; the cai)sule is adherent; wlien it is stripped off there are numbers of little abscesses beneath ; and the pelvis is enlarged, irregular in shape, blackened and ulcerated on the surface, and filled with a mixture of stinking j)us and phosphatic debris. Symptoms. — {a) Those Due to the Obstruction. — Complete retention is sometimes almost the first. In recent strictures the urethra is often peculiarly sensitive ; spasm and congestion may be caused by the slightest irritants and close the channels altogether, even though the opening is still fairly wide. More fre- quently the outflow is merely impeded. Simple twisting or flattening of the stream may be due to the shape of the meatus, and means nothing, but if it is forked or much reduced in size or force it is very suggestive. In old cases, when the obstruction becomes very great, the stream may fail completely, the urine only coming in drops. Generally, after micturition is finished, the last few drops flow away of themselves, owing to the action of the urethral muscles being interfered with but this happens also in enlargement of the prostate, and even after exposure to cold. {b) Those Due to Inflammation. — Usually there is a slight muco-purulent dis- charge (gleet), especially in the morning, or after exercise. In general it is only a drop or two, and many i)atients are unaware of its existence, but it may cause great annoyance. Pain is seldom felt, unless there is some inflammatory compli- cation or the urethra is forcibly distended. In cases of long standing there is usually thickening about the corpus spongiosum or the bulb. Spasm is rarely want- ing, and often leads, especially in recent strictures, to complete retention. As they grow old and cartilaginous, either the muscle loses its power or the surface its sensibility, but in this there is a strong personal element, and the urethra is much more sensitive, especially when inflamed, in some than in others. Any slight irri- tant, an excess of uric acid for example, alcohol, sexual indulgence, exposure to cold or wet, constipation, or even an inflamed pile, may set up sufficient spasm to render the closure complete. This is of great consequence in relieving retention due to stricture. If a catheter cannot be passed at once, teasing the stricture only makes the spasm and congestion worse, while relief (for a time, until more efficient measures can be adopted) can almost always be obtained by hot baths and other measures that pro- cure muscular relaxation. The course of stricture, if left to itself, is simi^ly from bad to worse. Tem- perament and the position of the stricture are of some influence ; deep ones, that is to say, are worse than those near the meatus, but the chief element in prognosis is the condition of the kidneys. As the bladder becomes involved, micturition becomes more frequent and the straining greater ; the patient has to rise at night ; retention is always liable to occur ; at first it may be relieved with an instrument or baths and purgatives, but each time it leaves a permanent change for the worse ; pain becomes a more prominent feature; there is a constant, dull, aching pain in the loins, and rupture, hemorrhoids, and other troubles follow. Then the kid- neys become affected, the specific gravity of the urine diminishes, the amount of solids is lessened, the patient grows weak and anaemic, digestion fails, chills and feverish attacks are of common occurrence, the skin becomes harsh and dry, and the health breaks down completely. Urinary abscess is of common occurrence, extravasation may take place, calculi may form, inflammatory troubles of all kinds may follow, or, if none of these things happen, the cpiantity as well as the quality of the urine diminishes, the albuminuria becomes more pronounced, and death is iio6 DISEASES AND INJURIES OF SPECIAL STRUCTURES. caused either by urethral fever and suppression, or more frequently by some inter- current disorder, such as pneumonia or pleurisy. Diagnosis. — The diagnosis of stricture can only be made by sight or touch. With the exception of those at the meatus, either an endoscope or a sound must be emjjloyed. Each has its separate uses ; one cannot replace the other. As most patients do not apply for relief until the narrowing of the canal is advanced, the sound is of greater service ; but in earlier cases, where there is little organic change, and where the symptoms are mainly due to spasm and congestion, the endoscope tells much more. With the one it is only possible to say that there is a tender spot in the wall of the urethra, giving rise to spasm, congestion, and pain ; with the other, the size, locality, and nature of the lesion can be accurately determined, in most cases with the greatest ease. For diagnosis, metal sounds are preferable to flexible ones : the information they give is more precise. For treatment this does not hold good ; a soft, flexible instrument can often find its way along the folds of the mucous membrane into the orifice of a stricture, while a rigid one becomes entangled at once. The best are of steel, as this takes a higher polish, and the curve should be sharp and abrupt. The smaller sizes may be of the same diameter throughout, but in the case of the larger ones the shaft is slender, so that it may move freely in the urethra, and the end expanded like a bulb. This may be either conical or ovoid ; the former are used for ascertaining the length of a stricture, in conical shape passing readily through the narrowed part ; on being withdrawn the shoulder catches at once. Unfortunately, English sizes are so arbitrary that it is scarcely possible to be accurate with them : the smallest is usually about one-fifth of an inch in circum- FlG. 477. — OtU's Urethrameter. ference, the largest (No. 12) nearly an inch. The French, on the other hand, are graduated accurately from one millimetre in circumference up to forty. The Size of the Urethra. — There is a distinction between the normal diameter of the urethra during life, and the size to which it can be stretched without injury. Even when urine is passing in full stream the walls are contracted and maintain a certain degree of tonic pressure upon it so as to ensure its ejection ; and they can be stretched, so far at least as the penile part is concerned, far beyond this. If a stricture is to be considered cured, it must be dilated until its width is as great as that of the adjacent part of the urethra when distended to iis utmost. Clearly, if it contracts again, it will close much sooner if it has been dilated to No. 21 F. than if it had been dilated to No. 28 F. But this is not all : if it is in a part which can be distended more widely (even though its diameter is equal to that of the rest when urine is passing), it remains an obstruction still ; the walls are hard and rigid instead of being soft and flexible, and they must be stretched until the induration is gone and the lining membrane falls into its natural folds again. How wide this may be differs in each part, and probably in each person ; and the only way to ascertain it is, either by carefully exploring with bullet sounds of different sizes (enlarging the meatus if necessary to admit them), or by measuring it directly with a urethrameter. The most convenient form of this instrument is that invented by Otis ; it consists of a straight shaft, carrying at its end a small expanding bulb. The size of this can be increased or diminished by means of a screw near the handle. The measurement is recorded on a gauge. The relation described by Otis between the size of the penis and that of the urethra only holds good in a limited number of cases ; and a stricture dilated to No. 21 may be cured in one ix;rson, while in another No. 32 is not too large. STRICTURE OF THE URETHRA. 1107 The meatus varies from a mere pinhole to the size of No. 30 mm. F. ; very often it is the narrowest part, and it never dilates readily. The fossa navicularis, on the other hand, is fairly wide, and can be enlarged without difficulty. After this the canal is narrow again, the diameter slowly increasing as the bulb is approached ; but the mucous membrane is so abundant and the tissues around so soft, that in most cases No. 30 F. and even No. 34 F. will pass with very little pressure and without any hemorrhage. At the membranous part again there is a very sudden constriction ; but here the structures around the canal are so rigid and unyielding that it can rarely be dilated beyond No. 12, or at the utmost No. 13 E. ; and very often instruments of this size only pass with considerable pain. After this in the prostatic portion the distensibility increases to such an extent that the forefinger (if an opening is made in the perineum) can be passed through it without difficulty, and without lacerating the mucous membrane. There are certain consequences which not uncommonly follow the introduc- tion of a bougie or catheter ; and. so far at least as most of them are con- cerned, the liability to their occurrence is distinctly greater when a stricture is present, especially if it is recent and the mucous membrane is soft, hyperaemic, and over-sensitive. In old cases, or where a catheter ha.s been repeatedly passed, it may be conjectured that the nerve-endings have to a great extent lost their sensibility. Most of these have been already mentioned ; some are due to mechanical violence (hemorrhages and false passages, for example) ; others to inflammation, affecting the urethra, bladder,' or prostate ; and others again to the influence upon the nerve-centres. Of these the most important are atony of the bladder muscle, leading to retention ; paralysis of the vasomotor nerves of the kidney, causing E. A. YAENALL Co., Phila. Fig. 478. — Bulbous Sound for Diagnosis. hsematuria, or suppression, syncope, shock, rigors and urethral fever in its various forms. The same precautions should be used in exploring the urethra with a sound as in passing a catheter. The patient should be prepared in the same way and the same method adopted ; but as the object is not to get into the bladder with the least friction, but to ascertain what sources of friction there are in the urethra, anaesthetics and cocaine are not advisable. Method of Exploration. — As a rule it is best to commence with a sound of moderate size. No. 15 or 17 F. ; if this passes smoothly and easily along the mucous membrane, stretching out the folds without meeting with any resistance, a larger one. No. 20 or 21 F., may be tried ; and if this is equally successful, it may be concluded that there is no serious degree of contraction. More frequently the instrument is grasped and held as soon as the point passes the fossa navicularis. The unstriped muscular fibre slowly contracts upon it, holds it fast for a minute or two, and then gradually tires itself out and releases it again. For this reason bulbous sounds with a comparatively slender shaft are more useful for exploring than those of which the diameter is the same throughout ; with the former the enlargement only is held, and the degree of resistance in different parts of the canal can be appreciated ; with the latter the shaft is grasped with as much tenacity as the end, and the delicacy of touch is to a great extent lost. This occurs even when the urethrals perfectly healthy, especiallv if a catheter is being passed for the first time, or if the patient suff"ers from gout or from highly acid urine ; the instrument is firmly grasped the whole way down. Very often a second sound several sizes longer can be passed more easily than the first. If however, before the membranous part is reached, there is one spot more sen.sitive than the rest, or if, after passing easily for an inch or two, the sound is suddenly iio8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. arrested and held for a time, and perhaps is stopped again a little further on (espe- cially at the bulb, for the muscular coat is thickest there), there is probably some local affection, not sufficient of itself to cause distinct narrowing of the canal, but quite enough to render it tender and sensitive when touched, and to make the muscular fibre of the deeper part of the urethra involuntarily contract upon the offending body and bar its further progress. In the bulbous part this is not unusual; and if the front portion of the urethra is not examined with sufficient care the mistake maybe made of imagining that there is an organic stricture deep down, while the real cause is some superficial lesion, a mass of granulations, per- haps, or a little inflammatory thickening near the orifice. Examination with the endoscof>e under an anaesthetic usually reveals at once the true state of things ; unlike an organic or true stricture, the obstruction disappears comijletely as the mucous membrane becomes insensitive, even with cocaine ; the largest tube then that the meatus will admit can be inserted without the least pain, and an accurate diagnosis made, both as to the seat and the nature of the lesion. When there is a definite organic stricture the sound is either stopped abruptly, or, if the spasmodic contraction relapses sufficiently to allow it to pass, the surface feels rough and irregular. The situation of the stricture, its size and length, and whether it is the only one present, must next be ascertained. Smaller sounds must be used for this, until one will pass ; but now, as the object is not to ascertain the presence of a stricture, but to find out how wide it is, flexible instruments, which will find the easiest path for themselves, are better than rigid ones. The length can only be ascertained by passing through the stricture a sound with the shaft graduated with inches, and a conical bulb at the end ; as this is drawn out, the base of the cone catches against the edge of the stricture and makes the furthest limit. Great care, however, is necessary for this. Recent strictures are easily displaced, owing to the looseness of the submucous tissue ; and if the shaft of the sound is too flexible, or if it is not held in the axis of the canal, it is easy to manufacture a stricture at any point ; as the bulb is withdrawn, it throws the mucous membrane of the urethra into little transverse wrinkles, over which it slips with almost the same sensation as over a definite fibrous ring. Deeper strictures, of course, can only be found out when they are narrower than the superficial ones. Treatment. — The object in treating stricture is not merely to dilate that portion of the urethra to its full dimensions, but to prevent it narrowing again. The first is usually easy ; the second exceedingly difficult, as the lymph thrown out resembles scar tissue in its tendency to contract ; but as cicatrices differ in this respect, according to their cause, those due to burns being the worst, so it is claimed for some of the methods used that they either insert in the stricture, as it were, a splice of material less prone to contract, or even cause the disappearance of the cicatricial tissue itself. General. — The first thing in all cases is to allay as far as possible the spasm and congestion, that are nearly always present. In cartilaginous strictures, it is true, they are not of so much importance ; but in recent cases, of only a year or two's duration, they are not unfrequently the main obstruction. It is a very com- mon thing to find that a stricture which at first aj^pears almost impassable, after a few days' rest in bed under proper treatment, allows a Xo. 9, or even a No. 10, to slip through with ease. When the attack is recent and acute, accompanied by retention of urine, this demands the first consideration. Either a catheter must be passed at once, or the patient must be placed in a hot bath, the bowels opened as soon as possible, and, if the condition of the kidneys is such as to allow it, a full dose of opium given. Where the case is not so urgent, a great deal may be done by attention to general treatment : the diet should be light and unstimulating ; the bowels kept well open ; and if the urine is very acid, or if there is a large amount of urates, the liver should be made to act thoroughly. Alkalies and hyoscyamus are of the greatest use ; opium, if required, should be given in the form of a suppository. No stimulants should be allowed ; the patient should have a warm bath every night; and, if he STRICTURE OF THE URETHRA. 1109 is not kept in l)ed or confinetl to his room, care should h^ taken that his clothing is warm, and that he is not in any way exposed to .cold. Irritability of the urethra and spasmodic obstruction, provided there is no organic change, usually disappear in a very short time, and a catheter slips in readily and without pain. If the spasm persists, the urethra may be stretched every second or third day by passing a fidl-sized bougie as far as the bulb, and leaving it until it is no longer grasped. At first the disturbance is often a little increased, but, provided there is nothing local to keep up the spasm, this rarely fails. If it does, the endoscoi^e usually reveals some cause, such as a small mass of granula- tions, or a slight roughness of the mucous membrane in the anterior part of the urethra, which will not get well without local treatment. Local. — There are five chief methods of treating stricture — dilatation, rup- ture, incision, excision, and electrolysis. Of these, the first three are the most important, and each of them is capable of being carried out in various different ways. I. Dilatation. — This may be either interru])ted or continuous. In the former instruments are passed every two or three days, but are not left in ; they are simply introduced and withdrawn again ; three or four sizes may be passed at each sitting, but none should be so large as to be tightly grasped by the stricture ; and each time it is as well to commence, not with the largest used on the previous occasion, but with one a size smaller. In the latter an instrument is passed and left in, so that the end only lies just at the. neck of the bladder. The principle in the two is somewhat different ; the former relies merely on mechanical means ; in the latter the instrument sets up a certain amount of irritation, which must have some effect upon the stricture tissue, for the dilatation succeeds as well with a small sound as with a large one. Indeed, if the instrument fits the stricture tightly, it is very likely to set up so great a disturbance as to require the treatment to be stopped for a time. {a) Interrupted Dilatation. — The instruments used for this purpose may be either catheters or bougies : the former have the advantage of allowing a drop of urine to flow away, and of showing that the bladder has been successfully reached ; but against this there is the serious objection that, especially in the case of the smaller ones, they are more inclined to break, owing to the eye, and also that it is not so easy to ensure absolute cleanliness. Soft ones should always be preferred to rigid : if the stricture is of wide calibre, they pass just as well ; if it is small, ihey find their way ; if they are properly made, infinitely better. A small metal instrument maybe guided by the hand more easily, it is true ; but the point is as sharp as a needle, and unless it is held with the lightest touch, it is sure to per- forate the mucous membrane, and either make a false passage or else convert an annular stricture into a bridle. The bougies in common use are of various kinds. The English or gum- elastic are made of woven silk, coated with copal varnish, so that they retain, to some extent, when cold, the shape given them when heated. These are of the same circumference the whole way down. The French or black bougies are made of the same material, but are much more flexible and of different shape. Some little distance from the point the instrument tapers gradually until it becomes ex- ceedingly pliant ; the point itself is either left unguarded, or, in the olivary bougies, is expanded into a small bulb supported upon a slender neck. Genuine French bougies are as flexible as india-rubber tubing, and if the bulb touches anything the neck bends at once. English black ones are stiffer, the neck especially is not so pliant, the bulb is usually too large, and, as soon as any pressure is made upon it, instead of the curve being limited to the neck, it involves a fourth of the length. The smaller sizes must be carefully examined to. see that the varnish is not cracked at the neck ; there is not so much danger as in the case of catheters, but it is not uncommon for the bulb to break off suddenly, and this might easily happen in the urethra with very serious results. Sometimes the shaft is made rigid by weaving it round a metal stylet, so that the instrument can be bent to any shape. For very mo DISEASES AND INJURIES OF SPECIAL STRUCTURES. narrow strictures bougies are made of whalebone, catgut, or silkworm gut. The first-named is too rigid, even when softened in boiling water, to be of much ser- vice. Catgut is more useful, but it soon grows soft in the urethra, and then bends upon itself. Silk-worm gut is employed where bougies of moderate length and great tenuity are required. Some of the.se should be straight; others bent or twisted a little at the point, so that, if the orifice is not found at once, the whole face of the stricture may be explored systematically, one part after the other, by merely twisting the instrument between the finger and thumb. Besides these, there are many contrivances for si)ecial occasions or for very narrow and tortuous strictures. Harrison's whip-like bougies are about two feet long, very thin, and tapering to a fine ])oint at the end. If this slijjs through the stricture, the thicker part will follow, and coil up in the bladder out of the way. Then it may either be left in to dilate the stricture, the urine passing by the side of it, or it may be used as a guide or pilot for a railroad or tunneled catheter {i.e., one with an opening at the end instead of the side), or for the hollow staff of a Maisonneuve-Teevan urethrotome. Sometimes, a silver tube, open at both ends, is of help ; it should be about six inches long, and as large as the meatus will admit. This may be passed down to the face of the stricture, and then filled with a number of filiform bougies ; if these are tried, one after the other, occasionally one will slip in. An instrument, known as a pathfinder, is further elaborated from this : it consists of a straight tube (20 mm. F. in diameter), the end of which is closed by a disc which can be made to revolve. In the disc is a small perfora- tion, through which a filiform bougie passes, and, as the disc rotates, this is car- ried successively all round the stricture, until at length the orifice is found. The endoscope answers better still : if the opening of the stricture can once be seen, a fine-pointed bougie can often be guided into it without diflficulty. A stricture should never be condemned as impermeable, so long as a drop of urine comes out from the meatus ; by trying one kind of bougie after another, by carefully and systematically exploring the face of the obstruction, the orifice can be found in nearly every case. Cocaine is of great value ; a few drops of a ten per cent, solution injected into the urethra render it insensitive, and do away to a great extent with the muscular spasm ; but, of course, care must be taken not to in- jure the mucous membrane. An anaesthetic is rarely necessary. Sometimes 4 c.c. of oil may be injected into the urethra with benefit ; occasionally the little granu- lation or fold of mucous membrane, which often covers in the orifice, and pre- vents the bougie entering, can be floated off in this way ; and, in some instances, where nothing else succeeds, a bougie can be passed during the act of micturition. False passages give most trouble ; they nearly always start from the floor of the urethra, and, though they are most common in the region of the bulb, they may occur in any part. As a rule, a slight check is felt at the moment the point of the instrument slips to one side, and, if this is carefully noted, it may be avoided afterward. The patient very often feels it as well, and sometimes is able to give valuable information. When there are several, or when flexible bougies persist in following the wrong track, metal instruments may succeed, the point being guided by the finger in the rectum. Sometimes, if the opening in the mu- cous membrane is occupied by one instrument, a second may be passed by the side of it in the right direction, but, when two or three of these pa.ssages start immediately in front of a stricture, the difficulty of avoiding them all is very great. If there has been great difficulty in introducing a bougie, it may be tied in for a time, beginning with continuous dilatation. When this is not necessary, the bougie is withdrawn, being left only so long as the spasm continues, and a larger one is passed at once before the track is lost. Two or three sizes may be passed in this way every second or third day with the minimum of inconvenience ; the best time'is in the morning, an hour before the patient is allowed to get up. When the stricture admits No. 15 to 17 mm. F., the intervals may be i)rolonged, but the dilatation should be continued until no obstruction can be felt with a fiill-sized bullet-sound. Even after this, a catheter must be passed occasionally — once a STRICTURE OF THE URETHRA. iiii week at first, then once a month, and after a time perhaps at longer periods still, to ensure that there is no recontraction. Unless the stricture is a very recent one, so that the greater part of the infiltration is still cellular, permanent cure is not to be expected. 'Fhe dilatation can be effected much more quickly by the use of conical or bellied sounds. The best are Lister's, made of plated steel, so as to combine weight with i)erfect smoothness of surface. The ends are enlarged a little ; behind the neck they increase gradually in thickness until, at the other end of the curve, they are about three sizes (English) larger than the point. With these the stric- tured tissue may be rapidly stretched to almost any size, and without tearing the mucous membrane. Many i)atients, however, resent the tension they cause, and there is the disadvantage that the point of the sound is no longer the only part of the instrument that touches the mucous membrane, and conveys .sensations to the hand of the operator. (/;) Continuous Dilatation. — In this, as already mentioned, the instrument is left lying in the stricture for twenty-four or forty-eight hours, the patient being confined to bed, or, in exceptional cases, allowed to move about a little in his room. A longer time than this, without changing the instrument, is not advisable : and, owing to the irritation that is set up, it is usually as well to allow an interval of two or three days before the next is introduced. Even then, there is usually a muco-purulent discharge from the urethra. The instrument should never be so large as to fill the stricture ; a small one acts just as well as a large onej and is much less likely to cause nervous symptoms, and it should be tied in so that the point lies just in front of the neck of the blad- der. Either a bougie or a catheter may be used ; if the former, the urine comes by the side; if the latter, the instrument may be pushed into the bladder every now and then, and withdrawn again. In this way a stricture, through which No. 3 F. can scarcely pass, will admit a No. lo, and even a No. ii easily, after forty- eight hours. The presence of the foreign body sets up a certain degree of hyper- gemia ; the fibrous tissues become soft and swollen ; all the meshes are filled with fluid, and the denseness of the cicatrix disappears for a time. Unhappily, if left to itself, without instruments being passed at frequent intervals, contraction sets in even sooner than when the stricture is treated in the intermittent manner. Merits of Dilatation. — This method is most useful in recent strictures, in which the effusion of lymph is still more or less cellular, and has not yet spread beyond the mucous and submucous layers, or involved the periurethral tissues. Those near the meatus, and those in which a band of lymph passes across from wall to wall, can be treated much more satisfactorily in other ways. Dense, old cartilaginous strictures frequently will not dilate at all, the tissues are too hard ; or, if they do, it is only up to a certain point. No. lo or ii ; then they stop and seem to be entirely unaffected by anything further. Sometimes, too, strictures re- contract so rapidly that incision offers a better prospect, and, occasionally, instances are met with in which patients resent the passage of an instrument to such an extent that it is advisable to get rid of the structure at all hazards by one operation. It is not uncommon to find that though, so long as a stricture per- sists, every attempt at passing a catheter is followed by a rigor, almost anything may be done, and with impunity, as soon as the constriction is divided. Continuous dilatation may be employed where there is a very small stricture and great difficulty in finding the orifice, but it is distinctly more liable to be fol- lowed by suppression of urine, acute nephritis, and other .serious consequences, and relapses are more rapid. Further, it practically necessitates confinement to bed, but in many cases it is almost essential as a first step toward something else. 2. Rupture. — Many instruments have been devised for rapidly stretching or tearing through stricture tissue without dividing the mucous membrane. Thomp- son's is composed of two blades, which are passed into the urethra closed, and then very slowly separated to any required extent by means of a lever worked from the handle of the instrument. Holt's is shaped like a catheter divided into par- 1 1 1 2 DISEASES AND INJURIES OF SPECIAL STRUCTURES. allel halves except at the tip ; between these there is a fine, central guiding rod (Fig. 479). Dilatation is effected by passing on this tubes of various size, so that, when they are forced down between the blades, these are driven asunder. In Berkeley Hill's, a wedge on the end of a slender shaft is used instead, so that there is much less friction, and the dilatation is limited to one i)art at a time. I'he tissue of which a stricture is formed is (]uite inelastic, and it is claimed that by the use of these instruments it is either stretched to its utmost, or actually ruptured, without the mucous membrane being torn, though, of course, it is badly bruised. The process is exceedingly simple, but as a matter of fact the mucous membrane is always torn or crushed, and there is no guarantee that the force is api)lied to the right place : the weakest ]jart, wherever it is, gives way first. More- over, this method is peculiarly liable to be followed by the more severe forms of con- stitutional disturbance — rigors, urethral fever, and suppression of urine; and re- lapses occur more quickly than they do after gradual dilatation. Even when it is essential, for some reason, that the stricture should be dilated at once, some form of urethrotomy, where what is done can be felt and regulated at the time, is to be preferred. 3. Urethrotomy. — (a) Internal, incis- ing the stricture from the urethra. This may be done in two ways, either from in front, cutting backward toward the bladder, §■ or from behind. In either place something i must be passed through the stricture first : ^ in the former to act as a guide for the blade 5 of the urethrotome ; in tlie latter to dilate 'i^ the narrowed part sufficiently to allow the o; instrument to pass through. Whichever .7 plan is adopted, it is essential that the Z stricture should be fixed in some way, and that it should be divided through its whole length and depth. Serious hemorrhage does not occur so long as the incision is limited to the proper structures. The in- cision is generally made along the floor of the urethra: if Civiale's instrument is used, this is necessary, as the main guide as to the depth of the cut is the .sensation conveyed to the finger placed on the skin over the stricture : with the others it is not essential, and the incision may be made at the sides if required. Owing to the presence of large veins, the roof of the urethra is better avoided, so far at least as the penile part of the urethra is concerned. Division from behind is scarcely pos- sible unless the stricture will admit a No. 10, or at least a No. 9 ; so that if this ])lan is followed it must in a large number of cases be preceded by dilatation. There are two methods in which it may be accomplished. In Civiale's instrument the end of the shaft is dilated into a STRICTURE OF THE URETHRA. 11J3 bulb, concealing a fine cutting blade; by means of a screw in the handle this can be protruded to the extent required (Fig. 480). The bulb is passed through the stricture with the blade sheathed : the penis is drawn up as far as possible so as to fix the part that is to be divided, and the screw turned. The forefinger of the other hand is pres.sed firmly on the skin over the stricture, and the knife is drawn through, cutting deei)er and deeper, until all the tough fiI)rous bands which grate like so much tendon against the edge are thoroughly divided. Then the knife is sheathed again and the instrument withdrawn. In Otis's, on the other hand, the stricture is fixed and stretched until it is quite tight by gradually separating the two parallel rods ; then the knife is protruded as far as is thought advisable and drawn quickly across the tightened bands (Fig. 481). If the divi- sion is not comiilete the side rods are screwed apart again and a fresh incision made. In the anterior part of the urethra these succeed equally well ; the one be- FiG. 480. — Civiale's Urethrotome. cause the strictured part can be held firmly with the fingers, and every fibre felt as it is divided ; the other because the touch of the instrument is so light when it is but a short way down the canal. In the deeper part, especially near the bulb, Civiale's is the most convenient. A stricture that is too small to admit these may be divided from in front by means of Maisonneuve's urethrotome, as modified by Teevan and Berkeley Hill (Fig. 482). A filiform bougie must first be passed, and on this an exceedingly fine catheter, so as to make sure that the end is really in the bladder, not coiled up in some false passage. The catheter may then be withdrawn and the guide that screws on to the end of the urethrotome passed instead. The instrument itself consists of two parallel rods, together only equal to a No. 7 F., joined at the tip, but allowing a wedge on the end of the shaft to slide down between them as far as the curve. The knife is concealed in the wedge, and is not protruded until this Fig. 481. — Otis's Urethrotome. has been passed as far as it will go ; in this way the wall of the urethra and the stricture are firmly held ; and the wedge being pushed forward bit by bit, as the tissue is divided with the knife, the whole length may be cut through without en- dangering anything else. The success of this operation depends very greatly upon the after-treatment ; if urine becomes infiltrated into the wound, suppuration is sure to occur, leaving behind it a cicatrix which reproduces the stricture in a still worse form ; and there is very great danger of other troubles — rigors, urethral fever, abscesses, and even pyaemia. A full-sized bullet-sound. No. 24 or 26, must be passed to make sure that the stricture is thoroughly divided ; the urine that remains in the bladder drawn off ; and the cavity washed out with boracic acid or a very dilute solution of corrosive sublimate. No catheter should be tied in unless there is profuse and con- tinuous hemorrhage. A morphia suppository (if the kidneys are fairly sound) may be placed in the rectum, and then the patient must be removed to bed, and en- 71 1 1 14 DISEASES AND INJURIES OF SPECIAL STRUCTURES. joined to delay micturition as long as possible, in order that the surface of the wound may be sealed with lymph before urine is allowed to flow over it. When the bladder must be emptied, which is often not for si.\ or seven hours, a large cup of tea should be given, with five grains of cpiinine and half an ounce of brandy, and the patient placed in a hot bath, so that the flow of urine may be as free as l)OSsible, and without any straining. If this plan is adojited there is rarely any fever after the operation ; sometimes a rigor occurs after micturition : within a few minutes the temperature begins to rise, the patient feels chilly and begins to shiver, there is a feeling of the most intense distress : the thermometer reaches 104° F. and even higher; then after twenty minutes or half an hour it begins to fall and pro- fuse sweating sets in ; but this is seldom of any imjiort. In any case the patient's temi^erature should be carefully taken after micturition, and if there is a sensible rise it should be met at once by repeating the quinine. No instrument should be passed for at least a week ; the patient must be kept in bed, on light diet and without stimulants ; the bowels may be opened on the third day, and a warm bath taken every night. At the end of a week a No. 22 bullet sound may be carefully passed down the urethra and withdrawn again ; if the operation has been success- ful, no hitch should be felt anywhere and there should be no stain of blood. Three days later another may be passed, and then the patient may be instructed how to make use of one for himself. Internal urethrotomy is employed by some to a very much greater extent than by others, but there are certain cases in which it is generally preferred. '. .',. YAR'-!PLL C3 PilLf- FlG. 482. — Teev.-in's Urethrotome. 1. Strictures near the meatus, especially those at the orifice itself; these may often be divided with an ordinary bistoury. 2. Strictures which re-contract rapidly after dilatation. 3. Strictures in patients who suffer severely from rigors or other troubles whenever a catheter is passed. In such cases it is best to finish the operation at a single sitting, and it is often found that the irritability of the urethra disappears altogether as soon as the stricture is divided. 4. If there is a perineal abscess present, and the stricture is divided before the mucous membrane has given way, a fistula may sometimes be avoided. Dense cartilaginous strictures that refuse to dilate may be treated in this way, but they fre(iuently require more than one operation, and for them external ure- throtomy is certainly to be preferred. In recent strictures, or where there is advanced disease of the kidneys, or where the urethra is inflamed, a cutting operation is not advisable. In advanced cases of cystitis, where the urine is ammoniacal and loaded with mucus, the stric- ture may be divided and an ojjening made in the perineum to drain the bladder and to prevent decomposing urine flowing over the surface of the wound. Complications. — Internal urethrotomy is liable to be followed by the same complications as simple catheterism, but some are more common and more serious than others. Rigors have been already mentioned. Hemorrhage (either at the time of the operation or later, especially at night, if there is an erection) is some- STRICTURE OF THE URETHRA. 1115 times very profuse. In the penile part it may be controlled by passing a large gum-elastic catheter down the urethra, and compressing the bleeding point against it with a bandage, until a coagulum has formed ; or an ice bag may be laid upon it ; when it is at the bulb a well-padded firm crutch, after (Jtis's plan, answers best. If there is evidence of infiltration of urine at the seat of operation, a staff should be passed down the urethra and a free incision made from the outside. Abscesses should be opened as soon as possible ; but if they occur in connection with the prostate they usually make their way into the urethra. Acute epididy- mitis is not uncommon, especially if the urethra is explored too soon and too much after the operation ; and, particularly if the kidneys are diseased, partial or complete suppression of urine may occur, though the liability to this occurrence may be greatly lessened by taking proper precautions. SubcKtancoiis Urethrotomy . — In the penile portion of the urethra short stric- tures may be divided from the outside by means of a long, narrow tenotomy knife. A staff is passed down the urethra, the stricture fixed with the fingers, and the knife thrust through the skin, making a minute puncture, and carried along the staff until all the resisting portion of the stricture has been divided. It is then withdrawn, and the puncture sealed. The after treatment should be the same as in internal urethrotomy. {F) External urethrotomy, where an incision is made from the outside into the urethra, passing through the whole of the stricture tissue. There are two distinct classes of cases in which this may be required. In the first a catheter can be passed through the stricture ; in the second it cannot, either because the urethra has been destroyed by extensive sloughing, or because S.A.y/'.RNALL CO, Fig. 483. — Syme's Staff. it is SO tortuous that, though urine can find its way out, it is impossible to worm a bougie through it. Sytne' s operation, external urethrotomy in the strict sense of the term, where an instrument can be passed into the bladder. Syme's staff consists of two parts of different diameters ; for the last two inches and a half, it is about the size of No. 6, and this is grooved on the convexity; the rest of the instrument is equal to a No. 18 or 19. The junction of the two is abrupt, so that there is a sharply marked shoulder, which is intended to rest upon the face of the stricture ; the groove is continued on to this, but no further. This is passed into the bladder, the finger being placed in the rectum, to make sure that it has not entered a false passage, and given to an assistant to hold. The patient is then tied up in the lithotomy position, and the assistant directed to push the convexity of the staff downward toward the perineum. The left forefinger is placed in the rectum, and an incision made exactly in the middle line, about an inch in front of the anus, and carefully carried down until the groove in the narrow portion of the staff is reached ; this is usually behind the stricture. The knife is carried forward, cut- ting from the anus, in the groove of the staff, right through the stricture as far as the shoulder. A probe-pointed narrow gorget is introduced through the wound into the groove, and pushed on until it enters the bladder ; the staff is withdrawn, and a full-sized catheter passed from the urethra along the gorget, using it as a director. Generally the catheter is tied in for the next three days, and then withdraw^n ; but I have not found this necessary. If the stricture is divided thor- oughly, the wound may be left entirely to itself, the patient being kept in bed, and treated in the same way as after the operation of internal urethrotomy. At the end of a week a full-sized bullet sound may be passed, follow-ing the roof of the urethra, a i&w drops of a ten per cent, solution of cocaine being injected into 1 1 16 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the wound to ])revent jiain ; and this may be repeated, at first every second day, and then gradually at longer and longer intervals. This oi)eration is esjiecially useful in dense cartilaginous strictures compli- cated with fistula, where internal urethrotomy has no chance of succeeding ; and it may be performed with very great benefit in advanced stricture deep in the urethra, where the bladder is diseased, the urine ammoniacal, and the kidneys affected. In this case, however, a drainage tube should be passed through the wound into the bladder, and connected with a receiver outside the bed. Of course, the prognosis in such cases is not good, but it relieves the bladder at once, the urine gradually becomes clear and acid, the amount of mucus diminishes, the con- :^:^?^ '^ Fig. 484.— Wheelhouse's Operation, showing the Sides of the Ureihra held apart by temporary Sutures, and the Apex of the Triangle stretched up by the Button 6n the end of the Staff. stant desire to micturate ceases, the patient enjoys such rest as he has not had for years, and very often the general health begins to improve at once. There is another advantage claimed for this operation, that it holds out a prospect of permanent cure. There is no doubt that sometimes, if external ure- throtomy is performed in cases of rupture of the urethra before extravasation of urine has taken place, the formation of a stricture can be prevented, but Harrison has described cases in which a dense cartilaginous stricture has apparently com- pletely disappeared. In 1867 Bickersteth performed Syme's operation for trau- matic stricture and urinary fistula of the worst type ; in 1869 the man was known ■^ ^.V:\T^N^\.v.rA.v\\\\.\. Fig. 485. — Grooved Staff, with Bulton-like End. to be quite well, though no precautions appear to have been taken by the i)atient. After his death, in 1885, the urethra was removed and carefully e.xamined, and no signs of the stricture could be found ; in fact, the urethra is described as being of larger calibre in proportion to the rest of the canal, opposite the line of section, as if the cicatrix had yielded to the pressure of the urine. I have myself the notes of a patient' on whom external urethrotomy was performed eighteen years before he came under my care, and though he assures me that he has not taken the slightest precaution since, there is no evidence of any recontraction. When a catheter cannot be introduced into the bladder, either the urethra should be laid open in front of the stricture, so that the face of it may be seen STRICTURE OF THE URETHRA. 1117 (Wheelhoiise's operation), or an incision is made into the urethra behind, through the perineum, and prolonged forward through the stricture tissue until the canal is reached again in front (Guthrie's perineal section, or Cock's operation). WJieelhouse' s Operation. — The patient is placed in the lithotomy position and a special staff passed down as far as the stricture. This instrument is straight, with on one side a groove, which runs down until within half an inch of the point, and on the other, at the point itself, a projection in the form of a blunt hook. An incision is made on to the staff so as to open the urethra a quarter of an inch in front of the stricture, and two sutures are looped through the edges of the mucous membrane, so that the sides can be held apart by assistants. The staff is withdrawn until the end appears in the wound, and turned round so that the i)ro- FiG. 486. — Teale's Probe-gorget. jection is hooked into the upper angle of the opening in the urethra. This is stretched in this way into the shape of a triangle, the base of which is formed by the front of the stricture. There is very little hemorrhage, and nearly always the orifice can be seen at once. A probe is then carefully passed through the stricture, and the whole length is carefully and deliberately divided along its under surface. The subsequent proceedings and the after-treatment are the same as in Syme's operation, a probe-pointed narrow gorget being used to pass into the bladder through the wound and act as a guide for the catheter. Perineal Sectio7i. — The patient is directed to hold his urine if possible for some hours before the operation, so that the neck of the bladder and the proximal part of the urethra may be dis- tended. The position is the same, and the surgeon begins by passing his left forefinger into the rectum to draw it back, and to feel the apex of the prostate. An incision is then made exactly in the middle line of the perineum an inch and a half in length and half an inch in front of the anus, and it is gradually deepened, until, if the patient strain or cough, the urethra bulges into the wound. If this does not happen, the point of the knife, guided by the finger in the rectum, must be pushed forward so as to hit off the membranous portion of the urethra or the apex of the prostate. If urine escapes through the puncture, difficulty is at an end. A director is then passed into the bladder, and along this a narrow probe-pointed gorget. The stricture may either be dealt with at once (the other end is easily found by passing an instrument down the urethra) or the bladder may simply be allowed to drain itself for some days. It is not uncommon to find that a stricture which obstinately resists all attempts before the operation can be easily passed afterward, and either dilated or divided. Fig. 487. — Cock's Operation for Tapping the Urethra at the Apex of the Prostate, or Perineal Section. iii8 DISEASES AND INJURIES OF SPECIAL STRUCTURES. In cases in which a large ])ortion of the urethra has been destroyed by slough- ing, and it is doubtful whether it is possible to establish a new canal, or whether, if it is established, the patient will take the trouble to maintain its patency, an opening may be made into the bladder over the jjubes, and fitted with an india- rubber tube and stoj^cock. With this arrangement patients may live and continue their ordinary occujiation, not only with perfect safety, but almost without incon- venience. 4. Excision. — In exceptional cases strictures in the penile portion of the ure- thra have been excised, and the edges of the mucous membrane sutured together, and even strips of mucous membrane from other parts of the body have been spliced in. Such operations, however, can very rarely be required, as most strictures so placed are amenable to simpler treatment. 5. Electrolysis. — The treatment of stricture by electrolysis has recently been revived by Newman, Bruce-Clarke, Steavenson, and others. The negative electrode is passed down the urethra, and allowed to remain in contact with the face of the stricture for the space of some minutes to half an hour; the positive is applied to some other part of the patient's body, and a current of three to five milliamperes used. In stricture near the meatus the gradual melting away of the cicatricial tissue under the influence of the caustic set free on the surface of the electrode, can be seen, and there is no doubt the same process takes place when the stricture is deeper ; but in many patients it is attended with quite as much pain as gradual dilatation. There is usually a considerable degree of soreness and irritation afterward, and unless the same precautions are taken, there is no greater degree of immunity. It is true that in some instances recontraction does not occur for a considerable time ; but in picked cases the same may be .said of nearly every other method, and I have known it take place within six months. Extravasation of Urine. Urine may escape from the ureter and pelvis of the kidney, from the bladder (entering the peritoneal cavity of the cellular tissue), or from the urethra. The last mentioned is by far the most common, and is generally understood by the term extravasation. Causes. — The urine may come from the prostatic, membranous, or penile portions of the urethra. In the first case the causes (and the symptoms) are prac- tically the same as those of extra-peritoneal rent of the bladder. It rarely occurs except as a result of fracture of the pelvis, or of operations, such as lateral lithotomy, when the lobe of the prostate has been too freely incised. In children, however, it sometimes happens from severe compression without fracture, owing to the elasticity of the bones of the pelvis. 'i1ie urine escapes into the prevesical space (that which is bounded by the two lamellae of the transversalis fascia, the one going to the pubes. the other along the urachus to the bladder), above the deep layer of the triangular ligament, or else directly into the pelvic cellular tissue, above the recto-vesical fascia. Extravasation from the membranous or penile portion of the urethra is caused either by injury (rupture, impacted calculus, urethrotomy, etc.), or by stricture. The latter is by far the more common. It may be either sudden or gradual. In the former case the urethra becomes thinned and dilated behind the stricture, owing to the constant pressure upon it, until, some day, under the effort of micturition it suddenly gives way, and the urine ])ours out into the tissues. In the latter a small follicular abscess forms, and gradually extends, ulcerating through everything under the constant pressure of the septic and decomjjosing urine, until at length it works its way to the exterior, and the urine escapes through a fistula without having been widely spread in the cellular tissue. This is not nearly so severe a form as the other, at any rate so far as the immediate symptoms are concerned. When the extravasation commences between the two layers of the triangular ligament, it naturally remains limited until one of them, usually the anterior, gives EX TRA VASA TION OF URINE. 1 1 1 9 way. If, on the other hand, it is superficial to this, under the deep layers of the superficial fascia, it spreads at once until it may actually reach the ensiform cartilage. Behind its progress is limited by the attachment of the fascia to the l)osterior margin of the triangular ligament ; in the middle line it cannot extend further back than the centrum tendineum of the perineum ; under cover of the rami of the ischium, it can reach as far as the tuberosity, but it never enters the ischio-rectal fossa. At the sides the fascia joins the periosteum, so that the urine cannot extentl on to the thighs. Only in front is the pa.ssage free, and if it is driven with any force it rushes into the scrotum under the dartos, passes over the pubes, and covers the surfiice of the abdomen, as low as Poupart's ligament at the sides, and perhaps as high as the ensiform cartilage in the middle. Consequences. — Wherever urine spreads it causes inflammation and gan- grene. The cellular tissue sloughs wherever it comes ; the skin perishes, and exposes intensely fcetid masses of dark-colored tissue, sodden with urine and pusl^ and even the penis, testes, and other structures may be destroyed when the planes of fascia which serve at first to limit the urine in certain directions, break down. Symptoms. — Sudden extravasation of urine is unmistakable. There is a history of obstruction, of some difficulty in emptying the bladder, for weeks or months before, if due to stricture — for the first time if the urethra has been rup- tured ; then, of the obstruction having suddenly given way, and of the bladder having emptied itself with a feeling of intense relief, but without any urine being passed externally. In a few minutes a smarting sensation is felt in the perineum and scrotum ; soon they begin to burn and throb ; in a itw hours they swell to more than double the size ; the patient becomes anxious and feverish, and a con- dition of extreme prostration sets in. By the next day, especially if the urine was already septic, the sloughing is well advanced. The perineum projects under the scrotum, reddened, tense, and hard ; the scrotum itself is swollen out to an enormous size, and is glazed and shin- ing, with a peculiar translucent appearance from the amount of oedema ; and the skin over the abdomen is dusky, pitting on pressure, and in bad cases crackling from incipient putrefaction. If there is a gangrenous spot on the penis, the prog- nosis, as Brodie first showed, is almost hopeless. The fever may be high, but more frequently the temperature is only moderately raised ; the patient lies in a state resembling that of typhoid ; the pulse is small and quick, the respiration hurried and shallow, the tongue dry and brown ; often there is muttering delirium ; and the eyes are sunken, and the face pinched, with a look upon it that cannot be mistaken. Treatment. — This admits of no delay : the patient must at once be placed in the lithotomy position, and a free incision made deep in the middle line of the perineum, until the main source is tapped. Then other incisions must be made all over the dusky area ; in the penis they must be perfectly straight and longitudinal, or the subsequent cicatrization may lead to serious trouble ; on the scrotum one on each side is usually sufficient, but it should extend thoroughly into the sodden cellular tissue ; over the abdomen their direction should correspond with the vessels. In most cases it is sufficient to make them two or three inches long ; as soon as the oedema subsides they shrink more than half; sometimes there is sharp hemorrhage from a cutaneous vessel, but this may always be stopped by pressure with dried lint. Any sloughs that are loose should be extracted at once, and as much of the putrid fluid as possible squeezed out of the openings. The treatment of the bladder, and of the stricture (if there is one), next requires consideration. It is distinctly of advantage to drain the former thoroughly, not only because it prevents more urine being extravasated, but because itself is almost sure to be in a state of advanced cystitis, half full of an intensely offensive putrid fluid. This may be accomplished either by dilating the prostatic portion of the urethra with the finger, first introducing a probe-pointed gorget into the blad- der as a guide, or, better, by passing in a full-sized soft rubber catheter, and con- II20 DISEASES AND INJURIES OF SPECIAL STRUCTURES. necting it with a receptacle under the bed. Whether the stricture should be touched or not depends upon the contiition of the patient. In most instances it is better to leave it alone ; if the patient recovers, a catheter can often be pas.sed without any difficulty ; owing to the prolonged rest, the spasm and congestion entirely disappear. When, however, the case is not a severe one, it is most expe- ditious to pass a staff down the urethra, and at once lay the whole stricture open, as in external urethrotomy. Great care must be taken to keep the patient dry ; all the discharges (and they are often profuse), must be soaked up with freipiently charged pads of absorbent wool, or finely picked oakum. Warm hip-baths, containing small quantities of some antiseptic, are of great service, if the patient's health permits. Sloughs should be removed as soon as possible, and the strength sustained by nourishing diet, quinine, and stimulants. The temperature requires very careful watching, as, like all oi)erations about the urinary organs, extravasation is liable to be followed by pyxmia. If the patient does not die from this, exhaustion or renal disease, the wounds granulate in a very short time, and the cicatrices left are always surprisingly small. Urinary Abscess. Peri-urethral abscesses are not uncommoii in the glands by the side of the frsenum in acute gonorrhoea, and occasionally they are met with in other parts of the corpus si)ongiosum, but the perineum is by far the favorite locality. They may be divided into two classes, those which communicate with the urethra from the first, having commenced on the surface of the mucous membrane, and gradu- ally involved deejjer and deeper structures ; and those which originate independ- ently of it, and if they do communicate, only do so secondarily, the mucous membrane covering them becoming thinner and thinner until at last it gives way. Causes. — i. Gonorrhoea. — Abscesses occasionally form in the corpus spon- giosum, but (except in the glands) they are not often met with unless there is an old stricture, or unless it has been necessary to pass a catheter frequently. Some- times they extend down from the mucous follicles, but they may originate inde- pendently, and, if the pus is let out in time, they may never communicate with the urethra at all. Cowper's glands are sometimes affected in this way. There is a small, hard, exceedingly tender spot, not quite in the middle line, by the root of the scrotum. After a time it works its way through the triangular ligament, toward the skin, or toward the rectum, so that its origin is often not recognized. 2. Injury. — Ru])ture of the urethra, impacted calculus, the formation of a false passage, internal urethrotomy, and forcible splitting of strictures, are occa- sionally followed by perineal abscesses. Some of these are due to infiltration of urine; but when, for exam i)le, a stricture is ruptured without the mucous mem- brane being torn, or when suppuration occurs in consequence of a catheter having been tied into the urethra, it is probable that the communication, if it exists, is secondary. 3. Stricture. — This is by far the most common. Usually the suppuration commences outside the urethra, in the thickness of the stricture tissue ; sometimes, however, it spreads from the interior — the mucous membrane is thinned and driven into pouches, which often contain small quanti- ties of decomposing urine ; ulceration spreads from these into the mass of inflam- matory exudation around, and the communication exists from the first. Abscesses may, of course, occur in the perineum from other causes, the ure- thra not being concerned in any way. Suppuration, for example, may occur in connection with the rectum and work its way outward in front of the anus, and peri-prostatic abscesses sometimes point in the .same situation. Symptoms, — Urinary abscess, except when it is the result of gonorrhea, is usuall\- of slow formation. If it occurs in the glans, there is a small, hard mass on one or both sides of the frrenum, exceedingly tender to the touch, and rapidly URINAR V FISTULA. 1 1 2 1 coming to the surface. In the perineum it depends to a certain extent upon the situation. Usually it is in the middle line, unless it originates in inflammation of Cowper's glands ; if it is in connection with the bulb, or the deeper part of the corpus spongiosum, it stands out to a certain extent from the fixed tissues beneath, and often runs forward with a hard, spur-like process in the median raphe of the scrotum. When it begins between the layers of the triangular ligament there is merely a hard, but exceedingly tender spot, scarcely raised above the level of the rest. Fluctuation cannot be felt unless the abscess is superficial. The pain at the first is dull and throbbing, with a great sense of weight ; the stream of urine (even without stricture) is reduced in size and force ; complete retention may occur, especially when the supjjuration is in connection with the fixed portion of the urethra; and sitting and walking are attended with great discomfort. Then, as the pus forms, the pain becomes more intense, and shoots down the thighs and into the groin ; very often there is high fever, with perhaps a rigor ; and constitutional symptoms of great severity may set in. If the abscess is allowed to break of itself, it may discharge into the urethra ; there is a sense of inten.se relief ; a certain amount of pus is washed down with the urine, and sometimes the cavity contracts and heals without any extravasation, and without an external opening. More often, especially if there is a stricture, the abscess bursts externally as well as internally, and though the channel contracts as soon as the tension is removed, urine escapes through the opening, and a fistula is formed. Treatment. — Urinary abscess should be opened in all cases as soon as pos- sible. It is no use waiting for fluctuation, the sheets of fasciae are so dense that the pus, if left to itself, often burrows long distances before it reaches the surface, and if there is no internal opening, a timely external one may prevent its occur- rence. Buckston-Browne has pointed out that in cases of stricture associated with ]:)erineal abscess, if internal urethrotomy is performed, and the abscess opened freely from the outside, a fistula may often be prevented. Care must be taken that the incision, if the abscess is in the perineum, is kept absolutely in the middle line. Urinary Fistula. Fistulse may occur in connection with the kidney, ureter, or bladder, after wounds or operations, and as a result of malignant disease. Sometimes they open directly on to the exterior ; sometimes they communicate with other organs — the rectum, vagina, or even the small intestine. Recent ones, in which there has been no great loss of tissue, and which are not kept open by a permanent irritant, gener- ally close of themselves if the natural channel is patent. Attention to drainage and position (the patient, for example, lying prone when there is an opening between the bladder and rectum), the free use of antiseptics and a.stringents, and the occasional application of caustics, such as the actual cautery, or nitrate of silver melted on a probe, are of material assistance. If, however, they are old, and the walls have degenerated into dense suppurating sinuses, the surface of which is very likely coated over with a layer of phosphates, or if there is any persistent irritant (the capsule, for example, of a scrofulous kidney drained through the loin), further and sometimes extensive operations are required. These, however, and vesico- vaginal fistuIcX must be dealt with by themselves. Urethral Fistulce. — These differ in severity, and may be divided into three classes : — 1. Simple straight channels, of recent formation, opening directly on to the exterior, without much induration around. 2. Complicated fistulae, sometimes very numerous (as many as fifty have been described), opening in all directions, over the penis, in the groin, in the ischio-rectal fossa — anywhere near, in fact, with pouches and sinuses in which urine collects and decomposes, and embedded in dense cicatricial tissue. 3. Fistulae, very often in the penile part, in which, owing to extravasation of urine, phagedaena, or other causes, there has been great loss of tissue. 1 122 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Urethral fistula, except in those rare cases in which portions of the penis are removed by injury, is always the result of inflammation, and therefore nearly always of stricture. Abscesses, however, leaving sinuses behind them, do occa- sionally occur from other causes, such as a rupture of the urethra, impacted calculus, or urethrotomy. It is not material whether the su[)puration commences on the surface of the mucous membrane, in connection with an inflamed follicle or dilated pouch, or whether it originates independently of this, in the tissues around ; in either case the urine finds its way out through an easier channel, and a fistula is formed. In the majority of instances it affords little or no relief to the stricture. If there is a very wide opening, or if, as in suprajjubic puncture of the bladder, the sinus is fitted with a suitable instrument, so that there is free exit for the urine, the bladder, being relieved from all tension, may recover its normal condition — to a certain extent at least, and the ill effects of stricture is avoided ; but, except in such cases as these, the orifice of the fistula soon contracts until it is no larger than a pinhole, fresh inflammation takes place around it, more abscesses form, each leaving a new fistula, and at length the whole perineum is converted into a dense mass of cicatricial tissue, riddled with openings in all directions. Treatment. — The treatment of urinary fistula depends upon the cause. The first thing is to remove any foreign body that is j)resent (a calculus, for example), and to see that the natural exit for the urine is unimpeded in any way. If the fistula is recent, and dependent, as it usually is, upon stricture, it will nearly always contract aijd heal up as soon as the stricture is healed. Sometimes it helps to stimulate the walls by injecting tincture of iodine, or to touch uj) the deeper part of the sinus with the actual cautery, or with a probe upon which some nitrate of silver has been fused. If, in spite of this, it will not close, means must be taken to prevent any urine passing through. Occasionally it is sufficient to press firmly with the finger upon the external orifice during the acfof micturition. More frequently it is necessary to draw the urine off with a soft catheter as often as may be recjuired, so that no drop shall flow along the urethra. This must, of course, be done before each act of defecation, and if, in spite of these j^re- cautions, the least drop escapes, the urethra must at once be thoroughly washed out with a weak astringent. It is no use tying a catheter in the bladder (unless it is connected with .some, constantly acting exhausting apparatus to suck the urine out), some will always pass by the side, no matter what the size may be ; and not unfrequently it is positively injurious, from the amount of irritation it creates. If this does not succeed and the stricture is fully dilated, it is possible that the irritation is kept up by some outlying sinus which cannot drain. In such a case it is best to perform external urethrotomy at once, cutting through the whole of the dense tissue in which the fistula lies. If there are many open- ings, or if there is an old cartilaginous stricture to deal with, this is almost always nece.ssary. Where a considerable portion of the wall has been destroyed by sloughing, a plastic operation may have to be performed in order to close the oi)ening. To secure union by the first intention, the bladder should be drained, either through the rectum, introducing a winged soft catheter, or through an opening in the peri- neum, according to the position of the fistula. Then the edges may be pared and brought together, or a flap of skin may be raised from some adjoining part, and sifted so as to cover in the orifice. The Female Urethra. The urethra in women is so short, and the extent of surface so small in com- parison with that of the male, that it is much less likely to become inflamed, and stricture and other consequences are more rare. Acute inflammation, commencing with great severity, and attended with scalding and purulent discharge, is not infrequent as a result of gonorrhceal in- THE FEMALE URETHRA. 1123 fection of the vulva. Milder forms are occasionally met with as a consequence of cystitis, and a slight but very troublesome degree of irritation, with increased secretion of mucus, is not uncommon during jjregnancy, in malposition of the uterus, and in other affections of the generative organs. As a rule, unless the cause is a persistent one, it sul)sides readily under the use of astringent injections, combined with hot baths and purgatives. Stricture, as a result of inflammation, is rare ; but it may occur from chancres or other sores at the orifice, and from sloughing of part of the anterior wall of the vagina. It may be treated either by dilatation or incision ; rigors have been known to occur, as in men, but very seldom. The opposite condition, dilatation, is occasionally met with, and when it in- volves the upper third, and still more the whole length, there is the most distress- ing incontinence. It may result from long-continued or often-repeated displace- ment, or from mechanical stretching. The adult urethra admits the forefinger easily, and, as a rule, if the dilatation is effected rapidly, no ill result hajjpens ; but if it is often repeated, or if it is carried beyond this, as in extracting a calculus, it may become permanent. Sometimes the middle portion only is dilated into a pouch (urethrocele) felt in the anterior wall of the vagina, and this, acting as a receptacle for decomposing urine, keeps up the irritation. When there is incon- tinence, due to impaired power at the neck of the bladder, galvanism, tonics, strychnia, cold, and other measures must be emi)loyed to restore the tone of the muscle. Urethral caruncle, a small vascular growth at the meatus, occurring more fre- quently in married women than in young unmarried girls, may give rise to the greatest distress. It bleeds with the least touch, and causes the most intense suffer- ing during micturition or when the parts are moved ; at the same time there is usually great irritability of the bladder and a profuse discharge of mucus. The symptoms cease at once on its removal. Fissure at the neck of the bladder is also occasionally met with, but it can only be diagnosed with the endoscope. There is a small superficial erosion of the mucous membrane, circular when the sphincter is stretched but appearing like a fissure as soon as it contracts. It gives rise to constant tenesmus and staining, with an intense burning pain at the end of micturition, and occasionally a few drops of blood. It may readily be cured by means of a light application of caustic, or by mechanically dilating the sphincter, so as to give the surface rest. The former method is preferable, as it is not always possible to graduate the effects of the latter sufficiently in individual cases. 1 1 24 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER XXIV. INJURIES AND DISEASES OF THE MALE ORGANS. MALFORMATION AND DISEASES OF THE PENIS. The roof may be defective (epispadias) ; or the floor (hypospadias) ; or the invagination that forms the fossa navicularis may fail to meet the part behind ; if in this case there is no other defect, the urethra is imperforate, the kidneys become cystic, and the child dies at or before birth. Usually, however, there is hypospa- dias, and occasionally the two channels run one above the other for a consider- able distance. Hypospadias. — The orifice is usually at the base of the glans, or a little further back ; the fraenum is wanting ; the prepuce forms a great fold on the dorsum like a cowl, and the corpus spongiosum possesses scarcely any erectile tissue. In other cases it lies at the end of the membranous urethra, the bulb and the scrotum fail- ing to unite in the middle line, and forming labia, as in the female. When the defect is slight, the fossa navicularis may run back and end blindly ; in other cases the penis is small, and the corpus spongiosum (if it is developed) incapable of erection. Epispadias. — The complete form is always associated with ectopia vesicae ; occasionally the urethra opens behind the corona, the rest of the penis being well developed. The treatment is not very promising. If the defect is slight, and micturi- tion not impeded, it is better not to interfere. The orifice should be dilated to prevent any strain upon the structures behind ; and if the urethra fails in front, so that it is impossible to direct the stream, an attempt should be made to carry it forward by means of a plastic operation. The flap must be double, so that a cutaneous surface may face the new channel ; the deeper layer is taken from the side of the penis near, and twisted round upon itself ; the superficial one borrowed from the redundant prepuce, the centre of the cowl being dissected up, and the glans thrust through the opening so that the dorsal surface becomes inferior, or vice versa, as the case may be. Phimosis may be congenital or acquired, following balanitis, soft sores, chancre, or injury. In the former case the glans is often adherent, and the orifice may be reduced to the size of a i)inhole, so that the prepuce swells out with each act of micturition. Circumcision should always be performed, unless the corona can be thoroughly and easily e.xposed ; the secretion collects inside ; there is a constant risk of balanitis and paraphimosis ; preputial calculi may form ; and the liability to syphilis and phagedasna is much greater. If gonorrhoea occurs, it is more severe ; and the constant irritacion undoubtedly favors carcinoma. Circumcision. — The prepuce is drawn well forward, and clipped with a pair of polypus forceps in front of the glans ; the projecting end cut off; the cutaneous sheath allowed to retract ; and the mucous membrane slit up along the dorsum as far as its attachment. Each half is then cut away, following the line of the corona, and leaving the fr^enum and just enough to hold a few sutures. If catgut is used, and the wound dried and covered with iodoform, the dressing may remain on until the skin has united. Paraphimosis is the condition produced by forcing the glans through the orifice of the prepuce when it is too narrow to admit it. The immediate result is con- gestion and inflammation, ending, if left, in ulceration and sloughing. The glans becomes swollen ; the prepuce overhangs it like an oedematous collar, and DISEASES OF THE SCROTUM. concealed behind thin is a tight, un- yielding ring formed by the orifice. In early cases reduction can usually be effected by oiling the parts well, and drawing the foreskin forward with the index and middle fingers of the two hands, while the thumbs compress the glans ; or the penis may be wrajiped round with lint, and gently squeezed in the hand until the oedema disap- pears ; but in cases that have already lasted some days, it is often necessary to slip the end of a director under the constricting band on the dorsum, Fig. 488.— Mode of Dividing Prepuce in Paraphimosis. and divide it with a bistoury. Epitheijo.ma of the Penis. Squamous epithelioma is not uncommon after middle life, commencing on the glans or the inner surface of the prepuce, especially in cases of phimosis. It usually begins as a warty nodule, which soon breaks down into an ulcer, with in- tensely hard base and edges. If left, the growth spreads rapidly, owing to the constant irritation of the urine ; the corpora cavernosa and the glans are quickly infiltrated ; the lymphatics in the groin become involved, and secondary de- posits follow. The diagnosis from syphilis rest chiefly on the character of the base, which is covered with decaying epithelium, and the intense induration beneath and around. Amputation is the only treatment. Until recently this wa.s accomplished either with a single sweep of the knife, or more deliberately, forming a flap of skin to cover the surface of the wound, leaving the corpus spongiosum and the urethra longer than the rest, and stitching the edge of the mucous membrane to that of the skin. Recurrence, however, is exceedingly common after this operation ; cica- tricial stricture at the orifice invariable ; and all power of directing the stream of urine lost. To avoid this Thiersch recommends an oval incision round the root of the penis, prolonged a little backward in the median raphe of the scrotum, and then dissecting off the whole of the corpora cavernosa from the rami of the pubes and the triangular ligament. The corpus spongiosum and the urethra are dealt with separately, through an incision in the median line of the perineum behind, as much being removed as appears desirable, and the rest sutured to the skin in front of the anus. Micturition must, of course, be effected in the sitting posture, but there is not the same tendency to the formation of stricture, and there is much further freedom from return of the growth. Wheelhouse has pointed out the greatly increased comfort the patient experi- ences when the testes are removed as well. DISEASES OF THE SCROTUM. (Edema may occur in Bright' s disease, causing enormous swelling ; and a similar affection (probably inflammatory in origin) is occasionally met with in infancy. Inflatnmation is very common, but unless the cause is very grave (as in extrav- asation of urine), or the nutrition much enfeebled, as in specific fevers, sloughing and gangrene rarely occur. It may arise from injury, eczema, the irritation of the urine, or retained perspiration, or it may start from the interior, or spread from other tissues. The swelling is usually immense, but the other signs, pain, heat, and redness, are seldom in proportion. 1 1 26 DISEASES AND INJURIES OF SPECIAL STRUCTURES. Elephantiasis. — Enormous hypertrophy of the tissues of the scrotum may be caused by lymphatic obstruction, or by repeated attacks of inflammation, as in cases of urinary fistula. The skin and subcutaneous tissues only are affected, the cellular elements and the fibrous tissue l)eing immensely increased, while all the interstices are filled with lymph, or in rarer cases with a mixture of this with chyle. Hydrocele is usually a.ssociated with it, and the skin of the penis may become in- volved, but the testes are never affected (see p. 291). Epithelioma is of interest from the fact that its origin can nearly always be traced to local irritation caused by soot — whence its common name, chimney- sweep's cancer. It begins as a wart or nodule, which slowly spreads at the margin as it decays and ulcerates in the centre. Induration is its chief feature. The edges are raised, hard, and ill-defined ; the base is covered with decaying epidermis and florid granulations which discharge a thin, off"ensive fluid, and the tissues around are swollen and oedematous. At first it can be pinched up from the structures beneath, and merely feels like an induration in the skin ; soon it infects the lymphatic glands in the groin, spreads to the rest of the scrotum and the jjenis, and involves the testicles as well. Fortunately, its character is so well known among those liable to it (soot may cause it in other parts of the body, and there is reason to believe that tar may do the same), and its progress (for epithelioma) is so slow, that removal in time is usually possible. Even if the inguinal glancs are enlarged and broken down, the whole of the disease may sometimes be successfully scraped out. EXAMINATION OF SCROTAL SWELLINGS. Swellings of the scrotum are divided into those that occupy the canal as well as the scrotum, and those that are confined to the latter situation. The distinction is made by feeling the cord immediately below the pubes, whether it is the natural size, with all its components distinct, or whether it is thickened or concealed in any way. I. Swellings that Occupy the Canal as well as the Scrotum; OF THESE, SOME ARE REDUCIBLE, OTHERS ARE NOT. {a) Reducible. Bubonocele and scrotal hernia may be recognized by the way in which they disappear, whether they consist of intestine or omentum. Varicocele, by its characteristic feel, the way in which it disappears when the patient lies down and the scrotum is raised, and refills in spite of the pressure of the finger on the ring. Congenital hydrocele, by its translucency. As the neck of the canal is often long and narrow, reduction is not always easy. {U) Irreducible. Hernia, either because it is strangulated (in which case there is no impulse on coughing), or because it is irreducible, i. e., so altered in shape, or so tied down by adhesions, that it cannot pass back. In strangulation, constitutional symptoms are present as well. Infantile Hydrocele. — The neck of the tunica vaginalis is obliterated only at the internal abdominal ring, and a collection of fluid extends from the bottom of the scrotum along the inguinal canal. The slow formation, commencing below and extending upward, the translucency and the ab.sence of true impulse (if it extends really into the canal there may be a kind of shock transmitted), are distinctive. Inflammatory Affections of the Cord. — In urethral epididymitis this is some- MALFORMATION OF THE TESTES. 1127 times swollen to a considerable size ; in tubercular disease the vas only is thickened, and all the structures of the cord can be isolated. Growths on the Cord. — The most common X's, encysted hydrocele, di small, round, and tense fluid swelling, due to incomplete obliteration of the funicular l)ortion of the tunica vaginalis. It is movable in the canal, but cannot really be reduced, and it is adherent to the cord, forming i)art of it and moving with it. Lipoma, sarcoma, and other growths may occur, but they are very rare. Sec- ondary infiltration is always present in malignant disease of the testis, if the gland is not speedily removed. Hamatocele of the cord has been described. 2. Swellings Confined to the Scrotum. (a) Those Connected with the Scrotum Itself. (Edema. — In Bright's disease, the whole scrotum sometimes becomes enor- mously distended, without the legs being much affected. A moment's consideration is sufficient, but I have known serious mistakes made. Elephantiasis. — In the tropical variety there can be no hesitation, but occa- sionally a greatly thickened and hardened condition, not so plainly recognized, is met with as a result of neglected stricture. Lipoma, epitliclioma, and other varieties of new growths may occur. (J)) Those Connected with the , Testis and its Coverings : these may be solid or fluid. The former include inflammatory diseases and tumors of the testis. The chief difficulty occurs with hsematocele and old hydrocele, the walls of which may be so thick that they are practically solid. The latter may be connected with the tunica vaginalis (hydrocele or haema- tocele) ; the testis or epididymis (encysted hydrocele) ; or the lower end of the cord (hydrocele of the cord) ; or they may be independent cysts — dermoid, for example, or hydatid. Some difficulty may arise from what is known as hydro- sarcocele, a collection of fluid in the tunica vaginalis, surrounding and concealing an enlargement of the testis, and the diagnosis may remain uncertain until the fluid is drawn off. Malformation of the Testes. The full development of the testis is not reached until sexual maturity. It may fail : (i) either in its original formation ; (2) in its evolution (including its descent into the scrotum) ; or in both together. In addition, it occasionally happens that, though perfectly developed, it becomes displaced (malposition). (i) Defective Formation. — The testis and epididymis are developed indepen- dently of each other, although they are in close connection ; sometimes one fails, sometimes the other. If the former, the epididymis and the vas may occupy their normal situation, the gland itself being represented only by a nodule ; if the lat- ter, the testis may be well developed and of its normal size, although its secretion fails to reach the urethra. Sometimes the whole of the epididymis is wanting ; more frequently only part, and the vas terminates blindly. If both testicles are wanting, sexual development at puberty does not take place, and often there is malformation of the other organs. (2) Defective Evolution. — The testis may fail to attain the normal size, or its normal jjosition, or both. {a) Imperfect Evolution of the Testis whe7i in its Normal Situation. — In most instances the cause is unknown ; the subject of it when the affection is bilateral, has an effeminate appearance ; the voice does not break ; the larynx remains small ; there is no growth of hair, and the limbs are smooth and rounded. When it is unilateral, it is often associated with varicocele, but it is more probable that they are both dependent upon the same cause, whatever that may be, than that one is the consequence of the other. 1 1 28 DISEASES AND INJURIES OF SPECIAL STRUCTURES. (^b) Non-descent. — Descent of the testis may be delayed, or may fail to take place, wholly or in part. In the former case, the testis is usually well (leveloi)ed, and the descent is completed at puberty, when the organ becomes sexually mature. In the latter it is usually small and flabby. The cause is very uncertain, except in those cases in which there is a distinct mechanical impediment, such as fusion of the two glands. Adhesions to neigh- boring structures (especially the intestine) are often present, but there is no proof that they are the reason. The gland may remain in the original position, or be arrested in the iliac fossa, or in the inguinal canal. The .sac of the tunica vagi- nalis nearly always remains open ; hernia is, in consequence, very often present as Avell, and, if not, is always liable to occur ; and, not infrequently, owing to slight attacks of inflammation, there are adhesions between the intestine and the gland. The symptoms and treatment depend upon its position and mobility. If it lies in the iliac fossa, it is well out of the way of injury, and nothing is required but a truss to prevent the development of hernia. If it lies in the inguinal canal and is sufficiently movable to pass out of the external ring, the same treatment may be adopted, a horseshoe-pad being used to avoid undue pressure upon it. If it is fixed between the muscles the conditions are different. In most cases a truss cannot be worn, and there is constant danger of hernia. The gland itself is always liable to injury and inflammation ; if this occurs, satisfactory evolution at puberty is improbable ; and, like other ill-developed organs, it is liable to become the seat of malignant disease. Under these circumstances, if the tendency to hernia cannot be prevented, or if there has been an attack of inflammation, the gland is better removed. It is, in all probability, functionally useless, and is a constant source of danger. In cases of strangulated hernia the treatment of the gland depends upon its condition. If it appears fairly well formed and not too much tied down by adhe- sions, and if the vas is of sufficient length and the scrotum will admit it, an attempt may be made to transplant it. If this cannot be done it should be excised. 3. Malposition. — The testis may be in its normal position, but inverted ; the epididymis and the vas deferens lying in front of the other structures. If hydro- cele or hematocele occurs, and this condition is not recognized, the gland is liable to be punctured instead of the tunica vaginalis* In other cases the testis passes out through the inguinal canal into the peri- neum, or misses this altogether and slips into the crural ring, even passing out on to the thigh. The treatment consists either in transplantation (waiting until the child is two or three years old) or excision, according to the condition of the scrotum and the gland and the amount of inconvenience it is likely to cause. Neuralgia of the Testis. Pain and retraction of the testis are of frequent occurrence in disease of the kidneys and affections involving branches of the lumbar plexus ; further, after obliteration of the vas, sexual intercourse, or even excitement, may be attended with severe pain and swelling of the gland ; in addition to this, however, the testes in certain people are liable to attacks of intense neuralgia, coming on at regular intervals or excited by the most trivial irritant. I'sually one only is affected, but both maybe ; the gland maybe ajiparently well nourished, or it may be small and flabby ; it may be exceedingly irritable, resenting the slightest touch, or there may be nothing noteworthy about it. In many cases there is a history of injury, but it seldom stands cro.ss-exami- nation. Gout, malaria, anaemia, and other constitutional ailments are sometimes present. It may occur in the most continent ; and though in many there is a history of abuse, it is difficult to connect one condition directly with the other. Sexual hypochondriasis may be associated with it, and often the family history is decidedly neurotic. DISEASES OF THE TESTES. 1129 Treatment is very unsatisfactory. Any local or constitutional cause that can be detected must, of course, receive thorough consideration ; a suspender must be worn ; lead, or some other cooling lotion ai)i)lied ; and the thoughts and ideas as far as possible directed into other channels. Cupping over the loins, massage of the back, and the free (local) use of anodynes may be tried as well. If there is a large varicocele, operation may give relief, but castration is u.sele.ss. Atrophy. Rupture or ligature of the spermatic artery and occasionally acute orchitis (especially that variety which is associated with mumps) are the chief causes, the testicle shrinking to a small nodule. I have known the same thing occur after a blow. Rupture or ligature of the vas deferens, chronic epididymitis, the pressure of ill-fitting trusses, and abuse, may be followed by the same effect ; but the wasting is seldom so extreme. Whether it is ever a result of varicocele is doubtful, though this is so often associated with a soft and flabby condition of the gland. The opposite result, hypertrophy, is said to occur as compensation in cases of unilateral retention. ORCHITIS AND EPIDIDYMITIS. Inflammation of the testis may be caused by injury, morbid conditions of the blood, as in gout or rheumatism, extension from the neighboring structures, or the presence of specific irritants, such as those of tubercle and syphilis. It may affect the testis, only or chiefly (orchitis) ; or the epididymis (epididymitis) ; and it may be acute or chronic, ending in resolution, organization, caseation, or suppuration, according to the cause. In addition, acute orchitis is sometimes due to " meta.sta- sis " in connection with mumps, but only after puberty, and not apparently with equal frequency in all epidemics. I. Acute Inflammation. (^a) Acute orchitis may be caused by metastasis (the parotid is occasionally not affected), injury, or pyaemia ; or it may be due to extension from the epididy- mis or tunica vaginalis. Subacute attacks are not uncommon in gout and syphilis. The gland is swollen and exquisitely tender, but owing to the toughness of the tunica albuginea it retains its shape, and is not so large as in epididymitis, or flattened on the side. The skin is red and oedematous ; the temperature raised, the veins swollen, and the cord thickened and tender, but the structures composing it are not matted together, and the vas is but little affected. The tunica vaginalis is filled with fluid (acute hydrocele) and sometimes obscures the local signs alto- gether — there is merely evidence of intense inflammation without its being possible to say from the appearance of the swelling whether it is confined to the tunica vaginalis or involves the testis inside. Pain is always severe and of a peculiarly sickening character, with heavy dragging in the loins; and the constitutional symptoms are often very grave, delirium sometimes occurring in the metastatic variety. Localized peritonitis with spasmodic contraction of the abdominal muscles is not unfrequent when a retained testis is inflamed, and it has been known to prove fatal. (J)) Acute epididymitis is nearly always due to extension from the urethra, though the actual outbreak is often determined by local injury. It may be caused by any irritation affecting the prostatic portion, gonorrhcea (not the acute stage, 72 II30 DISEASES AND INJURIES OF SPECIAL STRUCTURES. but later when the gleet is chronic), impacted calculus, injections, lithotrity, or even the jjassage of a catheter. Exceptionally it follows injury alone, or occurs in the course of pygemia. Subacute varieties are met with in the early stage of secondary syphilis, and occasionally as a result of stricture and chronic urethritis. This is of special importance, as sometimes, when there has been no acute attack, the enlargement closely resembles that due to tubercle before caseation has begun. The general symptoms are the same as those of acute orchitis, but the two affections can nearly always be distinguished. The shape is different ; instead of being rounded, it is flattened by the pressure of the thigh upon the outer side ; and the testes can be felt, soft and almost painless in the front. The skin is red and oedematous, especially behind and below, and it cannot be pinched up into a fold or lifted off the subjacent structures. The pain begins in the loins before there is local tenderness, and in the same way the groin may be exquisitely sensi- tive before the testis is affected. But the most important point of all is the con- dition of the cord : the vas deferens is enlarged ; the cord immensely thickened ; and all the structures in it matted together so that they cannot be isolated. Epi- didymitis is rather more common upon the left side than the right, and seldom involves both at the same time, though the second is frequently attacked as the first is getting well. The urethral discharge ceases so long as the inflammation is acute, and begins again as it subsides. Termination. — Acute inflammation, whether it involves the testes or the epididymis or both (for it not unfrequently extends from one to the other), usually ends in resolution, but not always. Partial organization may occur, affecting especially the exudation in and around the globus minor. An indurated mass is left, painless, gradually sinking into a small, hard nodule, apparently insignificant, but often leading to obstruction or stricture of the vas. If it occurs on both sides and does not undergo speedy resolution the subject is sterile. Atrophy may occur, and in the case of orchitis be complete. Epididymitis, even when the vas is obstructed, seldom leads to this; sexual intercourse may be very painful and be followed by the swelling of the gland, but unless the artery is obliterated at the same time the testis seldom wastes altogether. A curiously irritable condition sometimes persists, the testis and even the skin of the .scrotum remaining excjuis- itely tender. Suppuration occasionally follows ; gangrene of the scrotum and sloughing of the testis have been known ; and tubercular disease is not uncommon. Whether epididymitis has any connection with the vaginal hydrocele that so fre- quently develops in later life is uncertain. The acute effusion that accompanies the attack subsides with it, though it may leave permanent adhesions, and some- times causes obliteration. Treatment. — If possible, the patient should be confined to bed with the scrotum raised on a small pillow between the thighs. In other cases a suspender must be used, but the effect is not nearly so good. The bowels should be freely opened, liquid diet only allowed, and rest ensured by means of morphia or chloral. In young plethoric patients, with a hard, bounding pulse, full doses of antimony may be given at frequent intervals until there is a distinct feeling of nausea, but this is of no good after the first twenty-four hours, and only when the fever begins with severity. Smaller doses three times a day are useful later, if the skin con- tinues hot and dry, or the headache is severe. In urethral epididymitis cold is by far the best application, especially at the beginning. An ice bag may be laid upon the part, or Leiter's coils used, lead lotion being substituted after twenty-four hours. If the patient cannot remain in bed, the skin of the scrotum should be covered over with extract of belladonna and glycerine ; and then, the other testis being pushed out of the way, surrounded with many layers of cotton-wool and subjected to gentle compression by means of a laced-up bag suspender. A few common rubber bands may be placed outside niSEASES OF THE TESTES. 1131 this with advantage. The application should he renewed at least twice a day, the patient fomenting the part each time with hot water, or, better, sitting in a hot bath. If the belladonna causes any irritation, lead may be substituted for it. The urethra should, of course, be left alone, not only ^^^lOnV'^v during the inflammation, but after it has '^ ' subsided. If the effusion into the tunica vaginalis is at all considerable, a few punctures may be made with a fine tenotomy knife, or an ordi- nary trocar and cannula may be introduced; and if the veins of the scrotum are distended, Fig. 489.— Strapping Testicle. they may be pricked and encouraged to bleed ; or leeches may be placed upon the inguinal canal ; but, although it is largely practiced by some surgeons, and apparently with impunity, puncture of the testis itself is not advisable. Later, when the acute symptoms are beginning to subside, the testis .should be strapped. The affected organ is separated from its fellow, and isolated by winding round above it a long, narrow strip of soft leather covered with emplas- trum plumbi. The end that is applied first should be narrower than the other, so as to prevent the edge cutting into the skin. Then narrow strips of ordinary plaster are arranged so as to cover the whole organ evenly, beginning from the horizontal piece in front, passing down round the bottom of the scrotum, and ending on it again behind. Afterward a circular piece is placed over all the ends to keep them secure. If a small nodule obstinately persists, mercurial ointment may be rubbed in over it, or a thick layer of it may be applied upon lint under the strapping, but care must be taken that it does not irritate the skin. Traumatic orchitis may be treated in the same way. When due to metastasis warm fomentations are better from the first ; and if there is much infiltration of the scrotum, so that the condition of the circulation is doubtful, or if the patient is old and feeble, cold should not be used, for fear of gangrene. 2. Chronic Inflammation, This may begin as such or be the relic of an acute attack. When confined to the body of the testis it is nearly always due to syphilis ; gout and malaria are exceptional causes. If the epididymis only is concerned, it is probably tubercular or urethral, and in the latter case it may be either the remains of an acute attack or chronic from the first. Syphilis occasionally affects the epididymis only (in the early secondary period), and not unfrequently both epididymis and testis. l"he diagnosis is usually straightforward ; but sometimes, when it com- mences insidiously, without any obvious degree of inflammation, involving the body of the gland, and not the epididymis, and affecting one side only, it is diffi- cult to distinguish it from incipient malignant disease, except by watching the progress of the case and the effect of treatment. (a) Syphilitic Inflammation. Subacute epididymitis may occur in the early secondary stage, a painful irregular swelling making its appearance at the back of the testicle, involving the cord to a slight extent. It never possesses the severity of urethral epididymitis ; the skin may be reddened, but it is not oedematous ; and, like the other secondary symptoms with which it occurs, it subsides rapidly under mercury. True orchitis appears later, either during the intermediate period (when both .M^m^'^^: 1 132 DISEASES AND INJURIES OF SPECIAL STRUCTURES. glands are involved), or with the tertiary symptoms, when one is often attacked long before the other. As a rule, it does not affect Vj'-V; .'■ 1'%^ the epididymis or the cord, and is very chronic in its f*^^'Vj !?;«' progress; but often, in neglected cases, after the first ll^'!^''^*.^^^:., testicle has been enlarged for some time, the second ^./^Kj^^?v'^>>'^i^i>^ suddenly becomes actually inflamed, the skin grows hot and red, the tunica vaginalis distended, the epi- didymis affected as much as the testis, and the pain so severe that the patient is comi)elled to apjily for relief. Symptoms. — The character of the swelling "■''^f^' depends upon the distribution of the syphilitic exu- ■ ,^ " '3/ dation, and the changes it undergoes. In some '•'K^ {*\ cases, especially the earlier ones, there is uniform %'^''\ '-' .' enlargement of the whole gland, so that it remains '^.^^^^^^ ' v-" ovoid, smooth, and even, and merely becomes heavy """-sit-iS-Tirr '• and intensely hard ; in others the surface is nodular Fig. 490.— Syphilitic Disease of Testis; and uueveu in cousistence, dense indurated patches a Centra iimma. alternating with Others that are soft and clastic. The e.xudation, in other words, may be uniformly distributed throughout the whole of the fibrous tissue of the gland ; or aggregated either into one central gumma or into numerous scattered ones of various sizes ; and, according to the success of the treatment, it may be completely absorbed, merely leaving a slight depression, or become organized into cicatricial bands, or break down and undergo caseation and liquefaction. Occasionally this ends in suppuration and hernia testis ; more frequently partial absorption takes place, and a hard irregular mass is left, some- times in the middle, sometimes at one side of the testis, composed of a caseous or even calcareous centre, surrounded by an immense thickness of cicatricial tissue — a so-called chronic abscess. The size a testicle may reach under these conditions is something enormous ; usually when large it is painless and devoid of testicular sensation. Heat, redness, thickening of the cord, oedema of the skin, and effusion into the tunica vaginalis are signs of acute inflammation, and are only present when the testicle is first attacked, or when a fresh gumma suddenly develops. I have known cases of this kind to last for ten years, with occasional subacute attacks compelling the patient to apply for relief, until at length the testicles were enormously enlarged, irregular in shape, hard, painless, and absolutely devoid of sensation. The diagnosis of syphilitic orchitis is rarely difficult ; the only form that resembles it is that which occurs in gout. The chief features are the essentially chronic character of the affection (varied from time to time by more acute attacks) ; the smooth, hard, heavy character of the swelling ; the disappearance of the epi- didymis, which in many instances is so flattened out that it cannot be felt (occa- sionally it is enlarged) ; the absence of pain (during the greater part of the time), and of testicular sensation ; and the fact that both testes are involved, though rarely equally. Treatment. — In epididymitis and recent orchitis, mercury may be given freely with a view of causing speedy absorption ; later, especially if the disease has relapsed, more benefit is derived from small doses of bichloride, continued with occasional breaks. Iodide of potash always causes a rapid diminution in size, but absorption of the syphilitic exudation is rarely complete ; it progresses up to a cer- tain point, continues as the dose is increased, and then comes to a standstill, leav- ing a dense mass, over which nothing appears to have any influence. The acute symptoms, however, are quickly relieved by it. Occasionally other remedies are of service : mercury, for example, rubbed into the skin on the inner side of the thigh (it cannot be ai)i)lied to the scrotum), strapping, or the removal of hydro- cele fluid.^ . If suppuration occurs, the ab.scess must be opened ; and at length, if the testis becomes useless, and is a constant source of pain and suffering, castration may be advisable. DISEASES OF THE TESTES. ^^Zl (J)) Tubercular Disease. This is most common about puberty and in young adult life, although it may develop at any age, and it may be either primary, and followed by extension to other organs, or secondary, sometimes occurring as part of general tul)erculosis. Except in this case (which from the condition of the patient rarely admits of diag- nosis during life) it always begins in the epididymis as a deposit of gray miliary tubercle in the lymphoid intertubular tissue. From this it may spread into the body of the gland, working its way through the mediastinum testis, and infecting the lymphoid tissue around the tubuli seminiferi ; or up the vas, to the vesiculae seminales, prostate, and bladder ; or it may, under happier circumstances, after attaining a certain size, gradually cease to enlarge, and either discharge itself externally as a mass of caseous debris, or undergo calcification or fibroid degenera- tion. One side is usually attacked first, but it rarely happens that the other remains exempt for long. Symptoms. — The beginning is rarely noticed : a'hard nodule, already of some size, is usually discovered accidentally at the back of the gland. It is quite painless ; there is no hydrocele, and scarcely any inflammation ; it is only slightly tender even on pressure, and testicular sensation is not impaired. At first it may be rounded or irregular, but after a time it becomes crescentic, and grows out above and below the testis as well as behind. The gland itself is rarely affected at this stage. Sometimes this diminishes in size, and becomes harder and more irregular, probably undergoing fibroid degeneration. More frequently it continues to increase ; one part becomes softer than the rest ; the skin over it grows red and adherent ; then becomes thinner and thinner until it breaks, and gives exit to a turbid caseous liquid resembling pus. Occasionally even then the morbid process ceases ; more frequently other deposits break down ; more sinuses form ; the testis and vas become involved ; and at length secondary deposits make their appearance elsewhere. Hernia testis may occur, although it is not so common as in syphilis. Diagnosis. — Urethral epididymitis is usually acute. Sometimes it is chronic from the first ; but then therfe is seldom a real increase in size ; there is merely a certain degree of induration, usually limited to the globus minor. The secondary syphilitic form disappears within a week or ten days, under mercury. Cysts may cause a little trouble, but when they occur in connection with tubercular epididy- mitis they are never very large or distinct. Treatment. — Constitutional measures are of the highest importance ; in the early stage, when the diagnosis is still uncertain, or before the patient will allow an operation, they may succeed in arresting the disease ; in the later, when there is no longer any hope of effecting a cure by local measures, they will often check it for a time. Perfect rest, especially avoidance of sexual excitement, is most important ; sea-air, often a long sea-voyage, answers better than anything ; the food must be nutritious ; a moderate supply of stimulants allowed ; and tonics, especially cod-liver oil, given freely. The local treatment depends upon the stage the disease has reached. If the globus minor is merely indurated, without there being any definite increase in size, as compared with the other one, or any dis- tinct nodule, the condition of the urethra should be carefully examined, and the testis strapped over iodide of lead ointment. In most cases, however, this stage is already past, and there is a definite nodule, often commencing to soften, at the back of Fig. 491. — Tuberculrir Disease of the Epididymis with Miliary Deposits in the Testis. 1 134 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the testis, or even several of them. If the rest of the epididymis is free, and the vas not thickened, an attempt may be made to arrest the progress of the disease by laying it open, scraping out all the tubercular tissue, and plugging the cavity with iodoform. Such a state of things, however, is rare ; nearly always the whole epididymis is affected, and the vas distinctly enlarged before the patient applies for treatment. Under these conditions, if the opposite gland is sound, and no enlargement of the vesiculae seminales can be detected, the diseased organ should be removed at once, the vas being divided as high up as possible. When the di.sease is more advanced, much may still be done to husband the patient's strength ; sinuses may be scraped out and filled with iodoform ; the testicle carefully pro- tected : the inflammation checked by lead lotion or belladonna; and if there is any serious amount of discharge, weakening or distressing the patient, or if hernia testis forms, castration may be performed. (r) Gouty Orchitis. This is much more rare than either the syphilitic or tubercular variety, and in many of the cases in which it is assigned as the cause the evidence of gout is not so clear as might be wished. Subacute orchitis, however, is not uncommon in men past middle life, especially those of gouty habit, and occasionally is distinctly associated with gout. The testis itself is involved, not the epididymis ; a certain amount of hydrocele is usually present ; the pain and inflammation are severe, though not to the same extent as in urethral epididymitis ; and some chronic induration is not unfrequently left. In addition to this, subacute orchitis may occur in connection with urethral arthritis, hereditary syphilis, and possibly other disorders. 3. Suppuration. Acute orchitis, unless it is due to pyaemia, rarely breaks down and suppurates. In urethral epididymitis this termination is rarely more common, but the.abscess is seldom acute. Most cases arise in connection with syphilis or tubercle, sup- puration either occurring around the caseous mass before it breaks the skin and makes its way out, or, after this has happened, in which case the pyogenic organ- isms may gain entrance through the wound. In any case the abscess should be of>ened as soon as possible and drained. HERNIA TESTIS. Hernia testis, like hernia cerebri, is a protrusion of the substance of the organ through an opening in its unyielding capsule, due to inflammation. Suppuration is not essential to its production, but it is so uniformly present that it is usually regarded as the cause ; the opening in the capsule might, however, be produced in other ways, and the increased tension in the in- terior and softening of the subjacent layers might arise from other causes, such as syphilis or tubercle. Hernia testis must be distinguished from "malignant fungus " of the testis or "fun- gus hasmatodes " — the protrusion of a malig- nant growth through the coats ; and also from what has been called " false hernia" — a prolapse of the testis, covered with a layer of granulations, through an opening in the tunica vaginalis and scrotum. In the majority of cases hernia testis is due to syphilis : a gumma forms in the substance of the organ and breaks down ; the lavers of the tunica vaginalis fuse with each other and with the skin : this grows :.!^ Fig. 492. — Hernia of the Testicle following Tuber- cular Disease, removed from infant, act 2. TUMORS OF THE TESTES. thinner and thinner, until at last it gives way, exposing a cavity filled with caseous or sloughing debris, and lined by a still growing layer of syphilitic exudation. The external pressure is removed by the rupture of the fibrous wall, and if the syphilitic growth or the suppuration is active, a mass, sometimes of granulations, sometimes of the tubuli seminiferi themselves, is forced out through the orifice by the vascular tension. The same thing may occur with tubercle when this involves the testis, and with other forms of suppurative orchitis. The appearance is characteristic. A soft, red, granular mass, occasionally covered withsloughsor caseous debris, projects through an opening in the scrotum, to the margins of which it is closely adherent. In some instances it seems as if the whole testis is driven out, and the edges of the opening are everted and con- cealed beneath a mushroom-shaped mass ; in others there is merely an open sore with protuberant granulations at the bottom. It does not bleed very readily (like the malignant form), and, as there is now no tension, is not very painful; but, particularly in the tubercular variety, it may prove a serious drain upon the patient's strength. Treatment. — As in hernia cerebri, the first point is to stop the inflamma- tion. If this can be done the protrusion soon subsides spontaneously ; the wound becomes a granulating sore, and cicatrization begins. Occasionally, if the surface is perfectly clean, this may be hastened by Syme's operation — removing the nar- row edge of unhealthy skin around it by means of two elliptical incisions, one on each side, and drawing together the margins over it, but it often fails. In tuber- cular cases, in which the testis is pracfically destroyed and the caseous process will not cease, castration is usually advisable, not with a view of curing the patient so much as of relieving him of a source of infection and a constant drain upon his strength. TUMORS. Derinoid and hydatid cysts are occasionally met with. The former may be recognized by their congenital origin (though they often do not attain much prominence until late in life) and uneven consistence ; but no certain diagnosis can be made without puncture. Cystic adenoma is more common. Like parotid glandular tumor, it is pecu- liar to the organ from w^hich it springs, and only admits of a somewhat vague comparison with other growths. It consists of cysts of all sizes, lined with cubical or flattened epithelium, filled with a clear brownish or greenish fluid, and devel- oped from the tubuli seminiferi, the epithelium of which has either lost or has never acquired its distinctive charac- ters. In between is a variable amount of fibrous tissue, sometimes undergoing myxomatous degeneration, and occa- sionally mixed with cartilage. Intracys- tic growths may occur as well. Tumors of this kind may occur at any age, but they are rarely noticed be- fore puberty. Growth is slow and pain- less, the patient suffering no inconveni- ence other than that due to the weight. The vas is never affected, and secondary deposits do not occur, the cases in which this is said to have taken place having really been sarcomata, with an accidental development of cysts. Fibroma and enchondroma of the testis are met with in young adult life, but they are both very rare. The chief clinical feature is the slow growth of a Fig. 493. — Cystic Disease of the Testicle. 1 1 36 DISEASES AND INJURIES OF SPECIAL STRUCTURES. hard and heavy painless mass. The surface is usually smooth, but it may be nodu- lar and suggest the [presence of cysts. Growths of this kind do not extend along the cord, invade other organs, or recur ; but removal is always advisable. There is no means of distinguishing one from the other but by section. Carcinoma of the testis is nearly always encephaloid, though a few cases of scirrhus have been described. It is stated to be most common between twenty and forty years of age. The beginning is usually very insidious ; the testis is enlarged, smooth, ovoid, and at first fairly firm, the cord is not thickened, nor are its components matted together, but it feels fuller than the other, and the veins over the scrotum are distended. There is little or no pain or tenderness, and testicular sensation is soon lost. In a very few weeks there is a rajjid increase in size ; the tumor is softer, the surface uneven, the cord distinctly thickened, the shape becomes globular, and the epididymis flattened out at the back. If left, it becomes so soft that it almost seems to contain fluid ; the skin becomes adherent, the veins are more distended, the thickening extends higher up the cord, and, j^erhaps, if the patient is thin, an ill-defined sense of resistance can be made out by deep jiressure at the back of the abdomen. Soon the skin of the scrotum gives way, allowing a bleeding mass to protrude, the glands of the groin enlarge, secondary deposits make their appearance in other organs, and the i)atient sinks rapidly from exhaustion. Sarcovia of the testis presents greater variety of appearance and character. It may be round-celled, or spindle-celled ; and the latter especially may become more or less converted into cartilage (without, however, losing one atom of its malignant sarcomatous character) ; sometimes there are only nodules here and there, sometimes branching outgrowths, due, perhaps, to the spreading of the disease inside the lymphatics, and occasionally so much that the original sarcomatous growth is hard to find. In addition, both of these forms may be associated with cysts, due either to softening and hemorrhages, or to distention of the seminiferous tubules, with proliferation of the epithelium lining them, and occasionally intra- cystic growths, so that they may present a close resemblance to some of the forms of cystic adenoma. Sarcoma may occur at any age, even before birth, though it is most common under ten years and between thirty and forty. The round-celled variety, unless the patient is a child, or both testicles are attacked at once, cannot be distinguished from encephaloid carcinoma ; the progress is as rapid, and the glands of the lum- bar and other regions are involved as soon ; if possible it is even more fatal. The other variety is much less uniform in rate of growth and consistence ; it may, for example, be formed almost wholly of cartilage or fibrous tissue ; cysts are less common ; and it does not appear so ready to fungate ; but the ultimate results, the infiltration of the glands with growth of the same histological character as the primary one, and the secondary deposits in the lungs and other organs, are equally certain. Treatment. — Sarcoma and carcinoma should be removed as .soon as the diagnosis is made, the cord being divided as high up as possible. The i)rognosis is very unfavorable, but in all probability this is due in some measure to delay ; there is evidence to show that if castration is performed in time recurrence may not take place for many years. Even if the skin is involved, and the cord thickened, the operation is advisable to save the patient from the formation of a fungus, if only there is reasonable prospect of securing immediate union of the wound. Diagnosis of Tumors of the Testes. Age. — A tumor that api)ears in infancy is probably hydrocele ; sarcoma, syphi- litic and tubercular orchitis do occur, but they are very rare in comparison. Etiology. — A definite history of accident deserves consideration, though it may have merely drawn attention to an already existing, but unsuspected, enlarge- ment. Sarcoma may follow injury as well as hrematocele. CASTRATION. 1137 Rapiditx of Groioth. — Hajmatocele is an affair of minutes, or at most of hours, malignant disease of a few weelersists indefinitely and may be the cause of many troubles, both local and general. " Trachelorrhaphy " is the term applied to the oi)eration proposed by Emmet for the rej)air of the laceration. The patient is i)laced in the lithotomy position, and the uterus drawn down as far as possible by means of a tenaculum. The lacerated surfaces are well expo.sed, and a strip of mucous membrane removed on either side, leaving a broad tract un- denuded between them ; this tract will form the cervical canal and external os RUPTURED PERINEUM. 1,69 when the operation is completed ; the flaps are then approximated and the sutures applied. The insertion of the sutures is not an easy matter, owing to the difficulty of getting at the parts and the toughness of the uterine tissue. A short, very stout, and slightly-curved needle is required and a strong needle holder ; the needle should be armed with a silk loop, and when it has been inserted through both lips, a silver wire threaded into the loop should be drawn into position ; three or four sutures will be required on either side ; they are best secured with a coil and clamped shot, and one end left long to facilitate removal. They may be removed on the .seventh day, though some prefer to leave them until the tenth or even longer, as they seem to cause but little irritation. The operation should not be undertaken if there is any pelvic inflammation or cellulitis. Rupture of the pei-ineum is also an accident of labor. It may be " partial " only, extending through the fourchette, or "complete," involving the sphincter ani and more or less of the recto-vaginal septum. An attempt should always be made to repair the injury at the time of the accident, although it is not always suc- cessful. Innunlerable modifications have been proposed, and are employed jjy dif- ferent operators in the repair of the perineum. The operation for complete rupture is as follows : The bowels having been well opened and an enema administered the same morning, the patient is placed in the lithotomy position. An assistant stands on either side supporting the patient's knee under his arm ; with one hand he draws the labia apart, and the other is free to assist the operator. Sitting in front of the patient, the operator inserts the first and second fingers of his left hand into the anus, and putting the parts upon the stretch, he denudes the surface in the following manner : At a point about half an inch external to the septum, the point of a scal]jel or pair of scissors is passed into the tissues and carried along between the ^^._.^_— ^^ , _^ ^ -_ mucous surfaces of the vagina and rectum, v ' -j.- dividing the septum into an anterior and posterior flap ; the incision is terminated at an equidistant jjoint upon the opposite side. Sometimes the line of incision is more or less marked out by an area of pale cica- tricial tissue, but this is not always so. From either extremitv of this transverse .^. . , .,_.. . ,,^ incision, another is carried forward to the "^ SS^^ ) rS' lesser labium, and backward to the extrem- ity of the anal orifice. In this manner an H-shaped incision is formed. The inci- sions must be freely made, or the surface de- — - nuded will be insufficient to form a strong — —-I perineum, and the flaps will require further ~i'V" -—• dissecting up. Hemorrhage is generally considerable, but can be kept in check by " -^^^^^ii-^-^- .^' sponges and pressure forceps ; ligatures are - not required. The free edge of the an- Fig. 505.— incision in Rupture of the Perineum terior flap is secured by a couple of forceps and held up by the assistants on either side ; the sutures are then inserted. Some prefer to bring together the mucous membrane of the anus first, but no advantage is gained by this. Either silver wire or silk-worm gut may be employed. Com- mencing at the lower part, the needle, which is moderately curved and mounted on a strong handle, is entered on one side about a quarter of an inch from the margin, or, as represented in the figure, into the denuded surface just within the margin. ■ It is then carried between the layers of the recto-vaginal sejjtum and brought out in the middle of the denuded surface, threaded with one end of the suture, and withdrawn. The needle is then passed on the opposite side in a similar manner, the point being made to emerge at the same hole. It is threaded with the other end of the wire, withdrawn, and the suture thus completed. Three or II70 DISEASES AND INJURIES OF SPECIAL STRUCTLRES. four sutures are passed in this way through the recto-vaginal septum : one or two more are reipiired in front, and one or two for the rectum. In passing the rectal and vaginal stitches, care must be taken to enter them just at the cut edge of the mucous membrane, so that perfect adajjtation of the raw surfaces may be ensured. The sutures having been all inserted, the wound is carefully sponged, and the patient's knees brought together. The sutures are then tied firmly, but not too tightly, commencing from the lowest ; the wire may either be twisted or secured with shot and coil. The wound is dressed with some absorbent wool and a T- bandage applied. A morphia suppository should be administered, as the pain after the operation is often very considerable. The repair of a partial rupture is generally unattended with much difficulty. 1 i \ Fk;. 506. — Method of Inserting Sutures. Fig. 507. — Sutures in a case of Ruptured Perineum. A V-.shaped incision is made through the integuments, the apex being just in front of the untorn remains of the perineum and the branches extending to the labium minus on either side. The anterior extremities of these are united by an incision which crosses the mucous membrane about an inch and a half from the apex, and the enclosed surface is then denuded ; or the V-shaped flap may be dissected up and carried forward. Sutures are inserted as in the previous operation. The after-treatment consists in keeping the parts clean. The catheter is required every eight hours for some days. The bowels generally have a tendency to act of themselves about the fourth or fifth day. This may be encouraged by a mild aperient followed by an enema. It adds greatly to the discomfort of the patient to keep them confined by means of opium, and is quite unnecessary. The stitches may be removed about the eighth or tenth day. DISEASES OF THE NIPPLE. 1171 CHAPTER XXVI. DISEASES OF THE BREAST. Ahnormal Development. Complete absence of the mammary gland is very rare ; imperfect evolution at puberty, the breast retaining the infantile type, is not unfrequent, especially when the sexual organs are not developed. Polymastia is more common. In most instances, the supernumerary struc- tures are rjuite rudimentary, merely imperforate nipples with a linear depression and no areola; but sometimes they are well-formed glands, functionally active. Usually they lie in pairs along the line of the internal mammary artery, and are lower down upon the thorax ; but a few instances are recorded in which they have been found above the normal level, in the median line, and even in distant parts of the body and upon the limbs. In addition to this, milk-producing tracts of integu- ment, and, more rarely, small, well-defined glands, are, as Champneys has pointed out, occasionally developed in the axillary region during the lying-in period. Hypertrophy. — Proportionate overgrowth of all the parts of the breast is very rare, but cases of enormous and rapid enlargement, affecting the connective tissue only, are not uncommon in young women about the time of puberty, and even in men. It may affect one side or both, and the size may be so great that the patient is scarcely able to support the weight. The skin is thickened and rather coarser in texture, and the areola much longer than natural ; but in other respects there is no very conspicuous alteration, and the consistence is perfectly uniform, which serves to distinguish this at once from enlargement due to rapidly growing tumors. Nothing is known as regards cause, and no treatment has any effect. Excision may be performed if the inconvenience becomes extreme, but the operation is not a light one. In a few cases the enlargement increases very seriously during preg- nancy ; in the majority the breast either fails to secrete altogether, or does so only to a very limited extent. Affections of the Nipple and Areola. Inflammation of the nipple is of common occurrence during lactation, owing to the constant moisture and friction to which the part is subjected. The delicate epidermis is detached, leaving a superficial excoriation ; this deepens into a fissure, usually between the rugae or at the base, and in bad cases ends in serious ulcera- tion. The pain when the part is touched, or an attempt is made at suckling, is simply agonizing, and even when mammary abscess does not follow, often leads to grave impairment of health and strength. It usually occurs with the first child, and in those whose nipples are ill-de- veloped. During the period of pregnancy the skin should be carefully hardened by bathing it night and morning with spirits and water, and, if there is any need for it, the nipple should be gently drawn out by suction through a properly con- trived tube. Afterward the greatest care must be taken to keep it as dry as possible, and to cleanse it thoroughly every time the child leaves it. If there is the least excoriation, a mild or soothing ointment, such as almond oil, may be applied, and a shield should be used. If it continues and forms a fissure, it may be necessary to make use of a breast-pump, in order to save the patient the pain. Lead lotion, glycerine and tannic acid, styptic colloid, and similar remedies may be used at first (taking care that the nipple is cleansed before the child is put to it) ; but if the ulceration persists, it is better to touch the base with 1 1 72 DISEASES AND INJURIES OF SPECIAL STRUCTURES. nitrate of silver, the pain being prevented by applying a solution of cocaine first. When the scab drops off, the epidermis is sound beneath, though very thin. In addition to this, eczema of the nipple is occasionally met with during suckling, the locality being determined in all probability by the continual moist- ure ; abscesses may occur in connection with the sebaceous glands of the areola ; small sebaceous cysts and papillomata may develop, and, especially in wet-nurses, typical syphilitic chancres may form, the infection being derived from the fissures and mucous patches so commonly found at the angles of the mouths of infants suffering from hereditary disease. Facet's Disease. Eczema of the nipple must be distinguished from a peculiar disease of the skin closely resembling it, which was first described by Paget, and which is of great im{X)rtance from the frequency with which it ends in carcinoma. It affects the nipple and the areola. The surface in most cases is raw, intensely red, and finely granular, like that of an acute diffuse eczema, with a copious yellow and viscid discharge. In others it resembles a more chronic form, or it is like psoriasis, spreading beyond the areola, and covering the breast with scattered blotches. Nearly always there is itching and sometimes a sensation of burning. The base is always considerably thickened, and occasionally the ulceration is so extensive as to lead to destniction of the nipple. The chief features distinguishing it from ordinary eczema are the well-defined margin it presents, and the evidence of deeper infiltration of the papillary layer of the corium. What proportion of cases ends in carcinoma (it is probably a large one), and how long it continues before this breaks out. are questions still unsettled, but the intimate connection of the two (though not their identity), may be considered as w^ell established. The usual form is duct or villous carcinoma, but the squamous typ)e may occur. The microscopic appearances, according to the earlier observers, merely pre- sented a certain degree of proliferation of the deeper layer of the epithelium, with small-celled infiltration of the corium beneath, dilatation of the ducts, pro- liferation of the secreting cells in the acini, and finally the invasion of the epi- thelium and the development of carcinoma. Recently, however, another signifi- cation has been assigned by Darier, Wickham, and others, to certain peculiar highly refractile cells that are present in the epidermis and in the ducts of the milk and sweat glands, and are usually best developed at the growing margin. They may be found, in a scraping of the surface mixed with water, though their relation to the other cells can only be seen in sections. When small, they are difficult to distinguish ; as they increase in size a doubly refracting membrane forms around them ; the other cells are pushed aside or altered in shape, and at length they develop into {peculiar rounded bodies, much larger than the other cells, and either containing a mass of protoplasm, or else divided in two, very much in the fashion of a S|X) re-bearing cyst. The irritation causes the sui>erficial layers to desquamate, the inter-papillary processes grow larger, and at length the exudation accumulates to such an extent that the line of separation between the epithelium and the corium disappears. These cells are said to be psorosperms or coccidia, and to belong to the sporozoa. Undoubtedly they are characteristic of the eczematous stage, and, according to Wickham, they occur not only in the consecutive carcinoma, but in other forms of cancer as well. Similar structures have been described in connec- tion with moUuscum contagiosum. Cultivation has not succeeded, but it is signifi- cant that after maceration in water for sixteen days, when all else had disappeared, they still remained intact. Free removal is the only treatment. In many cases this means excision of the breast, as the nipple with the areola and the skin around must be taken away. INFLAMMATION OF THE BREAST. 1173 It is possible, however, if the view that the disease is really the product of these psorosperms receives confirmation, that microscopic examination of obstinate cases of eczema may lead to earlier operation, while the disease is still limited, and before such drastic measures are necessary. INFLAMMATION OF THE BREAST. Inflammation of the mammary gland may be acute or chronic. The latter (with chronic abscess) will be dealt with by itself, as its pathology is not certain. Acute Inflammation. This is common at birth, puberty, and during lactation. At other times of life it may be caused by violence, but it is, comparatively speaking, rare, and syphilis, tubercle, and other specific diseases seldom attack the gland (chancre, of course, is different). The starting point is usually some slight injury, such as friction or a blow. When it occurs at birth or puberty, it nearly always under- goes resolution, although suppuration may occur as in other parts. On the other hand, when it breaks out during lactation, suppuration is exceedingly common, the pyogenic organisms entering either through cracks and fissures of the nipple, or, po.ssibly, finding their way up the ducts into the acini and the periacinous spaces. 1. At Birth. — The breasts of infants of both sexes often secrete a milk-like fluid for a few days after birth. The gland is slightly swollen on the third or fourth day ; this reaches its maximum by the end of the week, and then subsides. The only treatment necessary is to protect the part from injury. If the skin is very hot, or the swelling continues to increase, a compress wetted with warm lead lotion may be laid upon it, but no attempt should be made to rub the milk away. If suppuration occurs, it must be treated as an ordinary abscess. 2. .At Puberty. — The same thing is occasionally met with at this time, owing to the rapid developmental changes that take place, but unless there is some injury, or the general health is greatly enfeebled, suppuration rarely occurs. 3. During Lactation. — Toward the end of pregnancy, and during the first few weeks of lactation, inflammation of the mammary gland is exceedingly com- mon, as might be expected from the extreme rapidity and extensive character of the changes through which it passes. It may be caused by any trivial injury, even the persistent drawing of an infant at a breast that cannot secrete, or the accumulation of the milk in one of the lobes. The whole gland, or the affected part, becomes even more tender than the rest, and very painful. When touched, it feels firm and dense, and if the area involved is large or near the surface, the skin is redder and warmer than that of the opposite side. In addition, there is usually a certain degree of feverishness, with thirst and anorexia, but it is difficult in most cases to say how far this arises from the affection of the gland. Distinct chills rarely occur without suppuration. The same thing may take place toward the end of prolonged lactation, especially in those women who are weakened by having borne many children in rapid succession, and, more rarely, at other times when the gland is entirely inactive. The treatment depends upon the condition of the gland. If it is at rest, the inflammation is, as a rule, merely periglandular, and it is sufficient to confine the arm to the side (or, if the attack is severe, place the patient in the recumbent position), cover the breast with compresses moistened with lead lotion, and pack it so as to exert a certain amount of uniform gentle compression. Cold is very beneficial, and may be conveniently applied with Leiter's coils, but many patients are inclined to resent it. If, however, the gland is in a state of functional activity, this is not sufficient. The nipple must be carefully examined to see if there are any obstructed ducts. Hardened lobules must be gently rubbed away with fric- 1 1 74 DISEASES AND INJURIES OF SPECIAL STRUCTURES. tion toward the nipple. The milk must l)e drawn off witli a hreast-piimp, or better with a suction tube. The patient must l)e confined to bed, the breast well sup- ported from beneath and at the side, and gentle pressure ai)plied around the gland, except toward the axillary border. If this does not succeed, lead lotion, or lead with opium or belladonna, may be applied ; but, as a rule, if the attack is taken in time, these may be dispensed with. Constitutional measures must be guided by the condition of the patient. If the gland is at rest, or if the inflammation com- mences in the earlier weeks of lactation, and the attack is acute, and the bowels confined, saline purgatives are very beneficial. If, on the other hand, the patient is weak and exhaustetl, and has been already suckling too long, the bowels may require to be opened, but (piinine and other tonics should be given instead. Mammary Abscess. Suppuration occurring in the mammary gland at birth or puberty requires no special description ; it follows inflammation as a natural consecpience if the vitality of the tissues is much lowered, and if the pyogenic organisms are brought in suffi- cient numbers by the blood. That variety, however, which breaks out toward the end of pregnancy or during lactation, when the gland is in a state of full physiological activity, is very different. It usually occurs either with the first child, in the first few weeks after partu- rition (and then it is nearly alway associated with cracked or defective nipples), or, in those who have borne many children, as a result of unduly i)rolonged lacta- tion. One or more of the lobules become inflamed ; the pyogenic organisms gain entrance, sometimes through the blood-stream, much more fretjuently through some minute excoriation of the nipple (the lymphatics of the breast radiate from this point through the gland to its base, and then for the most part run on the surface of the pectoral fascia to the axilla), or, perhaps, through the ducts themselves; and suppuration follows, diffuse or limited, according to the size of the area in- flamed and the vitality of the tissues involved. It is usual to divide mammary abscesses into three classes, according to their situation — superficial, intraglandular, and submammary. {a) Superficial Abscesses. — These require no sjjecial description ; they should be opened and drained as soon as the diagnosis is made, to prevent the skin becom- ing undermined. ij)) Intrai:[/anditlar ones are more serious. It is i)robable that they may begin either in the lobes themselves, or in the loose cellular tissue around them ; but it is rarely possible to distinguish one from the other. The earlier symptoms, those due to the inflammation, have been described already; sui)puration may begin acutely, with a definite chill ; more frequently the pain and swelling merely grow worse and worse ; the breast becomes larger and larger (the ni[)ple often being retracted owing to the tension on the ducts) without its being possible to indicate any definite locality as the seat of the mischief, and the constitutional symptoms more and more severe. After a few days, when the tough fibrous tissue that sur- rounds the suppurating lobule (if it commences in one) has given way, there is often a certain degree of improvement ; the pain is less severe, and the tempera- ture falls a little ; then, by degrees, the skin at one spot becomes thickened, oedematous, and tied down, giving some indication as to the direction in which the suppuration is progressing, and at length one spot softer than the rest can be made out in the centre of the swelling. The sooner the pus is evacuated the better, but it is necessary to wait until some idea can be gained as to its position and the direction it is following ; explor- atory operations in a breast in a state of full physiological activity are not advis- able. The incision should be free, radiating from the nipple so as not to cut the ducts across, and suitably arranged for drainage. As the interior of the abscess is always irregular in shape, it should be thoroughly explored with the finger ; a drainage-tube introduced into every pocket ; and the whole circumference packed INFLAMMATION OF THE BREAST. 1175 with soft absorbent dressings, so that the Ihiicl that exudes may be driven toward the opening. More than one incision may be required if the abscess is allowed to burrow in all directions through the gland before it is opened. Such cases, and still more those in which the pus is left to work its way out as it pleases, often leave irregular sinuses which persist for years, draining the patient's strength, and ultimately leading to the destruction of the gland as a secreting organ. (f) Submammary abscesses are fortunately rare. They may commence in the deeper lobes of the gland and spread through the subjacent fascia, or be due to direct infection through the lymphatics. In many cases they are a.ssociated with symptoms of pyasmia, and probably they are often embolic. The breast itself is but little affected ; it is thrust out from the chest-wall and floats as on a water-bed. Sometimes they develop insidiously ; more often they are attended with very severe symptoms. If left, the skin usually gives way below the gland ; but frequently large tracts slough, leaving great cavities fringed with blue, congested, overhang- ing flaps. I have known an abscess of this kind extend from the sternum to the spine, undermining the skin and destroying the cellular tissue half-way round the body before it broke. Great care must be taken in opening these to secure effi- cient drainage, and to bring the opposing surfaces into accurate contact, so that no decomposing pus may be retained in outlying pockets. Chronic Inflammation. Chronic interstitial mastitis, affecting one or more of the lobules, is of very great importance, from the pain and anxiety it occasions and from the difficulty of distinguishing it from the early stage of scirrhus. The interacinous spaces are filled with a small-celled infiltration, which becomes organized and contracts into dense cicatricial tissue. The acini disappear or become converted into retention cysts, filled with a clear but often colored liquid ; and by degrees the lobule becomes changed into a hardened mass of very irregular shape, adherent to the structures around (so that it cannot be pushed about like a fibro-adenoma) ; and sometimes, if it involves one of the larger ducts, attended with retraction of the nipple. No cause can be found in the majority of cases. It is most common about the menopause ; it is often associated with disorders of menstruation, and at each period it usually becomes painful and tender ; but, on the other hand, it may occur at any age and in those who are to all appearance perfectly healthy. Pain, often of a neuralgic character and sometimes very severe, and made much worse by handling, is usually the first thing noticed ; and the induration is only found on examination. The diagnosis, so long as the patient is under thirty years of age, is not very difficult (although the possibility of carcinoma must not be overlooked) ; in older ones it rests chiefly upon the physical signs. The hardness is not of that stony description characteristic of contracting scirrhus ; the surface is usually more nodular, from the presence of cysts) ; it may vary in size at each menstrual period ; sometimes there are several separate lobules in the same condition, either in the same or in the other breast ; and it may have been present too long. In many cases, however, the difficulty is so great and the risk so disproportionate that every endeavor should be made to induce the patient to submit to an exploratory inci- sion ; the question can be settled by the microscope while the patient is still under the anaesthetic. The treatment of chronic interstitial mastitis is very unsatisfactory. Some- times it slowly undergoes resolution or disappears so far that the patient takes no more notice of it, but it is rarely possible to connect this with any particular remedy. Paget recommends small doses of iodide of potash with liquor potassse, well diluted ; and of course any menstrual irregularity must receive careful atten- tion. Tonics (especially iron) often succeed better than anything else ; but the chief thing is to protect the breast against every source of irritation, and to 1 176 DISEASES AND INJURIES OF SPECIAL STRUCTURES. withdraw it as far as possible from notice, by covering it with a well-shaped belladonna plaster. Chronic Abscess. Thick-walled chronic abscesses are occasionally met with in the breast with- out any definite sign of inflammation around them. They may commence during lactation or after miscarriage, but they are also met with indeijendently of any such cause, after injury. In some instances they may be of tubercular origin, the caseous material gradually becoming surrounded and encapsuled. Their import- ance is derived from the extreme difficulty of distinguishing between them and carcinoma. Like it, they are a distinct addition to the substance of the gland (in which they differ from chronic interstitial mastitis) ; they are intensely hard, painful when handled, and adherent to the structures around ; and sometimes they drag distinctly upon the skin and the nipple. It is true that a certain amount of cedema may be present over the swelling, but this by itself is too slight a sign on which to base so important a diagnosis; and they have been known to last for months and even years, without any other change than a slight increase in size. The only treatment is free incision and drainage, scraping the interior out thoroughly if the wall is dense and hard. If the diagnosis is in the least uncer- tain, a preliminary incision should always be made before attempting anything further; for want of it the gland has before now been removed, under the impres- sion that the case was one of scirrhus. Gummata are met w-ith in the breast, but very seldom. Masses of caseous material, possibly of tuberculous origin, are rather more common, forming a con- siderable proportion of the so-called galactoceles. If allowed to break, they leave chronic ulcers and sinuses fringed with congested flaps of skin, similar to those met with in other parts of the body. TUMORS OF THE BREAST. These are simple or malignant. The former include the various kinds of cyst and the different forms of mammary glandular tumor ; the latter, carcinoma and sarcoma. In addition, melanotic sarcoma and papilloma may grow from the nip- ple and areola; squamous carcinoma may extend inward from the skin as a result of Paget's disease (usually this gives rise to duct cancer) ; and nsevi, lipoma, chondroma, and some other forms may occur ; but they do not so much belong to the breast as to the structures around. In the case of a suspected tumor, the first proceeding is to exclude lobular in- duration. The patient should be placed in a semi-recumbent position ; the dress arranged so that the whole of the gland is uncovered ; and the arm freed from all restraint. Then, before the fingers are allowed to feel it, the palm of the hand should be laid flat upon the suspected spot, and made to roll the lobules gently over each other. If there is a new growth it stands out distinctly as an addition to the gland ; if, on the other hand, there is merely lobular induration, it can scarcely be felt unless the breast is very thin. If this precaution is neglected, and the hardened tissue is grasped with the fingers first, whatever its nature, it feels exactly like a tumor. Even this, however, fails to distinguish simple induration from malignant infiltration (scirrhus) in its early stages. No examination is complete without thorough investigation of the axilla. The arm should be only moderately abducted, and the glands along the margin of the pectoral muscle felt for first, then those that lie along the axillary vein and at the apex. Unfortunately, even with the greatest care, it is only possible to detect them when they have attained a considerable size. Cysts. Cysts of the breast may be simple or filled to a greater or less extent with new growths of various kinds — paitillomatous, adenomatous, sarcomatous, or TUMORS OF THE BREAST. 1177 carcinomatous. As the imi)ortance of the latter class is derived from the solid structures associated with them, they will be dealt with later, under their several headings. Dcnnoid and liydatid cysts have been known to occur, l)ut they are very rare ; by far the majority of cysts are developed in connection either with the fdjrous stroma or tlie gland tissue. Cysts developed from the fibrous stroma {serous cysts') are usually single and more or less globular in shape, but they may be multiple and very irregular. Their walls are formed of fibrous tissue lined with epithelioid cells, and they contain a clear, albuminous liquid. The mode of origin is very doubtful, but possibly, like the similar cysts occasionally met with in the neck, they are connected with the lymphatic interstices. Glandular Cysts. — Of these there is a great variety. {a) Involution Cysts. — After the period of activity is past, the mammary gland not unfretjuently becomes studded with numbers of small cysts, developed not so much from the acini (which atrophy and disappear) as from the minute ducts. If there is a coincident development of fat, this change is not noticed ; but in thin people, and especially when the change is prominently developed in one particular lobule, it may give rise to great uneasiness, owing to the peculiar hardness of the cysts. Their rounded shape, however, the free mobility, the absence of any ad- hesions, and the presence in nearly every case of a similar transformation, either in other parts of the same breast or in the opposite one, are usually sufficient to m^ke the diagnosis certain. {b) Cystic Degeneration. — This is more rare. The whole gland, or the greater part of one, becomes studded with myriads of minute cysts, developed from the acini. They are lined when small with low columnar epithelium ; as they increase in diameter the cells become flatter, until in the largest (which may be the size of a small marble) they are almost pavement-like ; and they contain a clear, albumi- nous fluid, which may be green or brown, and even almost black in color, from the admixture of haemoglobin. In some cases the basement membrane of the acini is greatly thickened as well. This has nothing to do with the period of involu- tion : it occurs at a much younger age, and only affects one, and sometiuies only part of one of the glands, but its real nature is very obscure. Clinically, it causes a rapid, uneven enlargement, with the development of very irregular, hard- ened nodules ; and if the cysts are near the surface, and sufficiently large to admit of recognition, it is usually taken for a variety of cystic sarcoma. (c) Cysts Due to Chronic Inflammation. — Minute cysts are often present in chronic interstitial mastitis, caused by the constriction of the ducts ; but, except -for the way in which they add to the size of the lobule and increase the irregu- larity of its outline and the hardness of its texture, they are of but little im- portance. id) Retention Cysts. — These are the largest of the simple glandular cysts ; sometimes attaining the size of a small orange. They may be single or multiple, and occur at any age. Undoubtedly, they are developed from the ducts (whence their name, duct cysts), and not unfrequently some of their contents can be squeezed out (so that they are not all due to simple obstruction) ; but nothing is known as to the cause of their development. Their contents are usually clear and albuminous (sometimes colored), and many of them contain papillary growths. The diagnosis rests chiefly upon the even globular outline, and the absence of pain and of adhesions ; but, especially when they are deeply seated and in a large breast, it is often impossible, owing to their hardness, to distinguish them from chronic abscess or carcinoma without an exploratory puncture. As, however, it is impossible to say from this alone whether there is an intracystic growth or not, they should always be incised, and, if they are really simple, drained or wiped out with a sponge dipped in some strong antiseptic, so as to ensure their ob- literation. (/j Galactoceles or milk-cysts may be caused by rupture or distention of one 75 1 1 78 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the ducts during lactation, usually in one of the early months. Sometimes there is a history of injury. The swelling makes its first appearance rapidly, and in some of the ca.ses has varied considerably in size, increasing during the actual time of suckling, and diminishing to some extent in the intervals by condensation. Spontaneous cure does not seem to occur; the contents gradually become more and more inspissated, but the tumor does not disappear. In some instances, it has attained an enormous size. If the tumor is of rapid growth, the child must be weaned and every en- deavor made to arrest the secretion of milk. The size of the swelling should be reduced by asi)iration, and the increase checked as far as possible by gentle pres- sure. Aftervvard the cavity must be drained with great care, to avoid suppuration. Small cysts, and those which show no tendency to increase, may be left until the period of suckling has expired. It is probable, however, that many of the smaller stationary galactoceles are really caseous ab.scesses, the contents of which are more or less dried up, and which possibly were originally of tuberculous origin. The same may be true of the calcareous masses which have occasionally been described. Mammary Glandular Tumor. The mammary gland, like the j)arotid and thyroid, is liable to its own form of tumor. The histological elements that compose it are the same as those met with in other growths ; but its features are so distinctive that, like parotid glandu- lar tumor, for example, it requires separate description. It originates in connection with the lobules of the breast after puberty, some- times one element, sometimes another, being in excess. Where it is composed chiefly of glandular structures, it is known as adenoma ; if there is a fair propor- tion of fibrous tissue as well (the most common form), 2& fiiro- adenoma. In some cases the ducts and acini are flattened into slits ; in others they are enlarged into cysts of all sizes {cystic adenoma). Sometimes these cysts are simple, lined with one or more layers of epithelial cells, and contain a clear gelatinous or colored fluid ; sometimes there are growths of various character (adenomatous or papillo- matous) inside {proliferoi/s cysts). In other varieties, again, the matrix of the tumor, instead of retaining the character of firm fibrous tissue, resembles that of a sarcoma, and from this further forms arise : adeno-sai-coma when the gland tissue is not enlarged out of proportion to the rest ; cystic sarcoma (sero-cystic sarcoma or Brodie's disease) when there are cysts developed from the acini or ducts filled with soft sarcomatous masses sprouting from j'x their walls. These tumors may occur at y W %, any age after puberty ; there may l)e only one, or there may be any number in one or both breasts ; if left they may grow to any size, \ especially the sarcomatous forms ; and at length the skin over them may give way so that they develop into gigantic fungating ma.sses, causing the death of the patient by exhaustion ; but they do not affect the surrounding lobules of the gland (except by their pressure) or spread 'i through the lymphatics or the blood -ves.sels, .. and (though it often happens that other smaller ones grow up to replace them) they do not Fig. 508, — Cystic Tumors in Breast with ° ^ J , ri-., , Pedunculated Adenom.-itous Growth. recur after free removal. Ihe slow-growing fibrous forms are very common in young women ; the more rapid ones rarely occur before thirty years of age ; but some- times a tumor that has scarcely made any progress for months together suddenly begins to grow, and then it may attain an enormous size. Cysts may occur at any time of life. Diagnosis. — The distinguishing feature of mammary glandular tumors is SARCOMA OF THE BREAST. 1179 their mobility, especially while they are small ; they seem capable of being pushed among the other lobules in all directions. Those that grow rapidly, and are allowed to attain a large size, lose this feature to a great extent. Adenomata and fibro-adenomata are particularly hard, and often nodular on the surface ; adeno-sarcomata are softer, growing more rapidly, and the skin over them is covered with enlarged and dilated veins. Cystic adenoma can usually be recognized by the rounded outline and the elastic sensation it gives when pressed upon ; moreover, there is not uncommonly a history of a serous or blood stained discharge from the nipple, and sometimes the tumor has distinctly varied in size ; but it is impossible to form any idea of the character and scarcely any as to the presence of intracystic growths. They may be large or small, sarcomatous or papillary ; the fluid around them altogether conceals their rate of increase. Pain is seldom complained of in the case of the larger growths, although their weight and size may prove a serious inconvenience ; but some of the smaller and harder ones, especially those that occur in young unmarried women, are not unfretpiently the seat of intense neuralgia, especially after handling and during the menstrual period. The skin never becomes involved or the nipple retracted unless the growth has attained a very large size, or has spread among the other lobules of the gland. Treatment. — Excision of the tumor is always advisable. It is true that many of the smaller ones persist for a very considerable time without showing any change, but there can be no certainty of this, and not unfrequently after remain- ing latent for years they suddenly begin to grow at a rapid rate. The gland itself should never be removed unless the tumor is so large and so intimately fused with it that it is unavoidable ; and unless it is actually adherent, no skin need be sacrificed. The plan of operation depends upon the size and situation of the tumor. If it is small and superficial it may be fixed between the finger and thumb of the left hand, and a single incision radiating from the nipple, made down to it and through its capsule ; as a rule it shells out readily, though sometimes a certain amount of dissection is required. If it is deeply placed, or if there are several, it is better to adopt the method advocated by Thomas, of New York, and reflect the breast upward from below, the incision being made in the groove beneath the gland so that no scar is visible. Fortunately these tumors are for the most part so freely movable in the breast tissue, that, if there are several of them, a single incision will usually serve for all. For the larger ones no rules can be laid down, but, especially if the patient is nearing middle life, and the gland tissue is much involved, it is often simpler and more satisfactory to remove the whole. Pressure .should be carefully arranged afterward, so as to ensure complete obliteration of the cavity left. Whether a drainage tube should be used or not depends upon the amount of bruising. Sarcoma, All varieties of sarcoma, with all their forms of secondary degeneration, are occasionally met with in the breast, but the only one at all common is the spindle- celled. It may occur at any age after puberty, and forms a soft, rounded, or lobu- lated mass, pushing the gland on one side, and very difficult to distinguish, at first at least, from an adeno-sarcoma. If there are cysts in it, due to .softening or hemorrhage, or even if there are isolated masses of softer round-celled growth in the middle of the firmer part, the diagnosis may be impossible. Growth at first is usually slow ; after a little while, however, the tumor begins to increase with great rapidity, and very soon it develops into a gigantic mass, which, if left to itself, ulcerates through the skin and forms a huge fungating excrescence that bleeds with the slightest touch. The only treatment is free exci- sion, not only of the tumor, but of the capsule that surrounds it. Afterward the most careful watch must be kept. Infection of the glands or of distant organs is rare, but local recurrence is exceedingly common, and each secondary growth increases in size more rapidly than the one that preceded it. Operations may liave 1 1 So DISEASES AND INJURIES OF SPECIAL STRUCTURES. to be performed again and again ; sometimes at last the tendency to recurrence is overcome ; more frecjuently before this occurs the time arrives when surgical inter- ference is no longer practicable. Carcinoma. Carcinoma of the breast may be glandular, columnar-celled, or squamous. Of these the two last form together but a very small percentage of the whole. The columnar-celled type grows from the ducts (^duci o?- villous cancer) ; it can only be diagnosed by the cystic appearance it presents on section, although its nature may be suspected if there is a blood-stained or milky discharge from the nipple ; the squamous one spreads by continuity from the areola and is sometimes secondary to Paget' s disease. Glandular carcinoma presents many different forms, according to the relative proportion of tlie cells and stroma that compose it. The more rapidly-growing varieties as a rule occur in younger patients with full breasts, but there are many exceptions. («) Atrophic Scirrhiis. — This is the hardest and slowest in its growth of all : the contraction is so extreme that the breast grows smaller and more withered the longer it lasts, and the skin and the surrounding structures become bound together as if by dense cicatricial tissue. It is usually met with in thin, wasted breasts of old people, and it may last many years before it proves fatal ; when it is cut across it creaks and grates before the knife ; the surface becomes markedly cupped, but there is little or no cancer juice. Its color is grayish white, with streaks and dots of yellow, and it has no outline, but shades off imperceptibly into the healthy tissues around. (U) Nodular Scirrhus. — The wasting is much less, so that, although the con- traction of the stroma renders the swelling intensely hard, it is not sufficient to cause a diminution in size. There is a distinct hard nodule which can be felt as an addition to the breast gland when the palm of the hand is laid flat upon it. The cut section is much the same as the former, but it is more juicy, and the fibrous bands that traverse it are not so inextricably welded together. (r) Injil/ratifi!:^ Scirrhus. — This differs not only in the rapidity of its growth and the absence of wasting, but in the peculiar mode of its extension ; it seems to spread, not by gradual continuity of structure, but by leaps and bounds, and so quickly that it may even seem to originate ^^•^'JSs^K. in many separate points at the same time. -"^" "' '"-^ - '■ Its course, so far as life is concerned, is pro- portionately fatal. There are two varieties of it, according to whether it involves the x. glandular tissue or the skin. In the former /: ; . V the whole breast rapidly becomes enlarged ; / f ''--- '-.' ; no definite tumor can be felt; the nipjjle is p- s„^ >:: buried by the increased growth around it M: '■"" ._.'• as much as by its own retraction ; and the .^i - • _ .if 1\ .. whole gland is converted into a solid mass -''' ■ - .'. Qf carcinoma. In the latter the skin is chiefly involved; it becomes peculiarly ./ hard, thick, dense, and coarse (it has been / compared to a jjig-skin saddle) ; the color &; '/,'^ changes to a dusky red ; the texture is com- fv \-^/l pletely altered : it does not move on the C, : ' "S<^^ l)arts beneath, and it cannot be pinched up "''-■- " "^ into folds. Minor degrees of this are often Fir.. 509.— Scirrhus with Retracted Nipple, under- scen ovcr 3. carciuoma as it approaclics the going Colloid Transformation. surfacc, but iu this particular form the dis- ease may spread all round one side of the thorax {caiicer en cuirasse), and invest it with an absolutely rigid casing within the space of a few weeks. CARCINOMA OF THE BREAST. 1181 The cut surface, owing to the softness and rapidity of growth, often does not cup at all ; but the cancer-juice on scraping is very abundant. 0/) EncephaloicL — Very soft glandular carcinoma,such as occurs in the testicle for example, is seldom met with in the breast ; many of the cases formerly de- scribed as such were in all probability sarcomata ; but the softer infiltrating forms are sometimes termed encephaloid, from the striking contrast they present to the hardness of scirrhus. As a rule their growth is even more rapid than that of the preceding one. In addition to these cystic carcinoma has been described (the cysts being due to hemorrhage or softening) ; and occasionally colloid degeneration is met with ; but though this form of carcinoma is peculiar from the length of time it often lastsi it is not a distinct variety. Etiology. — Cancer in the breast is very rare before thirty years of age ; then It becomes more and more frequent until nearly fifty ; after that it begins to diminish again (not only absolutely, but relatively to the number living) ; but it may start even in extreme old age. Marriage, child-bearing, suckling or not, and disorders of menstruation have never been proved to have any relation to it! It occurs in all social conditions, and in those who have enjoyed perfect health as much as, and possibly even more than, in others. It may follow a blow, though, of course, too much reliance must not be placed upon ordinary histories ; and in a small proportion of cases it follows on chronic lobular induration, or develops in the neighborhood of an old abscess. Whether locality or climatic conditions have any effect is very uncertain, and, probably, owing to the freedom of communica- tion at the present day, will never be proved. Statistics show that it is not hered- itary, but as individual cases of the most striking character are met with from time to time, it is probable that this statement is too sweeping, and that the tendency exists, though it may not be marked, and may require other circumstances for its development. It is an old observation that carcinoma rarely develops during pregnancy or lactation ; and it has been said that a tumor that makes its appear*^ ance during either of these periods is almost certainly not cancer ; but the symp- toms at its first commencement are so exceedingly slight, and the changes through Avhich the gland tissue passes are so extensive, that this is very difficult to prove* Symptoms. — These naturally present considerable variety, but essentially they may be reduced to two. 1. The presence of a tumor. Unfortunately, this fails to distinguish com- mencing scirrhus from chronic lobular induration, as in both there may be an actual diminution in size. 2. The way in which the tumor infiltrates and (like a crab that has been turned upon its back) drags toward itself everything round. The same thing is true, though to a less extent, of chronic abscess, and this renders the difficulty of separating one from the other so great. The first appearance of scirrhus is an ill-defined, intensely hard nodule in the substance of the gland. There is no margin; it cannot be' separated from the lobules around it or moved freely in any direction. Whether, when the hand is laid upon it, it feels like an addition to the gland or not, depends upon the rela- tive amount of new growth and contraction. In a little while it becomes more definite. If it is near the skin this is dimpled over it, the vertical septa of con- nective tissue and the deep ends of the cutaneous glands being dragged down first ; the nipple (if it is near one of the larger ducts) is treated in the same way (often this can be best seen by gently pulling the growth to one side) ; and even the fascia beneath the gland is caught as well. Soon some of the intercostal nerves are involved, and then it gives rise to the most intense pain, sharp and stabbing, especially at night and when the breast is handled, sometimes limited to the gland, but more often spreading round the thorax, over the shoulder, or down the arm. In a little while the tumor grows more prominent, still retaining its extreme hard- ness ; the skin is bound down over a wide area and becomes a dusky red ; the lymphatic glands in the axilla are enlarged ; the nipple is perhaps entirely with- 1 1 82 DISEASES AND INJURIES OE SPECIAL STRUCTURES. drawn ; and by-and-by a small fissure makes its appearance about the centre of the swelling. At first this is covered by a scab of dried epidermis ; soon this falls off and a typical scirrhous ulcer is left, with a pale, waxy base, and raised, hardened, and rolled- in eiiges. The subsequent course is of the same character. The patient's health begins to fail, although it may be some time before there is a definite appearance of ca- chexia. The ulcer steadily increases in size ; if the cancer is soft and of rapid growth it may fungate and bleed ; more often it merely melts away on the surface, giving off a discharge of a peculiarly offensive description. The axillary glands become matted together ; the veins and lymphatics are closed ; oedema of the arm sets in ; the brachial plexus is compressed, causing the most intense neuralgia ; then the supra-clavicular glands are attacked ; pleurisy perhaps follows (the lymphatics from the inner half of the breast communicate freely through the intercostal spaces with those of the mediastinum and the pleura) ; and finally secondary deposits make their appearance in the liver, lungs, vertebrae, or other parts of the body. The relative prominence of these symptoms differ, of course, very greatly. In some the rapidity of the growth is the chief feature : a soft, elastic, almost fluctu- ating swelling seems to take the place of the breast almost at once. In others the skin is the part attacked, the extreme form being that known as cancer en cuirasse. In a third class again ulceration begins before there is much growth, and j>er- sists, quietly spreading year after year. The pain, the implication of the skin, the retraction of the nipple, and the fixation to the pectoral beneath (best seen when the muscle is in action) depend largely upon the accidental position of the growth ; and so, to some extent, does the direction in which lymphatic infection spreads. Diagnosis. — ^^"hen the skin is involved, the nipple retracted, and the axil- lary glands enlarged (the stage at which the majority of the patients present them- selves for treatment) the diagnosis is easy, but too late. If there is to be any hope of definitely curing a patient suffering from cancer of the breast, the diagnosis must be made before any one of these three is present. In the case of scirrhus the chief difficulty occurs in connection with chronic lobular mastitis, chronic abscess, fibro-adcnoma, and deep-seated cysts. The softer varieties are frequently not distinguishable from adeno-sarcoma, cysto-sarcoma, or t7-ue sarcoma, but this is less material, as in either case free and early exploration is the rule. The following are the most important points : — (a) Age. — Carcinoma is very rare before thirty, and rare before thirty-five years of age ; the other affections may occur at any time of life. (b') Fixity. — Unfortunately, chronic abscess and chronic induration are as adherent to the lobules around as scirrhus ; and in any case, when the growth is small and deeply seated in a full breast, this is most difficult to estimate. (r) Consistence. — Scirrhus is of stony hardness, the others are not ; but the difference is often inappreciable. A cyst near the surface is tense and elastic, chronic induration is often very irregular in its outline, and oedema is not unfre- quently present over a chronic abscess. (d) Period of Origin. — Chronic abscess is said to occur most frequently during lactation or after a miscarriage. This is not the case with carcinoma, although it is impossible to deny that it may happen. (^) Multiplicity. — If there are several nodules, especially if they are at some distance from each other (so that they are not caused by latent extension), or if there is asymmetrical induration in the other breast, it is strongly against carci- noma, and in favor of chronic mastitis. (/) Shape. — This is of little service ; but if the swelling is tense and globu- lar, or if one or more globular enlargements can be detected on it, it is almost certainly cystic, in part at least. (^) Tenderness is very important. In chronic induration the lobe is nearly always very tender on pressure, or on trying to separate it from the rest of the CARCINOMA OF THE BREAST. 1,83 gland ; carcinoma, on the other hand (in the early stage) is tolerably insensitive. This is often shown by the way in which the nodule is discovered ; in the one case the tenderness attracts the attention of the patient, in the other it is the presence of a hardened lump. {h) Pain. — The pain of carcinoma, whe-n it once begins, is nearly always described voluntarily by the patients as sharp and stabbing. That of chronic induration is often severe after handling (especially in women too young for scir- rhus), but it is neuralgic in character ; there are neuralgic points down the axillary line on the side of the thorax where the nerves perforate the intercostal muscles, and it varies in intensity at each menstrual period. Sometimes the patient is positive that the size of the suspected lobe varies too. (/') Dimpling of the Skin. — The skin is adherent over inflammatory swellings, and sometimes over large, rapidly-growing tumors, other than carcinoma, but the dimpling of scirrhus is different. At the first it is due to the dragging on the sus- pensory ligaments of the breast, which pass vertically inward from the surface ; later the ends of the cutaneous glands are involved, and then the subcutaneous tissue and the skin itself. This stage is of very great importance, not so much for the diagnosis of the disease, but as a criterion of the extent to which it has spread — practically it may be taken that the lymphatics are involved as well, whether they can be felt or not. iji) Retraction of the nipple is to a large extent a question of locality ; if, that is to say, scirrhus develops near its base, retraction appears very early ; if, on the other hand, it is far away, very late. It is due to the dragging upon the larger ducts, and it may arise from many other causes besides scirrhus. It may, for ex- ample, be congenital, or it may be the result of inflammation, past or present ; or it may be due to some other form of tumor pressing the ducts upon one side, or causing uneven enlargement of the gland. Retraction, therefore, is not distinctive, but when it occurs in connection with an indurated lobule, before this has attained any size, its presence is highly significant. Finally, if the diagnosis is in the least degree doubtful, an exploratory punc- ture should be made under an anjesthetic, and if this is not satisfactory a free incision with full permission to proceed further, if it is thought advisable. Prognosis, — The duration of life, in cases of cancer of breast that are not operated upon, is under three years on the average of a large number, but indi- vidual instances vary very greatly. The soft and rapidly infiltrating growths, and especially those which implicate the skin to a large extent, may prove fatal within six months ; atrophic scirrhus, on the other hand, may last for ten and even twenty years unchanged. Death may be due to exhaustion, septicaemia from the absorp- tion of the foul discharge, or to the occurrence of secondary deposits. Hemor- rhage from the surface of the sore, or pleurisy due to direct extension along the lymphatics, is not unfrequently the immediate cause. Treatment. — Cancer of the breast can only be cured by complete incision at the very earliest moment ; it can, it is true, be removed by caustics, but the process is slower, more painful, and absolutely uncertain. Whether an operation is to be recommended or not depends upon {a) the condition of the patient ; {f) the character of the breast ; (^) the nature of the growth; and (^) the stage it has reached. {a) The Patient. — In this the surgeon must be guided by the ordinary rules for operating. Excision of the breast»is a very favorable operation (so far as im- mediate results are concerned — the older statistics are quite valueless), if the patients are properly selected ; primary union is the rule, but no operation should be undertaken in cases of renal disease, diabetes, advanced pregnancy, cirrhosis of the liver, or extreme obesity, especially if associated with shortness of breath and a tendency to bronchitis. Age of itself is no bar. (J)) The Breast. — The larger the breast, whether due to the gland itself or to an accumulation of fat around it, the more unfavorable the operation in every way ; the wound is larger (in some cases the gland has outlying lobules under the margin 1 1 84 DISEASES AND INJURIES OF SPECIAL STRUCTURES. of the jjcctoral muscle), conii)lete removal is more difficult, the growth is almost certainly not of the nodular or atrophic variety, lymjjhatic enlargement is more difficult to detect, and if there is a thick layer of fat the wound does not heal so well. (r) T/ii' Nature of t)icGro7oth. — At one extreme are the very chronic cases, at the other the rapidly infiltrating ones. With regard to the former, it is sometimes questionable whether operation is advisable — the expectation of life without its being done is so much better than in the other varieties ; on the other hand, there is the certainty that ultimately it will prove fatal ; and the possibility, with but slight risk (for these cases are very favorable ones), of freeing the patient from a cease- less source of anxiety and pain. With regard to the latter, it must be admitted the results are exceedingly bad ; it seems impossible to 0{)erate soon enough, and the actual prolongation of life is very short. Whether, when the absolute im- portance of early operation, even in suspicious cases, comes to be more widely recognized the results will be improved upon, especially if the axillary glands are removed as well, remains to be seen. (r/) The Stage the Growth has Reached. — If complete excision is performed before there is any dimpling of the skin or retraction of the nipple, prolongation of life is certain (taking, of course, into consideration the risk of the operation), and freedom from recurrence highly probable, especially if the growth is one of the harder kinds. It is for this reason that it is so important to advise an explo- ratory operation in every case of chronic induration of the breast, in a patient nearing forty years of age, if the diagnosis is in the least doubtful. If the skin is dimpled, relief may be promised, and (almost certainly) local recurrence prevented again under the same conditions (complete excision, and one of the harder varieties) ; but absolute cure is much more questionable. In such a case it is impossible to prove that the axillary glands are not involved, and consequently the whole of the loose cellular tissue and the lymphatics that cover the mammary portion of the pectoral muscle and fill the axilla, must be syste- matically dissected out. The fact that the glands cannot be felt means nothing. Some advise that this j^recaution should be adopted in every case of carci- noma, and refuse the term "complete" to every operation in which it is not done. Undoubtedly it increases the patient's chance of ultimate cure; and, accordingly, where it does not too much increase the immediate risk, it should be practiced. In the later stages, when the skin is extensively adherent, and the glands are definitely enlarged and perhaps matted together, it must depend entirely upon the patient. Cure is very doubtful ; relief from pain, and from the i)rospect of an intensely offensive and perhaps fungating ulcer, is fairly certain (^provided the whole of the affected skin can be freely removed), but no more, and often the shock necessarily attendant upon such an 0])eration (even when primary union is assured) seems to make the disease light up elsewhere and grow with redoubled vigor. If the supra-clavicular glands are involved ; if the breast is adherent to the chest wall (not the pectoral muscle, but the fascia near the sternum), so that there is reason to apprehend the speedy onset of pleurisy; if there is oedema of the arms, or if nodules are perceptible in the liver or elsewhere, operations are not advisable unless there are definite local reasons for it, such as intense pain or imminent hemorrhage. Recurrence. — Unhappily, this is the rule. The average time seems to be about a twelvemonth. It may take place locally, in the cicatrix or near it (some- times in the scars left by the sutures), or in the axilla. The cpiestion of further operation must be determined by the same consideration as in the previous case ; permanent cure is, it is true, probably not to be hoped for, but, with very small risk and suffering, it is sometimes possible to enable a patient to live with a fair amount of comfort and without pain until visceral lesions make their appearance. The treatment of carcinoma of the breast, if operation is declined, is very unsatisfactory. Arsenic in continually increasing doses has been recommended, EXCISION OF THE BREAST. 1185 but it has not been proved to have any real influence. Cold lead lotion checks the growth a little by reducing the hyi)era3mia, but it must be kept up continu- ously ; poulticing makes it increase at a furious rate. Chloride of zinc with opium and starch paste ai)pears to be the most efficient caustic, strips of lint soaked in it being inserted in linear incisions made through the superficial layer, after the skin has been destroyed with nitric acid. After ulceration has set in, the surface must be kept clean and free from putrefaction by means of unirritat- ing antiseptics. Salicylic acid and resorcin have been used as local applications, but they can have no influence upon lymphatic extension. Opium is the only drug that relieves the pain, and for this it must be given in full and increasing doses. Life is not sufficiently prolonged for the evil effects of continued o[jium- taking to deserve consideration. DISEASES OF THE MALE BREAST. Inflammation may occur at infancy and occasionally later in life, but it is nearly always periglandular and rarely ends in suppuration. Carcinoma may occur, but other forms of new growth are very seldom met with. The treatment presents nothing special. Excision of the Breast. In cases of carcinoma it should be the rule to remove the whole gland, the nipple, the skin for a wide distance over the tumor, the fascia covering the mam- mary portion of the pectoral muscle, the lymphatics running up from this to the axilla, and to clear this space out thoroughly and systematically. If the operation is performed before the glands are enlarged, or while they are still small and iso- lated, there is little difficulty in accomplishing this ; if they are already matted together and to the surrounding structures, the operation becomes at once one of a very serious character. Mitchell Banks, Jacobson, and others, recommend that the pectoral muscles should be divided, completely if necessary ; the axillary vein ligatured above and below and cut away, and even more sweeping measures taken, if there is the least suspicion as to the thoroughness of removal. It may be noted that ligature of the vein, even when all the axillary lymphatics are cleared away as well, merely causes transient oedema. The patient is prepared in the usual manner ; the axilla shaved and thor- oughly cleansed ; the arm moderately abducted from the side ; and the rest of the body and the opposite side of the chest well protected with mackintoshes. The incision depends to some extent upon the situation of the tumor ; an elliptical one, running upward and outward to the axilla, is usually recommended ; but, in many instances, one shaped like an italic / placed horizontally ^^ ^ answers better ; it keeps the line of the cicatrix well out of view ; it can be carried up readily along the border of the pectoral muscle to the axilla, and, owing to the shape of the breast, it allows a greater amount of skin to be removed without sacrificing imme- diate apposition of the edges of the wound. The assistant stands on the opposite side. The lower incision is made first, and a flap of skin and subcutaneous tissue reflected from off the gland until its margin is reached and the edge of the pectoral exposed. The upper incision is then made in the same way ; or, if the gland is a small one, the pectoral fascia with the structures lying on it is stripped up at once from the muscle until the opposite border of the breast is reached. As soon as this is done the surgeon, holding the gland in his left hand, divides the skin over the upper hemisi)here, and with a ^tw touches of the scalpel sets the whole structure free, except at the upper and outer angle ; this part must be carefully preserved, as it contains the majority of the lymphatics and acts as a guide to the axilla. Hemorrhage may occur from the incisions in the skin or from the branches of II 86 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the internal mammary artery coming through the pectoral muscle in a vertical direction. The bleeding points should be covered at once with a sponge, and haemostatic forceps applied. Ligatures are seldom needed. The surface of the wound must then be carefully examined to see that the whole of the gland has been removed, and that no subjacent fascia is left behind (if the muscle is involved, the fibres should now be taken away) ; and if the skin will come together with the arm in a position of abduction, the sternal end of the wound may be washed out with a hot solution of corrosive sublimate and united as soon as the hemorrhage has been stopped. If this is not practicable, it should be carefully covered over with hot sponges, to avoid the chilling effect of exposure. The arm is then corai)letely abducted ; the incision carried along the lower border of the pectoralis major nearly up to the biceps, the fascia divided, and the contents of the axilla dissected out, beginning at the pectoralis major, removing the fascia for some little distance between it and the pectoralis minor, and then working under this until the apex is reached. If there is the least difficulty, there should be no hesitation in dividing these muscles at their insertion as far as may be required. The intercosto-humeral nerves are divided and some branches of Fig. 510. — Esmarch's Operation for Excision of the Breast. the long thoracic and other arteries cut, but there is very little hemorrhage. If, when approaching the axillary vein, or, what is nearly as important, the end of the sub-scapular, it is found the glands are extensively adherent, it is better to pass ligatures beneath the vessels and give them to an assistant to hold without tying them. In this way hemorrhage and the risk of air entering in can be easily avoided. Where structures require dividing high up, pressure forceps should always be applied first. The axillary wound is then thoroughly sponged out with hot lotion in the same way ; all hemorrhage stopped ; a final examination made to see that the axillary boundaries are really clear, and the arm brought down to the side to allow the edges to be approximated. Owing to the irregularity of its shape, a thick and wide drainage tube is always required for the axilla. The sternal end of the incision, on the other hand, unless the patient is very stout, may be left without. Three or four deep sutures of adjustment may be required to take off tension, but it is surprising how a wound that gapes widely when the arm is abducted, falls together as soon as it is placed by the side. If there is not sufficient skin, the surface should be thoroughly cleansed with corrosive sublimate, dusted lightly with iodoform, and covered with a piece of protective cut the e.xact size. EXCISION OF THE BREAST. ,,87 Afterward the skin of the arm and the axilla should he thoroughly dried, and the whole siJace, behind the shoulder, under the arm and along the thorax care- fully packed with loose j^ieces of some absorbent dressing. The elbow must be supported ; the arm fixed to the side ; the hand laid on the thorax, and the whole enclosed in a linen binder. As a rule, the wound drains better if the patient lies upon the sound side ; but as this may be inconvenient, or cause the injured one to move too much with respiration, this should not be insisted on. The drainage tube, if there is any oozing, must be cleared the next day; if the wound is really dry, it may be left till the second or third. The patient should on no account be allowed to sit upright, or move the arm until the axillary wound is practically sound. 1 1 88 DISEASES AND INJURIES OF SPECIAL STRUCTURES. CHAPTER XXVII. AMPUTATIONS. Amputation of the Limbs. Amputation may be required for injury or disease : and the former may be primarx (within twenty-four hours), intermediary (before suppuration;, or sec- ondary (after suppuration). But this division is of doubtful value. It is more important to distinguish those cases in which inflammation has not yet occurred from those in which it has already broken out (and the operation is performed with the view of saving the patient from acute septic poisoning), and from those in which the tissues have recovered and are beginning to protect themselves by throw- ing out a barrier of granulations. The chief points in planning an amputation are : (i) to sacrifice as little as possible ; (2) to provide an ample covering of skin ; (3) to arrange the flaps so that their weight shall keep them in position : (4) to make sure there is free exit for any fluid that may accumulate ; and (5) to keep the scar away from the line of pressure. The various methods can be reduced to three : {a) the circular ; {F) the old flap operation, in which all the tissues down to the bone are included ; and (<:) the modified flap operation, in which the covering is formed of skin alone, all the other structures being divided on a level with the end of the bone. (dr) The Circular. — The limb is divided by a succession of circular sweeps : the first through the skin ; the second (after the skin has been retracted) through the superficial muscles ; the third through the deep ones and the periosteum ; and the fourth, when all the tissues are drawn back, through the bone. It is prac- tically limited to the arm : it cannot be used over conical parts (as the skin cannot retract), or where the bone would lie in the centre of the stump, as then it would abut upon the cicatrix. If the limb is injured on one side only, it may be very wasteful ; and in cases of disease in which the tissues are hard and brawny, or the skin tied down by adhesions, it is impracticable. Where it can be performed the covering of skin is good, without much muscle, drainage is satisfactory, and the scar very small. {b) The Old Flap Operation. — This maybe performed either by transfixion, cutting from within outward, or by dissection, separating the soft tissues from the bones in an upward direction ; and the flaps may be antero-posterior, lateral, and equal in length, or one may be much longer than the other. With the exception of one special modification (Teale's amputation), the old operation is seldom performed on any part but the extremities : the flaps are heavy and thick, containing a large amount of muscle ,: the vessels may easily be slit, or wounded higher up than they are divided ; the surface of the wound is very large ; and the nerves are contained in the flaps. In Teale's amputation (which is reserved almost entirely for the lower third of the lower limb), the anterior flap, which contains all the tissues dissected up from the bones, is perfectly square, equal in length and breadth to half the circumference of the limb at the spot at which the bones are to be divided. The posterior flap is of the same breadth, but only one-fourth the length. The bones are divided at the line from which the flajjs spring, and the long flap folded round the end, and united behind it to the posterior one, the cut surfaces facing each other. The flaps are measured out and marked down first, and the two lateral incisions made before the transverse ones. The drainage is admirable and the stump left very soon becomes serviceable, if care is taken to keep the AMPUTATION OF THE LIMBS. 1 1 89 larger vessels and nerves in the shorter flap : in any other part of the body it is much too extravagant. (^) The Modified Flap Operation. — In this, one flap (or sometimes both) is formed from the skin and subcutaneous tissue only ; the rest of the structures are divided by a circular s\veei)at thesame level as the bone. It is a method capable of far wider application than any other, and may be modified in a number of different ways. In Garden's operation, for example (which, though first devised for the knee, may be employed in many other parts), a rounded or semi -oval flap is reflected from the front of the limb, and everything else divided down to the bone, this being sawn through slightly above the plane of the muscles. This leaves an almost flat stump, covered with integument ; the edges of the wound are depend- ent, and the cicatrix lies well out of the way. In other cases (amputation of the forearm, for instance) both flaps may be formed in this way, of equal length or not, according to the amount of tissue available ; or lateral flaps may be cut, as in the leg, or a kind of hood dissected up, as in Stephen Smith's method. The position of the surgeon in performing an amputation is always such Fig. 511. — Teale's .imputation. Fig. 512. — Garden's Amputation with Short Posterior Flap. that he can raise the flap with his left hand, without crossing with the right ; usually, therefore, he stands on the right-hand side of the limb. The number of assistants required depends naturally upon the part to be removed ; one holds the limb, and afterwards supports the stump in a convenient position ; another assists the surgeon in retracting the flaps, sponging, and tying vessels; and a third may be required to control the main artery. Where it is possible the patient should be carefully prepared ; the bowels opened ; the urine examined ; the pulse, respiration, and temperature noted ; and the limb thoroughly cleansed, and if necessary shaved. 'I'he last meal should be a light one and three hours at least before the operation. The anaesthetic, of course, requires a special assistant. During the operation the bed should be thoroughly warmed, and hot bottles, pillows, etc., arranged, so that the patient may be placed in a comfortable posi- tion at once, with the stump slightly raised and secured against any accidental movement or spasmodic contraction of the muscles. Unless the patient is thor- oughly covered up, the loss of heat during an operation (especially under ether) adds seriously to the shock. II90 DISEASES AND INJURIES OF SPECIAL STRUCTURES. SPECIAI- AMPUTATIONS. [Amputation of the Humerus and Scapula. Although this operation has been performed at intervals for a great many years, no definite rules were laid down for its performance until Berger's Mono- graph appeared in 1887. Professor Chas. T. Parkes, of Chicago, after experi- ments on the cadaver, and its successful performance on the living subject in .1889, thus formulated the method of procedure, in an article before the Chicago Medi- cal Society : — " Following the suggestion of Mr. May, who, in a late issue of the Annals of Surgery, reports two cases of this operation, I have looked through all the books in my library and have not found any specific method given. It remained for Paul Berger to give a plan for it. He was led to the plan he suggests after several trials upon the cadaver. The quickest and easiest method of doing the operation and securing the blood-vessels is according to his plan of i)rocedure. He makes his first incision from the inner extremity of the clavicle outward to the top of the shoulder, immediately uncovers the clavicle and turns it out of the way ; this leaves the subclavian vessels exposed so that they are easily secured. You all remember well, as a result of past experience, that as the front of the axil- lary space is uncovered there is always to be seen a ridge across it produced by the raising of loose tissue upon the external thoracic nerve. It is easily found, and I call attention to it because passing outward this nerve leads directly to the interval between the artery and vein, and hence to them. With the clavicle out of the way, the vessels are superficially situated, easily isolated, and free from di- verging branches. The artery should be tied in two places, an inch a])art, and divided, and the vein also ; then the circulation is al)Solutely under control. May advises that just before the vein is tied the arm should be elevated for a few minutes to allow the venous blood to drain from it, thus saving as much blood as possible for the patient. In my second case I applied the Esmarch bandage up to the axilla. As soon as the arteries are secured in this position, by a rapid cut with the scissors the brachial plexus can be divided and the pectoralis major and minor be severed. The flap portion of the operation is done in this way: Commence at the centre of the anterior incision and carry the knife directly across the anterior part of the axilla and inner arm to the lower angle of the scapula ; then from the outer edge of the incision, posteriorly, carry the knife behind the joint to the same point ; rapidly reflect the posterior flap ; then all the muscular attachments should be divided and the extremity removed without any trouble. This gives a per- fectly even anterior and posterior flap, coming together easily and nicely, and avoids the unseemly appearance of the anterior part of this wound which was caused by the too redundant anterior flap."] Amputation at the Shoulder Joint. Spence's operation is the most usefiil, as in case of doubt it enables the head of the bone to be examined with the least disturbance. The subclavian may be compressed by an assistant ; but as this is often a difficult proceeding, the vessels may be caught in the flap by the surgeon or his assistant, or isolated and secured before division. The position of the patient is semi-recumbent, with the shoulder projecting over the edge of the table and the arm moderately abducted. The incision runs from just outside the coracoid process to the insertion of the pectoralis major, which should be divided. The incision is then carried horizontally across the outer side of the arm to the posterior border of the axilla, dividing the deltoid. The inner incision, from the same point to join the ter- mination of the outer, may be marked out now, but it must not be deeper than the skin. The outer flap is raised ; the capsule, the tendons attached to the tuber- AMPUTATION AT THE SHOULDER JOINT. 1 191 osities, and the long tendon of the biceps divided l)y cutting on to the bone ; the limb disarticulated and the soft structures on the inner side cut through, the artery being either secured by an assistant, or exposed and ligatured before division. "^I'he axillary and the anterior circumflex are the only vessels necessarily cut. In cases of malignant disease, in which it is wished to retain as little of the Fig. 513. — Spence's Amputation. Fig 514. — Amputation by Transfixion. soft Structures as possible, skin flaps may be used instead. Lateral ones are marked out : {a) by an incision beginning in the middle of the axilla, pa.ssing down nearly as low as the insertion of the deltoid on the outer side of the arm, and then curv- ing upward to end just outside and below the coracoid process ; and (/;) by a second beginning and ending at the same points, only passing a sufficient distance down the inner side of the arm. Or a racquet -shaped incision maybe employed, start- FiG. 515 — Amputation at Elbow Joint. ing from the same point near the coracoid, and running first down the outer side of the arm and then circularly round it. In either case the skin is dissected up, the soft parts divided, and the vessels secured as before. In this method the pos- terior circumflex is usually divided as well as the anterior. Other methods are by transfixion from behind forward (or vice versa, according 1 192 DISEASES AND INJURIES OF SPECIAL STRUCTURES. to the side), forming a great external flaj) of the deltoid and the skin covering it; and Furneaux Jordan's, circular through the arm below, and then, after the ves- sels are secured, dissecting out the upper end of the humerus. Amputaiion of the Arm. The circular method usually gives an excellent result ; but skin flaps with circular division of the muscles, or one of these in front, and a short transfixion flap behind, may beado])ted instead. In this amputation, as in all others through the shaft of a bone, the periosteum should be divided some little distance below the bone, so that it may invest and adhere to the face ot the section. Amputation of the Forearm. Skin flaps with circular division of the muscles should be adopted wherever it is possible; but the circular operation, Teale's method, and transfixion (for one Fig. 516 — Ainpui.>t;uii of Forearm by Jlixed Method. flap) may be employed. Care should be taken to supinate the limb while the bones are being sawn, to ensure their being parallel. Disarticulation at the elbow and wrist does not require special mention. Amputation of the Thumb. This may be performed either with a racquet-shaped incision or with a palmar flap formed by transfixion. In the former case tlie thumb is held in Fig. 517. — Amputation of Hand. Fig. 5:8. — Amputation of tlie Thumb by Transfixion. the extended position ; the point of the knife introduced on the dorsal surface of the base of the metacarpal bone, and the incision carried down the bone, nearly to the phalangeal articulation ; then it winds around the bone, descending on the ulnar side (in the case of the left hand) and ascending on the radial until it joins the dorsal incision again. The skin is then dissected back, the AMPUTATION OF THE FINGERS. 1 193 carpo-metacarpal articulation opened, and the soft tissues divided, taking especial care of the radial artery. In the latter the thumb is slightly abducted, and a flap cut by transfixion from the muscles of the ball. If the left hand is in question. the point is introduced on the palmar side of the carpal joint, carried obliquely over the dorsal surface of the metacarpal bone to the ulnar side of the phalangeal joint, and thrust through the ball of the thumb until its point emerges through the original puncture. In cutting out it is advisable to keep close to the bone, but care must be taken not to lock the blade against the sesamoids. On the right hand the flap is cut first and its two extremities joined over the dorsum. Amputation of the Fingers. It must be remembered that, in all these joints, the bone that projects on the dorsal surface is the proximal one, and that, on the palmar surface, although the fold of the skin corresponds fairly well to the first inter-phalangeal joint, this is not the case either with the one above or the one below ; the circle formed by the skin (when the fingers are flexed) is smaller than that formed by the bones, and consequently the distance between the folds is less than that between the joints ; the nearest of the three is the thickness of the metacarpal bone below the articu- lation ; the middle one corresponds to it, and the furthest is the thickness of the phalanx above. {a) Amputation at the ■ Metacarpo-phalangeal Joint. — A racquet-shaped in- cision is the best, commencing on the neck of the metacarpal, running straight down on to the phalanx, and then winding round the finger below the web. It should divide the extensor tendon at once, and pass right down to the bones. Afterward, the lateral ligaments and a few other structures require division. In the case of the index and little fingers, the incision should be made at the side, as it is less conspicuous. Where strength is re- quired, the head of the metacarpal should be left, but, if it is wished to minimize the deformity at all cost, it may be removed obliquely with bone-forceps. (U) iTtterphalangeal Amputation. — This is usually performed with a single palmar flap ; but single dor- sal, lateral ones, or equal dorsal and palmar, may be selected instead. When a long palmar flap is chosen, the finger is bent to a right angle, and the knife (which should be long and very narrow) drawn across the front of the joint, so as to open it, and divide the extensor tendon at one sweep. The lateral ligaments are then divided, and the knife insinuated behind the distal phalanx, and, following its palmar surface, made to cut a long square-shaped flap from the under portion. It is usually recommended not to amputate through the proximal phalangeal joint, or through the proximal phalanx itself; but, as Jacobson points out, this rule should not be followed in the case of the index or little fingers, when all the fingers are amputated, or when the patient prefers to have it left. If the flexor tendons are stitched to the theca, the periosteum, or even to the skin, the stump follows all the movements of the other fingers. Fig. 519. — Outline Diagram for Ampu- tation of the Thumb and Fingers. Amputation at the Hip Joint. The older operations (antero-posterior transfixion flaps, and lateral skin or transfixion ones) have given place to Furneaux Jordan's method ; the shock is very much less ; the risk of hemorrhage not so great ; the wound is as far away 76 1 194 DISEASES AND INJURIES OF SPECIAL STRUCTURES. from the anus as it can be, and the stump is sufficiently long and well-nourished to carry an artificial limb, at any rate for a short time. The patient is brought well down to the edge of the table, and the vessels controlled either by Lister's tourniquet, Davy's rectal lever (p. 209), or Jordan Lloyd's elastic strap. This consists of a piece of stout rubber tubing carried obliquely from high \\\) in the groin, across the hip (one end above, the other beneath), to the middle of the iliac crest, where it is held by an a.ssistant. thither a pad, or a properly shaped block of wood grooved on its upper surface to prevent the strap slipping from off it, is fitted over the vessels at Poupart's ligament. [Trendelenburg first recommended that a steel pin be thrust through the thigh on the inner side, close to the bone, and then compressed with an elastic cord thrown over the ends in figure-of-eight fashion.] A circular amputation is then performed through the lower third of the thigh, the skin, fascia, and muscles being divided down to the bone, and the vessels secured. As soon as this is done, the wound is packed with sponges wrung out of hot corrosive sublimate lotion, and an incision made along the outer side of the limb, from the circular wound to a spot midway between the trochanter and the iliac crest ; the soft parts (including the periosteum, if it is thought advisable) are stripped off the bone ; the joint opened by cutting on to the neck, and the femur disarticulated by the assistant. It is doubt- ful if any bone is ever reproduced, but there is no question that the preservation of the periosteum adds to the stability and nu- trition of the stump. In the operation by lateral flaps, the surgeon stands on the right-hand side, and marks out the incisions successively, start- ing from the tuber ischii behind, running down a hand'sbreadth below^ the trochanter (or a corresponding distance on the inner side of the limb), and ending in the centre of the groin, imme- diately outside the femoral vessels. The external flap should be ^'dan'\°'Mrtho"d orAml dissectcd up first ; the vessels secured, and the joint opened ; putation at the Hip and then the tissues on the inner side of the limb, this part being finished either by dissection or transfixion. Disarticula- tion is ])erformed last. In the antero-posterior method, a flap, five inches long, is formed by trans- fixion from the tissues of Scarpa's triangle. The knife enters midway between Fig. 521. — .Antero-posterior Method. the anterior superior spine and the great trochanter, passes across the front of the joint (opening the capsule if possible), and, avoiding the obturator foramen, emerges close to the tuberosity of the ischium. On the left limb it takes the re- AMPUTATION AT THE HIP JOINT. 1195 verse course. One assistant holds the Hmb slightly flexed, while a second, as the knife cuts out the flap, follows it with his fingers, and seizes and compresses the vessels as they are divided. The flap is drawn up as far as possible ; the first as- .sistant extends and rotates the limb outward, to put the capsule on the stretch ; the joint is opened freely, an incision made around the great trochanter, and the head of the bone dislocated by over-extension and abduction. As soon as this is accomplished, the ligamentum teres is cut, and while the assistant raises the limb and draws it away from the body, the surgeon places the knife transversely in the wound, behind the head of the l)one, and cuts a short posterior flap. The ves.sels on the front of the limb can be controlled in this operation, but unless measures are taken to secure the internal or common iliac, the hemorrhage from those behind, and from the cut surface of the muscles, is very severe. [Notwithstanding the great advances made in the control of hemorrhage and prevention of infection, there is still great mortality attending the operation from shock, death occurring in about 60 per cent, of the cases. Professor Nicholas Senn has devised an entirely new plan for amputation at the hip joint. In a paper read before the Surgical Section of the Suffolk District Medical Society, February i, 1893, he thus describes his operation: — Exh-rnal Incision. — The external incision is Langenbeck's incision for resection of the hip joint, differing from this only in so far that it is carried a little further in a down- ward direction in order to afford more ready access to the shaft of the femur as far as the proposed Ime of section through the deep soft parts. The incision is made about eight inches in length, parallel to the long axis of the femur directly over the centre of the great trochanter, extending about tiiree inches above the upper border of" the trochanter. When the knife reaches the trochanter from above downward, its point should be kept in contact with the bone the whole length of the remaining part of the incision. The margins of the wound are now retracted and any spurting vessels, such as the circumflex arteries, secured by applying pressure forceps. Dislocation of Head oj Fcmnr and Clearing of Upper Portion of Shaft. — During this and remaining steps of the operation the body is drawn down so that the pelvis rests upon the lower edge of the table, so that the position of the thigh can be conveni- ently changed by the assistant who is entrusted with this work. The pelvis is tilted sufficiently upon the opposite healthy side to facilitate this step of the operation. The trochanteric muscular attachments are now severed close to the bone with a stout scalpel. The clearing of the digital fossa and division of the tendon of the obturator externus requires special care. The thigh is now flexed, strongly adducted, and rotated inward, when the capsular ligament is divided transversely at its upper and posterior aspect. The remaining portion of the capsular ligament is severed while the thigh is brought back to a position of slight flexion. After complete division of the capsular ligament the thigh is rotated outward, and, if possible, the ligamentum teres is divided ; if this cannot be readily done the head of the bone is forcibly dislocated upon the dorsum of the ilium by flexion, adduction and rotation inward of the thigh. After dislocation has been effected, the trochanter minor and upper part of shaft of femur are cleared by using alternately scalpel and periosteal elevator. In cases where it is deemed advisable the periosteum can be preserved. At the completion of this part of the operation the femur is in a position of extreme adduction. By pushing the femur through the opening as much of the shaft can be cleared as may be desired for the purpose of making a low amputation. Elastic Constriction. — During the operation so far, if the surgeon has kept in close contact with the bone, and has used the knife sparingly and the periosteal elevator freely, the hemorrhage has been very slight, much more so than if this part of the operation had been reserved for the last, as is done in Esmarch's method. Further loss of blood during the subsequent steps of the operation is now prevented by elastic constriction applied in the following manner : The limb is brought down in a straight line with the body, the thigh slightly flexed so as to push the upper free end of the femur forward into and beyond the wound, when a long, stout haemostatic forceps is inserted mto the wound behind the femur and on a level with the trochanter minor when in normal position ; the instrument is pushed inward and downward in a direction about two inches below the ramus of the ischium and just behind the adductor muscles. As soon as its point can be felt under the skin in this location an incision is made through the skin about two inches in length, through which the instrument is made to emerge. After enlarging the tunnel made in the soft tissue by expanding the branches of the forceps, a piece of aseptic rubber tubing three-quarters of an inch in diameter and about three or four feet in length is 1196 DISEASES AND INJURIES OF SPECIAL STRUCTURES. grasped with the forceps in the middle, and is drawn along the tunnel as the forceps is withdrawn. After tiiis has been done the rubber tube is cut in two at the point where it was grasped l:)y the forceps. With one-half of the tube the anterior segment of the thigh is constricted sufficiently firm to com|)lete]y interrupt both the arterial and venous circu- lation. Prior to constriction, the limb is rendered bloodless by elastic compression, or by keeping it in a vertical position for a few minutes, or both of these methods are combined in preventing unnecessary loss of blood. The elastic constrictor is either tied, or, still better, after having secured the necessary constriction both tubes are caught and held by a strong pair of forceps at a point where they cross each other. The posterior segment of the thigh is constricted by the remaining rubber tube, which is drawn sufficiently tight behind, when the ends of the tube are made to cross each other and are brought forward and made to include the anterior segment, when they are again firmly drawn and tied, or otherwise fastened, above the first constrictor. As the anterior segment of the thigh contains the principal blood-vessels this method of applying the posterior constrictor furnishes an additional security against hemorrhage from the large vessels when divided by the circular incision. Cutaneous Flaps. — Muscular flaps should be avoided in all amputations at the hip joint. Inclusion of muscles in the flaps is often accountable for incomplete removal of malignant or infective disease for which the amputation is made. An ideal stump can be made by cutaneous flaps and circular section of the muscles. If the conditions per- mit it, a long oval anterior and short posterior skin flaps should be made. If this is impracticable healthy skin must be obtained by making long external and short internal flaps, or a long posterior or short anterior, according to the location and extent of the disease. The long anterior and short posterior flaps are best adapted for a useful stump and efficient drainage. In making the anterior flap the incision is commenced at the lower tcrminusof the straight incision, dividing the tissues down to the muscles; it is carried downward in a gentle curve across the anterior aspect of the thigh, embracing about two-thu'ds of the circumference of the thigh; it is finally carried upward to a point on the inner side just below the opening in the skin occupied by the constrictors. The posterior flap is made in a similar manner, but about one-third shorter. The flaps are now reflected to the point where the muscles are to be divided, and should always include the deep fascia. The flaps are to be held out of the way, while the operator completes the ampu- tation by dividing the muscles with an amputating knife. This last incision will corres- pond to a point on the femur to where the bone has deen deprived of soft parts. The incision through the muscles should be slightly conical with the apex of the cone directed upward and corresponding to the location of the tube made by the enucleation of the femur. The sciatic nerve is now resected to the extent of an inch or more, and the femoral artery or arteries tied with catgut in the usual manner. The femoral artery and vein are now isolated, and a second catgut ligature, including both of these vessels, applied half an inch higher up. In this manner the vein is ligated, while the artery is secured by a double ligature, which places the end of the vessel in the best possible condition for definitive closure and cicatrization. The intermuscular septa are now examined, and any vessels that can be seen are tied. While the posterior constrictor is removed the poste- rior half of the stump is firmly compressed by applying a hot moist compress of aseptic gauze, over which manual pressure is made for a short time, for the purpose of diminishing parenchymatous oozing. After removal of the compress additional bleeding vessels are secured. The anterior part of the amputation surface is treated in a similar manner; after the removal of the anterior constrictor but few, if any, additional ligatures will be required here. The double constrictor presents many advantages in the prevention and treatment of hemorrhage in this amputation. Slipping of the constrictors is an impossi- bility, and they control the hemorrhage absolutely, while their proper use divides the wound into two halves, each of which is separately treated, thus reducing the loss of blood to a minimum. I applied this method to one case recently, and every one present was favorably impressed with the ease with which the hemorrhage was controlled during the amputation, and astonished at the small amount of blood lost after the removal of the constrictors. As this method of amputation does not require the presence of a skilled assistant, it will prove of special value in emergency cases. The operation can be per- formed with instruments contained in every pocket case. Should an elastic tube not be at hand the constriction can be made in the manner describea by substituting for it a cord made of sterilized gauze or bandage.] Amputation Through the Femur. {a) In amputations through the shaft, the mixed method (an anterior skin flilj with a shorter posterior one by transfixion) answers so well, that any other is AMPUTATION THROUGH THE KNEE JOINT. 1 197 seldom needed. Care must be taken not to slit or jjrick the artery as it is passing out of Hunter's canal, and, in arranging the dressings, it must be remembered that, owing to the rotation of the thigh, the (laps very soon assume a lateral l^osition. (J)) Amputation tlirough the condyles may be performed according either to Garden's or Stokes's method. The section of the bone in the former runs through the base of the condyles, and the anterior flap passes across the limb midway be- tween the apex of the patella and the tubercle of the tibia ; in the latter, the bone is divided above the condyles (supracondyloid), and the anterior flajj reaches down to the tubercle, the increased length being recpn'red by the patella, the sawn surface of which is removed, so that it may face and become adherent to the cancellous tissue of the femur. They are both far superior to amputation through the thigh, owing to their enabling the pressure to be borne (in part at least) on the face of the stump and their preserving the insertion of the adductor, and, in Stokes's, the extensor muscles. Gritti's amputation is similar to Stokes's, but the bone is divided half an inch lower, and the patella does not fit so well. In Garden's operation there is no posterior flap at all ; in Stokes's it is nearly as long as the anterior, and is cut either by dissection or transfixion, according to the bulk of the limb. Amputation through the Knee Joint. Stephen Smith's is the most satisfactory, as antero-posterior flaps require to be of such length (both on account of the depth of the femur and the tendency of Fir.. 522. — Stephen's Smith's Method of Amputating. Fig. 523.- — Posterior Aspect of Stump after Stephen Smith's Amputation at Knee Joint, showing Cicatrix. the posterior one to retract) that there is always danger of sloughing. The stump (w^hich includes the patella) is of excellent shape, and well calculated to bear weight. The incision commences one inch below the tubercle of the tibia, runs curv- ing downward with a wider sweep on the inner side than the outer, owing to the 'f'}'':i Fig. 524 — Amputation through Knee Joint by Long Anterior Flap (Erichsen). greater depth of the inner condyle, over the side of the leg to the middle line behind, and then upward for about three inches and a half to the centre of the popliteal space. A similar flap is shaped from the other side ; the skin and fascia are reflected upward ; the ligamentum patellae divided ; the joint opened, and the soft part separated by a circular sweep round the limb. It is recommended to leave 1 198 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the semilunar cartilages attached to the femur, as they jirevent retraction to some extent. This operation does not enable the suprajiatellar pouch to be dealt with in any way, and accordingly is better suited to cases of injury than of disease. Amputation throucjh the Leg. In the uj^per half, Stephen Smith's method, or that in which lateral flaps are combined with circular division of all the subjacent tissues, gives the best result; but, particularly in cases of injury, it may be advisable to adopt others. In sawing Fig. 525. — Amputation of the Leg by the Mixed Method. Fig. 526. — Stump after an Amputation of the Leg by the Mixed Method. the bones, care must be taken to divide the fibula before the tibia, and to remove the sharp angle left by the crest of the latter, for fear of its causing undue pressure. The lower half of the leg is the favorite situation for Teal's amputation. Amputations at the Ankle Joint. The most important are those known by the names of Syme, Roux, and Piro- goff. Symes. — The whole of the foot is removed with the malleoli, and the stump covered with a flap formed from the heel. The incisions are : (i) from the tip of the external malleolus across the front of the ankle joint (very slightly convex •A Fig. 527. — Syme's Amputation of the Foot. Fig. 528. downward) to the corresponding point (half an inch below and behind th« inter- nal malleolus) on the inner side ; and (2) between the same points across the sole of the foot, slanting slightly backward on to the point of the heel. On the left foot the incisions are begun on the inner side. The ankle is su])ported on the ^(VgQ of a form cushion at a suitable height and the fore part of the foot held by the operator's left hand in a position of extreme AMPUTATIONS AT THE ANKLE JOINT. 1 199 dorsal flexion. The plantar incision is made first, carrying it right down to the bone (the knife is short and stout) ; then, the grasp being altered so as to place the foot in extreme plantar flexion, the dorsal one, taking care not to cut on to the astragalus (or still more the joint in front of it), but to open the ankle joint at once. The foot is now depressed more and more ; the lateral ligaments divided ; the upper surface of the os calcis exposed, and then the tendo-Achillis. This is separated from its insertion with the point of the knife, taking care not to button- hole or score the flap, and with a few touches the foot is detached. The tendons must be shortened with scissors, and the malleoli removed ; but unless the lower end of the tibia is diseased, there is no need to remove the cartilage. The arteries divided are the dorsalis pedis and the two plantars. It is of consequence not to cut the posterior tibial before its division, as the nutrition of the flap depends mainly upon the calcanean branches. Roux' s. — In this the flap is taken from the inner side. The incision forms an irregular oval, commencing at the apex of the external malleolus, running across the front of the ankle as far as the scaphoid on the inner side, then sweeping round to gain the middle line of the sole, passing up the posterior border of the tendo-Achillis, and ending where it began. Pirogoff^ s. — The posterior portion of the os calcis is sawn off and brought face to face with the cut surface of the tibia. The limb is longer than after a Syme's, and the stump wastes less, but it is not suited to cases in which the bones are diseased. The position of the foot and the incisions are almost the same as in a Syme's, but the plantar one, instead of sloping backward, passes transversely across the sole from point to point, or, if the arch of the foot is very high, may even slant a little Fig. 529. — PirogofTs Amputation. Heel Flap with Os Calcis. Fig. 530. — Stump after Piro- goff's Amputation. ■ forward. The amputation may either be performed in the same order as a Syme's, the OS calcis being sawn through from above instead of being detached, or the bone may be divided through the plantar incision as soon as this is made, the chief advantage being that it is more easily held. In either case the line of section should run from above downward and forward so as to secure a large surface and prevent tension upon the tendo-Achillis. Pirrie advocates sawing the tibia through in the same way from the dorsal incision without opening the joint, a itw tendi- nous and ligamentous bands only requiring division afterward. Apposition of the bony surfaces is best secured by one or two chromic gut sutures passed through them. Amputations through the Foot. The most important are Chopart's, Tripier's, the subastragalar operation, and Hey's or Lisfranc's. Formal oj^erations, however, are seldom performed ; in cases of disease in which local measures have failed, it is rarely possible to leave much of I200 DISEASES AND INJURIES OF SPECIAL STRUCTURES. the tarsus ; and after injury it is better simply to prevent decom])Osition and wait until it is seen how far the tissues can repair the damage of themselves. P'ollowing this principle, on one occasion, in which the contents of a gun had blown a hole through a man's foot, I succeeded so well that within six months the patient could walk three or four miles and ascend ladders without inconvenience. Fig. 531. — I. The Incisions in Pirogoff 's Amputation. The dotted line shows the direction of the plantar incision in that of Syme. 2. The incision is subastragaloid ; and 3, those in Chopart's amputation. Choparf s Amputation through the Mid-tar sal Joint. — The foot is supported as in Syme's operation, and the anterior part held in the left hand so that it may be placed in extreme plantar or dorsal flexion as required. The tubercle of the scaphoid and the corresponding point on the opposite side (midway between the !• ir,. 532. — Stump left after Chopart's Amputation. tic. 533. — Tripier's Amputation of the Foot, (a) Section through the skin ; {J>) through the soft parts. external malleolus and the base of the fifth metatarsal) are defined, and the plantar flap marked out first. It extends from behind the tuberosity of the fifth metatarsal along the outer side of the foot to the ball of the toe, then obliquely forward across the sole (.so that it may be longer on the inner side than the outer), and back along the inner border to the scaphoid. The dorsal incision may be made AMPUTATION 7HR0UGH THE FOOT I20I next, but, as in disarticulating there is some risk of wounding the structures in the sole, it is better to dissect the plantar flap back from off the bones (taking care to include the artery) and have it held well out of the way. The two ends of the plantar incision are then connected over the dorsum by a second, slightly convex forward, the extensor tendons and ligaments divided, and disarticulation com- pleted. The stump left by this operation is in many cases exceedingly good ; but some- times it tilts so far forward that the cicatrix presses against the ground. It is probable (as the os calcis and astragalus, having lost the support of the anterior pillar of the arch of the foot, must always tilt downward in this way) that this arises from the i)Iantar flap being too short ; or it may result from unopposed con- traction of the gastrocnemius. It can usually be prevented by dividing the tendo- Achillis and suturing the extensor tendons in front into the periosteum or the cut ends of the ligaments. Tripicr s. — The under part of the os calcis is sawn off horizontally just below the sustentaculum tali (having as far as possible preserved the periosteum) in order to leave a surface at right angles to the axis of the tibia. The incision (through the skin only) begins at the outer edge of the tendo- Achillis, on a level with the external malleolus, and runs downward and forward below that projection to the base of the metatarsal bone of the fifth toe. Thence it passes slightly convex forward, across the sole, until it reaches the inner side of Fig. 534. — Stump after Hey's Amputation. the foot, well in front of the projection caused by the base of the first metatarsal ; and winding upward over the inner border, continues across the dorsum until it joins the first over the calcaneo-cuboid articulation. As soon as the skin has re- tracted, the soft parts are divided down to the bones ; disarticulation effected at the mid-tarsal joint ; the periosteum detached from the under surface of the OS calcis, and the bone sawn through, from behind and within, forward and outward. The Subastragalar Operation. — The incision for this is nearly the same, but it commences an inch below the external malleolus (instead of at the tendo-Achillis) and does not run quite so far forward on the sole of the foot. The soft parts must be dissected off the under surface of the cuboid and os calcis ; the interosseous ligament between the latter bone and the astragalus divided from in front (space can be obtained by depressing the toes) and then the tissues on the inner side and the tendo-Achillis. The operation is one seldom performed in England, and opinions as to its merits are undecided. Hef s afid Lisfranc' s Amputation of the Toes at the Tarso-metatar sal Articu- lation. — In the former the saw was used to a limited extent (in one of the original operations the internal cuneiform was divided) ; in the latter the disarticulation is complete. The operation is performed in the same way and by the same incision as Chopart's, with the exception that instead of the scaphoid and the calcaneo-cuboid articulation being used as landmarks, the bases of the first and fifth metatarsals I202 DISEASES AND INJURIES OF SPECIAL STRUCTURES. are taken. A ])lantar flap running across the heads cf the metatarsals and longer on the inner side than the outer, is marked out and dissected back ; the posterior ends of. the lateral incisions are joined by one across the dorsum, and the toes being depressed as far as possible, the dorsal ligaments of the three outer and the inner metatarsal articulations divided. The articulation of the second, which is placed in a recess posterior to the others, must either be dealt with by itself, using the point of the knife lightly, or the base of the bone sawn off. Amputation of the Toes. The incisions are the same as in the case of the fingers, but on no account may the part of the sole that receives the pressure of the foot be interfered with. Fig. 535. — Incision for Amputation of the Great Toe. ■-^^li^J Fig. 537. — Incision for Removal of the Meta- tarsal Bone of the Great Toe. Fig. 536.- Dubreuil's Opera- tion for the Removal of all the Toes. Fig. 538. — Stump after the Removal of Metatarsal Hone. The tendon-sheaths should be secured by sutures, as otherwise they form open ver- tical drains (when the patient is lying in bed), conducting into the sole of the foot any discharge that does not escape at once. Amputation of the great toe is jjerformed by means of a racquet-shaped inci- sion ; the head of the metatarsal should always be preserved if possii)le, and when it is necessary to remove this bone (which may be done through a similar incision DISEASES OF STUMPS. 1203 commenced further back), the base, with the insertion of the pcroneus longus, shouUl be left intact. Diseases of Stumps. The tissues in a stump always waste to some extent ; the bones atrophy, the muscular fibres disappear, the' vessels contract, and the temperature falls. The skin, however, should retain its natural texture and color, there should be no tender spot, the scar should be well out of the way of pressure, and not adherent to the bone, and there should be a good pad of fatty and fibrous tissue around the end. Conical Stump. — A stump may become conical either from a deficiency in the soft parts, or from growth of the bone. The former usually arises from the flaps having been originally too short, from their having retracted owing to the amount of muscle contained in them, or from their having sloughed. The latter seldom occurs except in children, and in them especially in the leg. The treatment con- sists either in excising the end of the bone, slitting up one side of the stump to render it more accessible, or re-amputation, according to the condition of the part. Necrosis. — This may arise from the periosteum having been stripped off too far, so that the end of the bone is deprived of its blood sui)i)ly, or from inflam- mation. In the latter case the extent depends upon the severity of the attack — there may be merely a scale from the end of the bone, or a long, tubular seques- trum. Aneurysm has been known to develoj), and one or two cases of arterio-venous ajieurysm are on record. Neuralgia (p. 177) may arise from a nerve being involved in the cicatrix, so that it is dragged upon by the scar tissue, or from the end of one becoming bulbous. In the latter case there appears to be a growth of nerve fibres, but the bulk of the mass is made up of connective tissue (pp. 137 and 305). The pain, when one of these is touched, is described as like an electric shock, shooting down the distribution of the nerve. The only treatment is excision, and usually it succeeds at once. There is, however, another variety of neuralgia very much more serious in character. The stump is red and glazed ; to the touch it is icy-cold, but the patient complains of an intense ceaseless burning; no one part is worse than the other ; the whole of the limb for some distance is exquisitely tender and the seat of agonizing pain. It is not known to what this is due ; nerve section and nerve stretching have only a transient influence on it, and I have known it return again and again in the stump after amputation had been performed in the hope of secur- ing relief. Muscular spasm of a chronic character is sometimes met with. Usually it is due to reflex irritation, but in many cases no cause can be found. Relief, when only a single muscle is affected, can be obtained by tenotomy, but unless the source of irritation is removed the spasms are very likely to recur. In addition, stumps are liable to be attacked by epithelioma, cheloid, and the other affections of scars ; and in cases of amputation for disease, if the line of section is not sufficiently high, recurrence takes place in the stump. I204 THE PRINCIPLES OF MILITARY SURGERY. CHAPTER XXVIII. THE PRINCIPLES OF MlL/TAIiY SURGERY. Bv THE Editor, John B. Hamilton, m.u. It is not contemplated in this chai)ter to touch upon any of the duties of the military surgeon, except those i)urely surgical, or which relate directly to the care of the wounded. It is recognized that the most important military duty of the medical officer is the preservation of the health of the troops, by the application of general hygienic rules, modified according to the local environment and the duty on which the command is engaged. There are important military regulations relating to the official conduct of young officers, their duty in the field and the camp, hospital organization, medical and subsistence supplies, and the examination of recruits. However appropriate the consideration of these topics to a special work on military medicine and surgery, it may well be omitted here. The Medical Department of the U. S. Army now issue very complete instructions on these points, and on api)lication through jjroper channels, it is understood that the medical officers of the U. S. National Guard will be supplied with the following : — "U. S. Army Regulations," ''Standard Supply Table," " The Manual of Drill for the Use of the Hospital Corps," " An Epitome of Tripler's Manual and other Publications on the Examination of Recruits," by Deputy Surgeon General Greenleaf; and the "Handbook for the Hospital Corps," by Major Charles Smart, Surgeon, U. S. A. The Bureau of Medicine and Surgery of the U. S. Navy issue the "Regulations of the Medical Department of the Navy," and "First Aid to the Injured and Transportation of the Wounded," by P. A. Surgeon Beyer,* U. S. N. First Aid to the Wounded. — ^The U. S. A. Hospital Corps consists of hospital stewards and enlisted men. This corps, under the command of medical officers, perform all necessary hospital service in garrison and in the field, and the ambulance service in action. In addition to this force, there are in each company four men who are designated as company litter bearers. These men, as well as the Hospital Corps proper, are instructed four hours each month in the duties of litter bearer and the methods of rendering first aid to the wounded. During an en- gagement the company litter bearers maybe designated to give first aid and carry wounded to the dressing station in the rear, and continue to so act until relieved by the Hospital Corps, when they immediately rejoin their company. Under existing regulations those wounded during an engagement receive attention in the following order : i, With the line of battle under fire ; 2, at the first dressing station ; 3, at the ambulance station ; 4, at the division hospitals. " The first dressing-station is established at the nearest place to the combatants, where the wounded and those caring for them may not be unnecessarily exposed to fire." Ambulance stations are established " at some ])lace of security in the rear, or in some convenient building near the field of battle." The division hospital may be establi-shed in such secure place as the medical director may designate. * In addiiion to the official publications above mentioned, the following will be found useful : " First Aid in Illness and Injury," by Captain James E. Tilcher, .Assistant .Surgeon U. S. A., New York, 1892 ; " The Surgeon's Pocketbook," by Surgeon- Major ]. H. Porter; revised and edited by Brigade Surgeon C. II. Y. Godwin; and an article in the "International Encyclopedia of Surgery," vol. vi, page 764, by Bvt. Lieutenant Colonel Bennett A. Clements, Surgeon, U. S. A., entitled •' Preparation of Military Surgeons for Field Duties ; Apparatus Required ; Ambulances ; Duties in the Field." HANDKERCHIEF BANDAGES. FIRST AID TO THE WOUNDED. 1205 Each soldier should l)e supplied with a packet which will contain the materials necessary for a first dressing in case of wound. The contents of this package are those recommended by Esmarch. viz. ; Two antiseptic compresses of sublimated gauze in oiled paj^er ; one antiseptic bandage of sublimated cambric with safety pin ; one E.smarch's triangular bandage with safety-pin ; mode of application illustrated on same. The directions accompanying the packet are as follows : " Place one of the compresses on the wound, removing the oiled paper. In cases of large wounds open the compress and cover the whole wound. Apply the anti- FiG. 539. — Esmarch's Triangular Randage. septic bandage over the compress. Then use the triangular bandage as shown by the illustrations on the same." The packet may also contain a tag on which the soldier's name, company, and regiment may be written. The company litter bearers may be so well instructed that in many cases the second dressing at the dressing station may be dispensed with. The accompanying illustration from Pilcher shows the methods of application of the triangular bandage. It will be seen on investigation that the figures show the bandage is really the triangular bandage invented by M. Matthias Mayor in 1838. Surgeon General I jf^"*^ Fig. 540. — Lifting the Patient. Esmarch, however, although giving due credit to M. Mayor, caused them to be introduced into the Prussian Army in 1869, and they have borne his name in Germany. The bandages having been applied, the wounded man is placed on the litter and carried to the dressing station, where a medical officer examines the patient, and again dresses the wound if necessary. In case the nature of the wound is such that immediate attention is necessary, a cloth tag is then pinned on to the wounded man, of a certain color, which in- sures such attention at the hospital, to which the patient is then taken by litter or I2o6 THE PRINCIPLES OF MILITARY SURGERY. ambulance. The following illustrations from the " Drill Manual " show the method of bearing the wounded to the litter by the company bearers. Fig. 541. — By Two Bearers. Fig. 542. — Carbines Used as Stretcher. "The Rifle Seat." The wounded man is usually taken from the dressing station by an ambu- lance or by the travois. Fig. 543. — By One Bearer Across Shoulders. Fig. 544. — By One Bearer Astride of Back. In the naVy the first care of the wounded falls directly upon the medical officer, who has to assist him, the apothecaries and bay men. The bay men are appointed by the senior medical officer, with the approval of the commanding FIRST AID TO THE WOUNDED. [207 Fig. 545.— The Travois Fig. 546. — The Gorgas Cot Fig. 547.— The Gihon Cot. i2o8 THE PRINCIPLES OF MILITARY SURGERY. Fig. 548— Walton-Wells Cot. Fig. 349. — The McDonald's Ambujance Lift. GUNSHOT WOUNDS. 1209 officer, and act under the orders of the medical officer on duty. The wounded are cared for usually by being brought immediately into the sick bay, or hos])ital, where their wounds are dressed as in a field hospital. No system of litter drill has as yet been adopted by the Navy Dei)artment, although it would seem desir- able. Various forms of cot or combined stretcher with cot have been devised by naval surgeons for the transportation of the wounded on shipboard, and from one ship to another. The respective cots, of Gorgas, Gihon, and Wells are shown in the diagram. The Walton-Wells cot is made of canvas, and when rolled tightly takes up much less space than any other. The figure rei)rescnts the Wells cot — a, rolled ; h, at an angle ; c, cot without poles ; d, with poles. McDonald's ambulance lift as shown in the cut (Fig. 549) will be found very useful either in lowering a wounded man over the shii)'s side or in bringing him on board. Gunshot Wounds. The literature of this branch of military surgery is almost wholly modern, the use of gunpowder having been rediscovered by Schwartz in 1320. The first important engagement in which cannon was used in Europe was at the battle of Crecy, August, 1346. At first stones were used as projectiles in cannon, but lead and iron soon came into use, and muskets and pistols caused new varieties of wounds. While the general' subject was new, the surgeons of the time considered that gunshot wounds were poisoned by the action of the powder, an idea which was not dissipated until the beginning of the fifteenth century. "Giovanni de Vigo" (b. 1503), says Sprengel, " attributed the danger from gunshot wounds to the round form of the balls, the burning of the parts, to the poisonous qualities of the firearm, and of the powder. After this he established two indications for treatment: first, a humectant (moistener), to cure the burn ; second, a desiccator, for the abatement of the poison. He applied a red-hot iron with a view of destroying the poison. He also had recourse to ' Egyptian ' ointment or boiling oil, followed by friction with fresh butter to detach the eschar, and he highly praised a ' digestive ' composed of yolk of egg and spirits of tur- pentine to calm the pain." Alphonse Ferri {b. 1515 d. 1595), of Naples, also believed that these wounds were poisoned. He was probably the first to speak of the " wind of the bullet," which he asserted caused death almost as often as the bullet itself. He treated these wounds by a caustic composed of corrosive sublimate, sulphate of copper and impure carbonate of lead (litharge). He regarded the extraction of the ball as precedent to cure, and invented a bullet forceps, which after him was called the Alphonsin. The accompanying plate from Scultetus shows the instrument as supplied to surgeons in his time. It will be noticed that what would now be termed antiseptic treatment, although rather heroic, figures largely in the means of cure. Gunshot wounds differ in few essential particulars from other wounds. The velocity of the ball determines its course through the tissues and the relative lac- eration. The results show that these wounds are distributed over the regions of the body in pretty close ratio to the area of exposed surface. The changes in the shape of projectiles have correspondingly changed the character of the wounds ; stronger powder, conical projectiles, and rifled bores have increased the velocity of bullets and lessened the laceration. This remark can only apply to small arms, for the immense weight and size of cannon projectiles produce crushing wounds, like those of railway wrecks. The effect of smokeless powder can now only be conjectured, as no engagement has taken place where it has been used, but it is probable that, with the greater accuracy of aim, the relative proportion of wounded to the whole number engaged will be increased. The effect of velocity has been mentioned. A ball, striking the body at a very high velocity, may pass directly through a bone without splintering, or may perforate the body or the skull. A 77 I210 THE PRINCIPLES OF MILITARY SURGERY. ball, having its velocity reduced by distance or obstacles, on striking the body produces greater laceration, and may pursue a quite erratic course, being deflected by bone, tendon, or skin. Instances are frequent where a ball has passed almost around the body, around the skull, or, striking a long bone, has traversed its length At short range, and with modern weapons, we should expect the bullet to take a nearly straight course. Neglect of this presumption sometimes causes the patient much unnecessary suffering, and the surgeon much annoyance in his search for the ball. TaBVLA 2CV A 1 =© Fig. 550.— Ancient Bullet Extractors. (From Scultetus ) Examination of Gunshot Wounds.— \^ is useless to expect that the company bearers at the front will have the time, knowledge, or disposition to make a com- plete examination, and their duties should be considered as satisfactorily performed when they apply the compress or plug the wound, put on the triangular bandage, and carry the wounded to the dressing station. At the dressing station, if the hemorrhage is stopped, and there is little shock, no further examination should be made nor any attempt to remove the ball, but the patient sent immediately to the GUNSHOT WOUNDS. 121 I hospital. If there is hemorrhage, both ends of the bleeding vessel should be tied in the wound, and at this time the ball should be extracted when i)racticable. If there is shock, apjjropriate remedies should Ijc administered, and heat applied if possible. If there is fracture of the arm or leg, a temporary splint, or compress, should be applied. When the patient arrives at the hospital, systematic examina- tion should be made as soon as practicable after reaction shall have taken place. Q= K. A. YAUNAI Fii;. 551. — The Nelaton Probe. No anaesthetic should be administered while there is shock, the presence of which is an excellent reason for postponing examination until reaction is complete. Gunshot wounds are divided into perforating, penetrating, and lacerated wounds and fractures. No ball passes into the tissue with such velocity as to make an incised wound, but some of them come very near it. The clothing should be examined for the purpose of ascertaining whether there is loss of its Fig. 5:2.— Longmore's Electric Explorer. A, Pocket compass ; B, Copper sheeting (a penny piece will answer) ; C, Plate of zinc ; D, Flannel saturated with dilute acid ; E and F, Insulated wires ; G, Exploring needles. (Porter.) substance, and whether any pieces were carried into the wound. Sometimes the projectile itself is found during the examination of the clothing. The hands of the surgeon and his assistant having been cleansed and rendered aseptic, the skin about the wound is shaved, scrubbed with soap and water, and then with alcohol or ether. The wound may now be probed by the little finger of the surgeon or the bullet probe. The Nelaton probe is one of the most generally useful. Lecompte's probe nippers (stylet pince) are occasionally 1 212 THE PRINCIPLES OF MILITARY SURGERY. useful. Fluhrer's aluminium probe, on account of its light weight, is less objectionable than many others. It is especially useful in wounds of the brain or lungs. Electricity has been brought into use by the construction of electric probes. Taylor's, DeWilde's, Liebreich's, Bell's, and Sir Thomas Longmore's are those which have recently been used. Longmore's instrument, which can be readily made by any electrician instrument maker, or mechanician, is thus described by Porter: "The magnet of an ordinary pocket compa.ss, which has had some turns of wire covered with thread wound round it as an induction coil, is employed for the electric indicator, while a piece of zinc sheeting bent round a small plate of copper, but separated from it by a flannel padding saturated with the usual dilute acids, forms the voltaic pile. Thfe exploring instrument is formed by two insulated wires bound together but the points left free. These parts being connected, when the circuit is completed by contact with metal, the indication is given by movement of the magnet of the compass." Extractiofi of Balls. — The number of instruments devised for this purpose is almost infinite, but what is known as the American bullet forceps will be found adapted to the greatest number of cases. For fragments of shells, the ordi- nary elevator from the trephining set or a lithotomy scoop will be found useful. When the bullet is near the skin it should be fixed by needles or grasped between the thumb and finger while the incision is made over it. In case the ball is lodged in the bone, it must be cut out. After the ball has been extracted the wound should be irrigated thoroughly Avith some antiseptic solution, sublimate, Fig. 553. — American Bullet Forceps. iodine, or bromine, and during the irrigation the surgeon may re-introduce his finger to search for pieces of clothing, buttons, or spiculae of bone. All foreign substances having been removed, a drainage tube should be inserted to the bottom of the wound (in the brain aseptic horsehairs may be used instead of drainage tubes), and the wound then dresssd by antiseptic compresses, absorbent cotton, and bandage. In case there is no rise in the temperature, or hemorrhage, on the fourth day the wound should be examined, the drainage tube permanently removed, the bullet track irrigated with an antiseptic solution, rebandaged and allowed to close. In cases where the patient arrives at the hospital with the wound septic, the most thorough irrigation should be made twice a day, or oftener if there is need. Almost any wound may be made aseptic if sufficient care is taken that the antiseptic fluids touch every portion of the pyogenic track. In case an abscess cavity has formed, a counter opening should be promptly made, so that perfect drainage may be secured. Gunshot Fractures. — These injuries, after the ball has been extracted, should be treated the same as open fractures. That is to say — the ball is removed, the bleeding arrested, the wound irrigated with sterilized water, or weak sublimate solution until entirely clean, the skin is shaved and properly cleansed, all loose fragments of bone are removed, the limb is placed in position, and, when practicable, the fractured ends are brought together by sewing the periosteum across the line of fracture, or fastened by Senn's bone thimble ; drainage is secured, the wound is dressed aseptically. and over all a plaster GUNSHOT FRA CTURES. 1 2 1 3 bandage is applied. After the plaster hardens a fenestra may be cut opposite the wound. When treated in this way, and treated early, amputation will rarely be required. Ihe special symptoms and treatment necessary in wounds of the various regions have been treated of so thoroughly by our author that separate mention here is not required, and the reader is referred to the chapters on injuries for the discussion of wounds of the particular organs. Wherever a joint is involved it should be immobilized. Bayonet, lance, and sword wounds are in no respect different from other punctured and lacerated wounds. The requirements are the same, and in their treatment antiseptics and drainage are the essentials. * ' • INDEX. Abbe, trephining spine, 721 Abdominal aneurysm, 256; Loreta's case, 247; nephrectomy, 1015; aorta, ligature of, 273; compression of, 273 ; distention in strangu- lation, 919; section in ectopic gestation, 1 146 Abdomen, injuries of, 870; wounds of, 872 Abduction, in hip disease, 591 Abductors of larynx, paralysis of, 81 1 Abnormalities. See Malformations Abnormal mobility in fracture, 361 Abscess, 46; alveolar, 766 ; antral, 767 ; of bone, 448, 451 ; of breast, 1173; cerebellar, 667, 670 ; cerebral, 665, 671 ; chronic, 1 175; of chest wall, S64; diagnosis of, 51 ; hemorrhage i into, 56; of hip, 595; ischio-rectal, 973; of liver, 949; lumbar, 704; mediastinal, j 863; perineal, I119; peri-urethral, 109S; pointing of, 46; psoas, 705, 709; pus of, 46; pyremic, 75; ^e^idual, 369; retro- pharyngeal, 704, 709 ; sacro-iliac, 603 ; spinal, 703, 709; subcranial, 661; subdural, 669; symptoms of, 47; treatment of, 51; tubercular, 586; urinary, 11 20; varieties of, 49 Absorbents, diseases of, 281 Absorbent wool, 168 Absorption of bone, 446; callus, 351, 354; cartilage, 546 ; of neck of femur, 421, 570, 589 ; sequestra, 445; of thrombi, 228 Accessory thyroids, 84 1 Accidents, railway, amputation in, 376 ; from taxis, 889 A. C. E. mixture, 189 Acetabulum, disease of, 589; fracture of, 411, and neck of femur, 420 Acids, application of, in piles, 963 Acne, ill syphilis, 100 Aconite in inflammation, 38; in aneurysm, 241 Acquired talipes, 332; varieties of, 333; tumors of scalp, 656 Acromion, fracture of, 391 Actinomycosis, 89 Active clot, 236 Actual cautery in piles, 963 Acupressure, 211, 229 Acupuncture, 247 ; in aneur\'sm, 247 ; for hydro- cele, 1 141 ; in neuritis, 301 Acute arthritis of infants, 462 ; epiphysitis, 454, 559 ; necrosis, 453 ; progressive myositis, 31 1 ; rickets, 479; suppurative osteomyelitis, 453, 493. 559 Adams, 318 Addison's cheloid, 178 Adduction in hip disease, 591 Adductor longus, rupture of, 307 Adductors of larynx, paralysis of, 811 Adenitis, 282 Adenoma, 144; of breasts, 1178; mouth, 770; testis, 1 135 Adeno-sarcoma, 141 Adhesions in intussusception, 915 ; as a cause for strangulation, 911; in hernia, 893; in ovariotomy, 11 54 Age as a cause for fracture, 347 ; influence of, in repair, 356; in lithotrity, I051 ; in lith- oiomy, 105S Agnew, 325 Aid to the wounded, 1204 Air, entry of, into veins, 219; exclusion of, in burns, 182 Air-passages, wounds of, 814 ; foreign bodies in, 818 Albumin in urine, 1009 Albuminoid degeneration, 55 Albumose in anthrax, 84 Alcohol as a cause of neuritis, 300 ; in inflam- mation, 38 Alcoholic coma and concussion, 647 AUingham, formation of spur in colotomy, 939 ; speculum, 957 Alopecia, syphilitic, loi Alphonse Ferri, 1209 Alternating strabismus, 724 Alveolar abscess, 766; sarcoma, 140 Amastia, 1 1 71 Ambulance lift, 1208 Ammonia in inflammation, 38 ; erysipelas, 81 ; shock, 152 Amputation, 11 88; in aneurysm, 244 ; at ankle joint, 1 198; of arm, 1192 ; in arthritis, 563 ; of breast, 1185; in burns, 183; Garden's, 1 189 ; of cervix uteri, 1166 ; Chopart's, 1 200 ; in dislocations, 503; of foot, 1200; of fore- arm, 1 192; in fractures, 376, 428; in frostbite, 68; Furneaux Jordan's, 1192; in gangrene, 68; Gritti's, 1197; for hemorrhage, 215: for hip disease, 603 ; Senn's new method, 1195; of the hand, I192; Iley's, 1201 ; at the hip, II93; humerus and scapula, 119O; in inflammation, 74; at the knee, 1197; Erichsen's method, 1197; of the leg, 1 198; Lisfranc's, 1201 ; of the penis, 1 124; Piro- gofif's, 1200; Roux's, 1 199; at the shoulder, 1 189; Stephen Smith's, 1198; Spence's, 1 189; Stokes's, 1 197; subastragalar, I20I ; Syme's, 119S; Teale's, I188 ; of the toes, 1202; Dubreuil's operation for, 1202; Tri- pier's, 1 20 1 I215 I2l6 INDEX. Amussai's operation, 9_}7 Ancemia in syphilis, loo Anceslhesia in reduction of fracture, 371 ; of larynx, 81 1; after nerve section, 292; in spinal injury, 690 Anaesthetic leprosy, 117 Anesthetics, 1S5 ; in fractures, 371; in intes- tinal strangulation, 91S; in ophthalmic work, 73S ; in taxis, 8S9 Anast(jmosis of nerves, 292 ; intestinal, 946 Anatomical tubercle, 91 Anatomy of hernia, S7S Anel's method of ligature, 243 Aneurysm, 235 ; abdominal, 256; by anastomo- sis, 136, 221 ; arterio-venous, 217, 737; of aorta, 248; and atheroma, 226, 235 ; axillary, 25s ; cirsoid, 221 ; of carotid, 251 ; of femoral, 259; of gluteal, 25S; of innominate, 248; of internal iliac, ligature of, 257, 269; nee- dles, 262; non-pulsating, 240; of orbit, 253; of popliteal, 259; of pudic, 258; at root of neck, 248; sciatic, 258; subclavian, 254: traumatic, 206, 217, 235, 248, 367 Aneurysmal dilatation, 240, 251 ; varix, 217, 252 Angeioma, 137, 220 ; cavernosum, I37 Angeiolithic sarcoma, 142 Angle of neck of femur, 414 Angular curvature of spine, 710; splints for fracture of humerus, 398 ; staff, 1058 Ankle, amputation of, 1198; disease of, 611 ; dislocation of, 540; compound, 542; exci- sion of, 628 ; Mickulicz's operation on, 612; shape of, in synovitis, 550. Ankle joint, excision of, 628; tubercular disease of, 611 Ankylosis, 616 ; in caries of spine, 701; after fractures, 359 ; of hip, 604 ; of jaw, 769 ; after nerve-section, 294 Annular structure, 1102 Anodynes in pyiemia, 78 Antal's cystectomy, 1071 Anterior tibial artery, ligature of, 279 ; in frac- tures, 366, 441 ; tibial tendon, division of, 330 Antero-posterior curvature of spine, 710 Anthrax, 84; on face, 746 Antimony in inflammation, 38 Antiseptic baths in arthritis 563; in burns, i8i ; in fractures, 379 ; gangrene, 67 ; in wounds of joints, 416, 504. Antiseptics, in treatment of wounds, 165 Antrum, dropsy of, 768; polypi, 767: suppura- tion in, 767 ; tumors of, 770 Anus, artificial, 947 ; dilatation of, in piles, 962 ; epithelioma of, 983 ; fissure of, 974; fistula, 976; imperforate, 955 ; inflammation of, 973 ; malformations of, 955 ; prolapse of, 967 ; pruritus, 970 Aorta, aneurysm of, 245, 248; ligature of, 273 ; wounds of, 858 Aphasia in brain-injury, 644 Aphonia, functional, 812 Aphthous stomatitis, 763 Apparent lengthening in hip disease, 592 Appendages, removal of uterine, i 146, 1 162 Appendix, inflammation of, 931 Apple-jelly deposit of lupus, 189 Apposition of wound surfaces, 167 Approximation plates, 945 Arachnoid cysts, 663, 673 Arch, of foot, ji-^gging, 338; hemorrhage from palmar, 210 Areola. See Nipple Arm, amputation of, 1 192; innervation of mus- cles of, 692 Arrest of gnjwth after fracture, 363, 394, 426, 441 ; of hemorrhage, 203, 207 Arsenic in lymphadenoma, 2S8; onychia, 200 Arterial angeioma, 221 ; hemorrhage, 201 ; after fractures, 366; hamatoma, 206, 217 ; throm- bosis, 226 ; varix, 221 ' Arteries, compression of, 242; division of coats of, 261 ; operations on, 261 ; rules for ligature, 262; rupture of, 205 ; as a cause of aneurysm, 236 ; wounds of, 207 ; injury of, 205 ; diseases of, 222; degeneration of, 226 Arterio-venous aneurysm, 217; of orbit, 737 Arteritis, 222; in syphilis, 102 Artery and vein, ligature of, 218 Arthrectomy, 587 Arthritis, 554; acute, of infants, 462, 558; acute suppurative, 454, 593, consecutive, 558; com- plicating gonorrhoea, 1098; deformans, 570; after dislocations, 498 ; exanthematic, 566 ; gouty, 564; neurotic, 547, 576; puerperal, 564; pyamic, 563; rheumatic, 569; of hip, 420, 570; suppurative, 558; tubercular, 580; urethral, 564, I097 Articular osteitis, tubercular, 605 Artificial anus, 947; after hernia, 894; eyes, 739; feeding and rickets, 498; nose, 751 Arytenoid, muscles, paralysis of, 812 Ascending paralysis, of Landry, 122 Ascites and ovarian cysts, 1 152 Aspect in hernia, 886 Aspiration in abscess, 53; in arthritis, 561 ; of bladder, 1035; of extravasated blood, 156; in fracture of patella, 43 1; in osteo-arthritis, 575; of thorax, 1035 As[Mrator tor lithotrity, 1049 Asthenic fever, 43 Asthenopia, 726 Astigmatism, 725 Astley Cooper on fracture of neck of femur, 416, 418 Astragalus, angle of, 325 ; dislocation of, 543 ; excision for talipes, 332; of head of, 338 Astringents in inflammation, 37 Asymmetry in fractures, 360 ; as a cause of scoliosis, 712 Atheroma, 206, 224, 235 Atlas, dislocation of, 688, 691 Atlo-axoid disease, 702 Atony of the bladder, 1029, 1074; of rectum, 966 Atrophic catarrh of nose, 753; scirrhus, 1180 Atrophy in ankylosis, 617; of bone, 444; of cartilage, 546; of choroid, 734; as a cause of fracture, 347; after fracture, 568; of muscles, 309, 571, 593; after nerve-section, 293, 310 ; after strains, 306; of neck of femur, 416; of testis, 1229; and varicocele, 1138 Atropin in iritis, 731 Attitude in hip disease, 591 ; in spinal disease, 705 Auditory nerve, injury to, 650 Auricle, blood tumors of, 800 ; malformations, 799 Auriscope, 799 Auscultation of oesophagus, 850 INDEX. 1217 Avery, method of suture, 760 Axillary aneurysm, 255; artery, ligature of, 268; rupture of, 518; pad in fractured clavicle, 389 Bacillus anthracis, 84; of glanders, 73; of tubercle, 91 ; of leprosy, 1 16; of tetanus, 119 ; mallei, 87 ; pyrocyaneus, 46 Back, injuries and diseases of, 685 ; malfurmation of, 680 Ball, on colotomy, 939; on radical cure of hernia, 901 Ballance, 669 Bandages, dextrin, 507 ; in fractures, 372 : Pick's, 390; Sayre's, 389; in sprains, 496; for fracture of clavicle, 388 ; triangular, 387 ; Velpeau's, 508 Bandaging, 188 Bands, as a cause of strangulation, 912 Bardenheuer, exci.sion of rectum, 986 Barker, 587, 625 ; on excision of tongue, 789 Bartholin's gland, 126, 1 168 Barwell's adhesive straps, 327; shoe, 335 ; sling for scoliosis, 717 Base of skull, fracture of, 637 Bassini's operation for hernia, 904 Baths in compound fractures, 379 ; in gan- grene, 69 ; in wounds of joints, 494, 50 5, 562; in phagedcena, 69; in taxis, 889 Bavarian splint for fractured leg, 438 Bayonet wounds, 1213 Beading of ribs, 476 Bearing the wounded, methods of, 1206 Bed, fracture, 369 Bed-sores, 65 ; after fractures, 365 ; in injuries of spine, 694 Belladonna in aneurysm, 242 ; in incontinence, 1032 Bellocq's sound, 752 Berlin wool truss, 882 Biceps tendon, absorption of, 573 ; dislocation. 309 ; rupture, 306 Bichloride of metliylene, as an anaesthetic, 187 ; of mercury, 165 Bigelow, 1047 ; on fracture of femur, 417 Bilharzia, 1023 Biliary calculi, 951 Bird's nest bodies, 146 Birth palsy, 662 Black eye, 727 Bladder, atony of, 1029 ; with enlarged pros- tate, 1072; calculus, 1041 ; diagnosis by cystoscope, 107 1 ; drainage of, 1040, 1063, 1070; in enlarged prostate, 1079; excision of, 107 1; extroversion of, 1024; fissure at neck of, II23; foreign bodies in, 1071 ; after fracture of spine, 693, 695 ; inflammation of, 1037 ; injuries of, 1026 ; irritability of, 1030 ; sacculated, 1038,1045,1104; tapping, 1035; tumors of, 1064; treatment of after cystoto- my, 1069; washing out, 1039; with en- larged prostate, 1079 Blandin's gland, 126, 770 Bland Sutton, 130 Bleeding, arrest of, 204, 207 ; in inflammation, 37 ; from varicose veins, 228 Blepharitis, 735 78 Blister in erysipelas, 82 Blood-clot, cystic transformation of, 156; or- ganization of, 156; suppuration of, 156 Blood-cysts, 127 ; of neck, 826 Blood in urine, 1019 ; vessels, diseases of, 220 ; injuries of, 218 Blucher's splints, 423 Boils, 192 Bone setting, 555, 618 Bones, abs(jrption, 446; abscess, 448; ankylo- sis, 616; atrophy, 444 ; chronic abscess of, 451; curving in rickets, 475; diseases of, 444; failure of growth in rickets, 475 ; in syphilis, 469 ; hypertrophy, 444 ; inflam- mation of, 444; skull, diseases of, 657; tumors of, 484 Bones and joints, diseases of, 322 Bony ankylosis, 618 Boracic acid, 165 ; baths in burns, 181 ; fo- mentations, 192 ; as an antiseptic, 166 Bose on tracheotomy, 828 Bottini's prostatotomy, 108 1 Bougies, dangers of, 1108; oesophageal, 849; size of, 1 106; varieties of, 1 109 Boutonniere, la, I079 Bowlby, 223, 245, 292, 690 Brachial artery, ligature of, 270; plexus, distri- bution of, 692 ; rupture, 294, 518 Brain, abscess of, 665; concussion of, 640 ; contusion, 641 ; compression, 645 ; cysts in, 673; diseases of, 660; glioma of, 664; gum- ma, 662, 673 ; hemorrhage into, 641 ; hernia of, 672 ; incisions in, 676 ; inflammation of, 676; chronic, 662 ; injuries of, 640; lacera- tions of, 64 1; sarcoma of, 674 ; softening of, 660 ; suppuration in, 664; syphilitic disease of, 107; tubercle of, 664, 673; tumors of, 673 ; wounds of, 648 Branchial cysts, 827 ; fistula, 814 Brasdor's method of ligature, 243, 246 ; opera- tion for aneurism, 246 Breast, abnormalities of, 1172 ; adenoma, 1 178, 1179; adenosarcoma of, 141 ; cystic disease of, 126, 1 1 76; enchondioma of, 134; fibro- adenoma, 144; hypertrophy of, II71 ; inflam- mation of, 1073 ; lobular induration of, 1 175 » pigeon, 476; removal of, I185 Bridle stricture, 1 103 Brisement force, 328 Broad ligament cysts, 127, 1151 Brodie's disease of the breast, 127, 1178 Bromide eruptions. Bromine as an antiseptic, 166 Bronchi, foreign bodies in, 819 Bronchocele. See Thyroid Broncho pneumonia after operations on the tongue, 790; after wounds of the neck, 816 Brown's solution in gangrene, 70; vapor, pre- venting erysipelas, 82 Bruiiton's speculum, 799 Bryant, 212; on osteitis deformans, 481 ; splint for femur, 426 ; splint in hip disease, 597 ; triangle, 415 Bubo, 282 ; syphilitic, 97, 99 ; suppurating, 98, 282 ; in chancroid, 97 Bubonocele, 11 26 Buccal cysts, 770 Buckston- Browne's tampon, 1057 Bulb, suppuration in, 1121 I2l8 INDEX. Bulbous sounds, 1107 Bullse, after extravasation, 156; after nerve- section, 293 ; in pemphigus, 203 Bullet extractors, 1210 Bullet forcejis, 12 12 Bunion, 3 10 Buphtlialinos, 733 Buried sutures, 168 Burn anteri(jr polar, 731; concus- sion, 732; lamellar, 732; ojierations for, 740 ; posterior polar, 731 ; senile, 732 ; trau- matic, 726 Catarrhal inflammation of conjunctiva, 728; larynx, 804; nose, 753; mouth, 762; oph- thalmia, 728 ; rectum, 970; stomatitis, 763 ; tonsil, 791 Catarrhal suppuration in joints, 550 Catgut, 168; ligatutes, 212 Catheterization of ureter, loii Catheters, accidents from, 1093 ; in enlarged prostate, 1077; method of tying in, 1095; size of, 1 106 Cauda equina, injury to, 689, 695 Causalgia after nerve section, 294; in neuritis, 299 Caustics in lupus, 191 ; phagedsena, 115 Cautery in hemorrhage, 210, 237 ; in laryngeal growths, 811 ; joint disease, 557; in nsevi, 197; for piles, 963; prolapse of rectum, 968; tonsillitis, 792; tubercular glands, 286 Cavernous angeioma, 137,220; lymphangeioma, 289; tumors, 137 Cell-nests, 146 Cellulitis, diffuse, 70; and erysipelas, 70; after lithotomy, 71 ; of orbit, 71; of neck, 71, 824; after poisoned wountls, 70; of scalp, 71, 623, 655 Celsus on the su'geon, 184 Central necrosis, 460; sarcoma of bone, 488 Cephalhematoma, 155, 450, 632 Cephalhydrocele, 635 Cerebellar abscess, 667, 670 ; trephining for, 672 Cerebral abscess, 665; trephining for, 672; localization of, 670 Cerebral hemorrhage, 649; hernia, 672 ; hyper- emia, 663; after injury, 643; irritability, 663 ; localization, 678 Cerebritis, 660 Cerebrospinal fluid, escape of, 639 Cerumen, accumulation of, 799 Cervical fascia, section of, 824; nerves, distri- bution of, 691 ; vertebrce, injuries of, 691 Cervix uteri, amputation of, 1 1 66; laceration, 1 168 Chalazion, 736 Chancre, 98; duration of, 99; of eyelid, 736; excision of, lio; relapsing, 99; soft, 96; treatment of, 114 Chancroid, 96; of skin, 146 Charcot's disease, 577 Chassaignac's drainage-tubes, 172 Chaulmcogra oil in treatment ol leprosy, 117 Cheloid, 178; in cicatrice, 178 Chemical irritants causing inflammation, 71, 452, 547 ; causing fever, 82 Chest, abscess of, 862 ; aspiration, 865 ; drain- age, 865; injuries of, 853; tubercle, 864; wounds of, 855 INDEX. 1219 Chicken-bone drains, 172 Chills in suppuration, 163 Chimiiey-sweep's cancer, 146, I125 Chloride of zinc, 166 ; for abscesses, 53 Chloroform in delirium, 152; as an anaesthetic, 186 Cholecystectomy, 953 Cholecystotomy, 953 Chondro-sarcoma, 135 Chordee, 1097 Choroid, diseases of, 734; in myopia, 724; rupture of, 728 Chojiart's amputation, 1200 Chromic acitl applied to the tongue, 782, 783 Chronic abscess, 50; of bone, 448, 451 ; of breast, 1 1 76; osteitis, 451 ; synovitis, 55 H ulcer, 193 ; of leg, 195 Chylous hydrocele, 291 Chyluria, 291, 1021 Cicatrices, 175 ; in syphilis, loi ; treatment by transplantation of flap, 176 Cicatrized wounds, 159 Circular amputation, 11 88; of the arm, 1192 Circulation in fracture of spine, 692; effect of irritants on, 26 Circumcision, 1124 Circumflex nerve, rupture of, 518 . Cirsoid aneurysm, 221 ; of scalp, 657 Civiale's urethrotome, 11 13 Clamp, for enterectomy, 942 ; for piles, 964 Clavicle, dislocation of, 506 ; Ellis's splint, 390 ; fracture, 385 ; sarcoma, 490 ; Pick's quad- rangular bandage, 390 ; Sayre's dressing, 390; triangular bandage for, 387 Clavus, 198 Cleanliness in treatment ot wounds, 164 Cleft palate, 759; operation for, 760 Cloaca;, 456 Closure of jaws, 768 Clot; active and passive, 237; cysts from, 156; in hemorrhage, 202; laminated, 237, 241 ; organization of, 29, 156; suppuration, 156 . Clove-hitch, 516 Clover's crutch, 1052 ; inhaler, lS6 Club-foot, 325 Club-hand, 324 Coagulation necrosis, 45 ; and thrombosis, 230 Coates's truss, 882 Cocaine as an anesthetic, 185; in enterotomy, 920; in stricture, I no Coccidia, 1 172 Coccygodynia, 412 Coccyx, fracture of, 412 Cock's operation, 1 117 Cod-liver oil in rickets, 475 Coin-catcher, 846 Colchicum in gout, 568 Cold abscesses, 50; affusion in delirium, 152 ; in arthritis, 551, 557; in bleeding, 2og ; as a cause of shock, 149 ; inflammation, 36, 380 ; in taxis, 889 ; as a cause of neuritis, 299 Colectomy, 945 Coleman's gag, 760 Cole's truss, 880 Colic, renal, 998; in intestinal obstruction, 926 Collapse in burns, 180; in strangulation, 864 Collateral circulation, 215, 232 CoUes' fracture, 405 ; law, 109 Colloid carcinoma, 148 Color of syphilitic eruption, loi Colotomy, 937 ; inguinal, 939 ; lumbar, 937, 940 ; in stricture of rectum, 983 Coma, distinguished from concussion, 646 Comminuted fractures, 346 Common iliac, ligature of, 273 Compact exostosis, 136 Compensatory curve of spine, 711 Complete fractures, 345 ; dis'ojations, 497 Complicated fractures. 345 Compound dislocations, 497, 503; fractures, 345 ; in vault, 635; amputation in, 377, 381, 428; into joints, 381 ; treatment of, 375; ganglion, 315 Compression in abdominal aneurysm, 257 ; in aneurysm, 242, 246; of aona, 273; of oesophagus, 849; in arthritis, 551,557; of brachial artery, 271 ; of brain, 645; of caro- tid, 264; in caries, 703; in extravasations, 157 ; for hemorrhage, 210; as a cause of in- testinal obstruction, 924; of nerves, 295 ; of spinal cord, 698 ; in sprains, 496; of sub- clavian, 268 Concussion and alcoholic coma, 647 ; of brain, 640; of eye, 727; cataract, 731 ; and opium coma, 647 ; of spinal cord, 698; and uraemia, 647 ; treatment of, 651 Condylar fracture of humerus, 398 ; separation of, 401 ; fracture of femur, 426 Condylomata, 198; in syphilis, 100; treatment of, 114 Cone of light, 799 Confinement as a cause of ankylosis, 616 Congenital cyst, 127; cystic tumor, 289; affec- tions of tongue, 778; dislocation, 322; hy- drocele 1 140 ; hygroma, 130, 288, 826 ; hyper- trophy, 290; inguinal hernia, 878; lipoma, 132, 684; sacral tumor, 129, 684; syphilis, 109. See Hereditary; of bone, 467; talipes, 325 ; varieties of, 325 ; torticoUi, 824 ; tumors of scalp, 656; umbilical hernia, 907 Congested ulcer, 194 Congestion in burns, 181 ; after fractures, 366; due to thrombosis, 228 Congestive stricture, 1 103; abscess, 50 Conical stump, 1203 Conjunctiva, diseases of, 728 Conjunctivitis, 728 Consecutive arthritis, 558; displacement in dis- location, 497 ; meningitis, 660 Constipation after fractures, 366 ; in hernia, 888, 915 ; in obstruction, 926 Contagiousness, duration of, in syphilis, I02 Continued fever, 34 Continuous baths in compound fractures, 379 ; extension in fractures, 371 ; suture, 170 Contraction of muscles, 31 1; as a cause of fracture, 349, 430; in arthritis, 55 1 ; after nerve injury, 299 Contraction of palmar fascia, 318; of scars, 175 Contracture, 31 1 ; after fractures, 369 Contrecoup, 637, 644; fracture by, 349 Contused wounds, 157, 174 Contusions, 155; of abdomen, S70; of brain, 641; of chest, 853; as a cause of osteitis, 450; of eye, 727; of joints, 495 ; of muscles and tendons, 306 ; of nerves, 294 ; scalp, 632 ; spinal cord, 698 ; signs of, 156 INDEX. Convergent strabismus, 724 Convul>ions and rickets, 477 ; after injuries to the brain, 643 ; in compression, 644 Copaiba rash, 1099 Coracoid process, fracture of, 391 Coredialysis, 728 Corns, 198 Cornea, diseases of, 729 ; foreign bodies in, 729 Cornu cutaneum, 199 Coronoid process, separation of, 409 ; fracture of, 409 Corpus spongiosum, abscess of, 1 1 21 Corrosive sublimate, 165 Cortical lesions, 643; in cerebral tumors, 673 Coryza, 753 Costal cartilages, fracture of, S54 Cots for wounded, 1207, 1208 Counter-irritants, in intlammation, 37, 41 ; in delayed union of fractures, 35S; in neuritis, 301 Counter-ojienings in compound fractures, 379 Coup de fouet, 307 Cowper's glands, 126; suppuration in 1097, I121 Cramp, writer's, 310 Cranial nerves, injuries of, 639, 650 Craniotabes, no, 475, 659; in congenital syph- ilis, no; in rickets, 475 Cranium, nodes on, 465. See Skull Crepitus as a sign of fracture, 360 Cretification in tubercle, 94 Cretinism, 838 Crico-thyroid muscles, paralysis of, 812 Croup and rickets, 47S ; spasmodic, 820 Crushing for piles, 964 Crutch paralysis, 295 Cubebs, 1099 Cupping, 37 Curdy pus, 46 Curvature of spine, 710; in rickets, 476 Cut throat, 814 Cyanide of zinc and mercury, 165 Cyclitis, 731 Cylindrical celled carcinoma, 147 Cylindroma, 141 Cyrtometer, Wilson's, 679 Cystic adenoma of breast, 1179 ; of ovary, 1149 ; adenoma of testis, 1135; degeneration of breast, 126, 1177; of enchondroma 134; sarcoma, 4S7 ; ganglion, 315 ; goitre, 842 ; sarcoma of breast, 1187 Cystin in urine, 1017 Cystitis, 1036; in fracture of spine, 693 Cystoscope, 1067; in diseases of bladder, 1071 ; in position, 107 1 Cystotomy, 106S, 1069 Cysts, 125 ; of antrum, 768, 773 ; arachnoid, 673; from blood, 156; in bone, 491 ; brain, 673; branchial, S27 ; of breast, 11 76; car- cinomatous, 827 ; dentigerous, 773 ; eyelids, 737; face, 748 ; hyo-lingual, 826; inflamma- tory, 125; jaws, 773; kidney, 997 ; labium, I168; broad ligament, II51 ; larynx, 810; of mouth, 771 ; meibomian, 736; of neck, 826 ; periosteal, 768, 773 ; of pharynx, 827 ; popliteal, 321 ; of scalp, 656; from the semi- membranosus bursa, 575; thyroid, S26; of tongue, 784; of vagina, 1168 Czerney's suture, 943 Dactylitis, 473 Davies Colley, 84 Davy's rectal lever, 209, 274 Deafness in hereditary syphilis. III Decalcified drainage tubes, 172 Decomposition in wounds, 163 Defecation after injuries to spine, 694 Definite callus, 350 Deformity in caries of spine, 702; in disease of knee, 608; in fracture of spine, 688 ; in hip disease, 593; in infantile paralysis, 333; in leprosy, 1 17; as a sign of fracture, 360; in rickets, 478 ; of limbs, 322 ; of nose, 75 1 Degeneration of arteries, 226 ; from arterial obstruction, 223; gelaiiniform of bone, 468; of nerves after division, 292 ; of thrombi, 231 Delayed union, 354 Delirium after fractures, 364; tremens, 152; traumatic 153 Demarcation in gangrene, 67 ; in necrosis, 460 Dentigerous cysts, 773 Deposits in urine, 1021 Derangement of knee, internal, 537 Dermato-keras, 199 Dermoid cysts, 128; of brain, 673; breast, 1 1 77; eyelids, 737; face, 748; mouth, 770; ovary, 1150; sacrum, 684; scalp, 656; spine, 6S4 ; tongue, 784 Desault's splint, 422 Descent of testes, 1 128 Detachment of iris, 728; in myopia, 724 Dextrin bandages, 507 Diabetes, 102 1 Diaphragm, rupture of, 858; hernia through, 909 Diathesis, hemorrhagic, 222 Didot, 325 Dieulafoy's aspirator, 53 Diet in inflammation, 37; in syphilis, 113 Diffuse lipoma, 133; inflammation of cellular tissue, 70; suppuration, 51 ; of meninges, 665 Digital compression, 243; for hemorrhage, 2 lo Digitalis in aneurysm, 242 Dilatation, aneurysmal, 240 ; of stricture, II08; of oesophagus, 850 ; of rectum, 982 ; of female urethra, 1069; of lymphatics, 289 Dilator, Golding Bird's, 821 Dioptric system, 723 Diijhtheria, tracheotomy in, S3I Diphtheritic exudation, 34; of cellular tissue of neck, 823 Direct inguinal hernia, 898 Dislocations, 497; amputation for, 503; of ankle. 540; anomalous, 534; astragalus, 543; clavicle, 506; compound, 503; congenital, 322 ; by destruction, 563, 590; by distention, 566, 594; diagnosis of, 500; of elbow, 519 ; excision for, 503 ; of finger, 527 ; and fractures, 368, 396, 504; of foot, 541 ; of hip, 527 ; of humerus, 50S; of knee, 536; of lens, 728; of lower jaw, 504; of muscles, 30S; by muscular action, 504 ; old, 535 ; of os magnum, 505; of patella, 535; of pisiform bone, 525 ; pubic, 534; of radius, 522; of radius and ulna, 519: recurrent, 511 ; reduction of, 513; by manipulation, 501, 515 ; by extension, 502, 516; by hyperabduction, 516; of scapula, 508; of semilunar cartilages, 537; of spine. INDEX. 688; subastragalar, 544 ; subclavicular. 510; subcoracoid, 509; subjjlenoid, 510; subpen- ous, 510; of tendons, 308; of thumb, 526; of ulna, 522; unreduced, 517; of wrist, 524 Disorders of muscles, functional, 308 Displacement, consecutive, in dislocation, 497 ; as a si^jn of fracture, 360; of tibia in disease of knee, 607 Dissecting aneurysm, 235 Distal compression for aneurysm, 246 ; ligature, for aneurysm, 245 Distention of abdomen in strangulation, 918; of bladder, method of, 1060; in intestinal obstruction, 926; of rectum, method of, 1062 Distribution of leprosy, 115 Divergent strabismus, 724 Division of coats of arteries by ligature, 261 ; of stricture of rectum, 981 ; of stricture of ure- thra, I123 ; of ligament in talipes, 330 Doran, 128 Dorsal abscess in disease of spine, 704 ; disloca- tion of hip, 530; region of spine, injuries of, 694 ; vertebriv, fracture of, 695 Dorsalis pedis, ligature of, 2S0 Double inclined plane, 424; ligature for arteries, 213, 262 Douching in inflammation, 41 Drainage of abscesses, 709 ; of antrum, 768; in arthritis, 562; of bladder, 1040, 1063, 1080 ; in compound fractures, 379; of chest, 866; in goitre, 842 ; of hydrocele, 1141; of knee-joint, 494 ; of the medulla of bones, 458; of pleura, 865; tubes, 52, 172; in wounds, 167, 171 Dressings of compound fractures, 377 ; of wounds, 167 ; for gangrene, 67 Drilling in fracture of patella, 432 Dropsy of antrum, 768 ; of gall bladder, 952 Dry gangrene, 59, 63, 232 Dumb madness, 122 Duodenal ulcer in bums, iSo Duodeno-jejunal fossa, 911 Dupuytren's classification of burns, 179 Dupuytren's contraction, 317 ; enterotome, 948; fracture, 439 ; splint, 441 Dura mater, fungus of, 658; inflammation of, 659 ; sarcoma of, 658 ; tumors of, 673 ; wounds of, 648 Duverney, 523 Dysentery as a cause of stricture, 923 ; and ulcer of rectum, 971 Dysphagia from compression, 849 ; paralysis, 848 Dyspnoea in ansesthesia, 1187; after trache- otomy, 832 E Ear, eczema of, 800 ; examination of, 797 ; ex- ostoses of, 800; foreign bodies of, 800; fungi, 800; furuncles, 800; granulations, 802; hemorrhage from, 639; inflammation of, 665, 801 ; polypi, 802 ; suppuration in, 801 ; spec- ula. 799 Eburnated exostosis, 1 35 Eburnation, 570 Ecchymoses, 156; in fractures, 362 Ecraseur for removal of tongue, 787 Ectopic gestation, 1147 Ectopia vesicae, 1024 Eczema of nipple, 1 172 ; of scalp, 644 Eczematous ulcers. 193; urethritis, 1098 Elastic ligature for fistula, 979; tourniquet, Lloyd's, 1 194 Elbow, ankylosis of, 613; dislocation of, 497, 519; excision of, 621 ; fracture near, 398, 402 ; shape of, 550 ; syphilis of, 469 ; tubercle of, 612 Electric bullet explorer, 121 1 Electrolysis in ectopic gestation, 1147; '" goitre, 843; for n;T:vi, 197, 220; for nasal polpi, 756; in stricture of the rectum, 982 ; of the urethra, 11 18; in uterine fibroids, II61 ; in trichiasis, 98 Elephantiasis, 290, I126 Elevation in arthritis, 557 ; in fractures of the skull, 636; in hemorrhage, 212 Ellis's splint, 390 Embolic abscesses, 75; arteritis, 222; gangrene. Embolism, 232 ; in aneurysm, 238 ; as a cause of aneurysm, 236; fatty, 366, 457; in frac- tures, 367 ; in pyxmia, 74 ; in suppuration, 49; in tubercle, 92, 472, 545, 580 Emotion as a cause of shock, 149 Emphysema, 861 ; interstiiial, 853, 861 Emprostholonos, 118 Empyema, 863; as a cause of scoliosis, 7 1 2 ; of gall-bladder, 952 Encephalocele, 630 Enchondroma, 134; of bone, 477; of jaw, 772 ; of testis, 1 1 35 Enchondromata, 134 Enclavement, 128 Encysted calculus, looi, 1002; hernia, 898; hydrocele, 1141 Endarteritis, 222 Endocarditis, 223, 233 Endothelioma, 142 Endotheliomata, 142 Enemata in intussusception, 921; in obstruc- tion, 930 Enlarged prostate, 1072; catheterism for, 1078; retention in, 1033 ; tonsils, 791 Enterectomy, 941 Enterocele, 879 Enteroepiplocele, 879 Enterorrhaphy, 942 Enterostomy, 936 Enterotome, Dupuytren's 948 Enterotomy in strangulation, 9I9 Enucleation of thyroid gland, S42 ; of uterine fibroids, 1 162 Epicondyle of humerus, separation of, 401 Epidemic goitre, 839; tetanus, 119 Epidermic globes, 119; grafting, 146, 160 Epidermis, repair of, 160 Epididymitis, syphilitic, 101,1131; tubercular, 1 133; urethral, 1 129 Epilepsy after nerve-injury, 298 ; traumatic, 654; neuralgia, 301 ; nerve-stretching in 303 , ligature of vertebral arteries for, 268 Epiphora, 735 Epiphyses, acute inflammation of, 454 ; 462 ; tubercular inflammation, 582; separation of 363; of humerus, 395, 402, 521 ; of femur, 426 ; of radius, 404 ; of tibia, 441 ; in osteitis, 457; premature union of in rickets, 475; in syphilis, 467; union after separation, 393, 425. 441, 448 INDEX. Epiplocele, 879 Epispadias, 1 1 24 Epistaxis, 751 Epithelial tissue tumors, 143 Epithelioma, 144; of bladder, 1065 ; face, 749; gums, 771,774; intestines, 924; after lu])us, 190; of cvsopiiagus, S49 ; penis, 1 124; rec- tum, 9S3 ; scars, 17S; scrotum, 1 125 ; tongue, 784 ; in cicatrix, 178 Epulis, 139, 486, 771 Erasi m, 619 ; in caries, 474 Ergot in uterine fibroids, 1161 Erichsen's splint, 393 Eruptions, after nerve section, 294 ; iodide, 114; serpiginous, 105 ; syphilitic, loi Erysipelas, 79, 290 ; and cellulitis, 70, 79 ; of face, 747 ; of seal]), 655 Erythema in leprosy, 116 Erythematous tonsillitis, 791 ; lupus, 192 Escape of cerebro-spinal fluid, 638 Eserine in glaucoma, 733 Esmarch's bandage, 208, 244; operation, 769 ; operation for excision of the Ijreast, 1 186; tourniquet, 208; triangular bandage, 1205 Estlander's operation, 867 Eiher in inflammaiion, 38; as an anccsthetic, 186; spray in burns of fauces, 183 Eucalyptus oil, 166 Eustachian catheter, 798 Evacuating tubes, 1049 Evolution cyst, 127 Examination of bladder, n8o; calculi, 1043; wounds, 1210; joints, rectum, 929 ; spine, testis, 1136; urethra, 1092, 1107 Exanthematic arthritis, 564; necrosis, 464 Exostosis, 484 Excision of ankle, 628 ; compared with arthrec- tomy, 586; of the astragalus, 332 ; of wall of bladder, 1071 ; of breast 1 185 ; of cancer, 112; of cirsoid aneurysm, 221 ; of joint, 619, of condyle of jaw, 769 ; in compound dislocation, 508; of the elbow, 621 ; of eyeball, 738; of the hip, 603, 625; hydrocele, 1143; jaws, 774 ; knep, 434, 626 ; lymph glands, 285 ; larynx, 810, 835; Meckel's ganglion, 304; ofnsevi. 197,220, piles, 965; prolapse of rec- tum, 968; rectum, 9S5; rib, 868; shoulder, 620; stricture, II18; subperiosteal, 621 ; thumb, 625; tongue, 787 ; tonsils, 793; vari- cocele, 1139; varicose veins, 228 ; wrist joint, 623 Excitement in shock, 149; during anaesthesia, 187 Exclusion of aneurysm, 247 Exercises in lateral curvature, 716 Exfoliation, 459; after scalp wounds, 633 Exfolium, 59 Exophthalmic goitre, 839, 844 Exostoses, 136, 484 ; of cranium, 659; of audi- tory meatus, 800; of jaws, 772 Expansile pulsation, 237 Expansion of bone, 447, 473 Exploring needle, 51 Extension in arthritis, 557; as a cause of an- kylosis, 617; for cicatrices, 176, 183; in dis- locations, 501, 516; in dislocation of the spine, 696; in fractures, 371 ; in hip disease, 598 1046; breast, 1 176, eye, 722 ; of gunshot 548; prostate, 1076; 716; scrotum, 1 1 25; Extensor tendons of wrist, dislocation of, 309 External hemorrhoids, 959; iliac, ligature of 275; urethrotomy, 1 1 15; incision in removal of tongue, 787 Extirpation of uterus, 1 166; by extra-peritoneal method, 1 167 Extra-articular ankylosis, 616 Extraction of cataract, 740; of balls, I2I2 Extrauterine fo-tation, 1147 Extravasation of blood, changes in, 29, 155 ; treatment of, 156; of urine, 1118; from kid- ney, 990 Extroversion of bladder, 1024 Exudation in chronic inflammation, 39; cysts, 125 ; varieties of 34 Eye, diseases of, 722; injuries, 726; examina- tion of, 722 Eyeball, excision of, 738 Eyelids, diseases of, 735 Face, acne of, anthrax, 84, 746 ; carbuncle on, 746; dermoid cysts of, 128,748; epithe- liomi, 749; erysipelas, 747 ; fracture of bones of, 381 ; injuries and diseases of, 745 ; lujjus, 192, 747 ; leprosy, 1 16, 748; malformations, 742; moUuscum, 749; rhino-scleroma, 748; syphilis, lio, 747; rodent ulcer, 146, 749; tumors of, 748 Facial artery, ligature of, 266; nerve, injury to, 650; neuralgia of, 301 Fsecal accumulation, treatment of, 930; fistula, 895. 947 Faeces as a cause of obstruction, 927 Failure of growth in rickets, 475; in syphilis, 469; of union, 354; of humerus, 398; of patella, 433 Fallopian tubes, inflammation of, 1 145 False joints, 355 ; of humerus, 398; passages, 1094, 1 110; spina bifida, 680; pelvis, fracture of, 41 1 Farabfjeuf, 526 P^aradic excitability after nerve section, 293 Faradization in dysphagia, 848 Farcy, 87 Fascia, section of cervical, 824 ; of plantar, 328 ; con'raction of palmar, 317 ; lata, in diagnosis of fractured femur, 420 Fat-emboli-m after fracture-, 364; in osteitis, 457 ; in urine, 1021 Fatty degeneration of arteries, 226 Fauces, injuries of, 762 Feeding after herniotomy, 894 ; laparotomy, 921 ; tracheotomy, 831 Fehleisen, 79 F'emoral aneurysm, 259; ligature of artery, 276 ; compression, 276; hernia, 905 Femur, absorption of neck, 421, 571; amputa- tion of, 1 196; compxjund fracture of, 428; dislocation of, 527 ; fracture, 413 ; necrosis of head of, 589; osteitis of neck, 582, 588; in rickets, 477 Fergusson's staff, 1053 Ferments, fever-causing, 33, 86, 154 Fever, causes of, 32 ; asthenic, in inflammation, 33 ; irritative, in inflammation, 34 ; in fracture, 363; neurotic, 154; septic, 42, 163; sthenic, INDEX. 1223 in inflammation, 33 ; surgical, 44 ; syphilitic, 100 ; traumatic, 44, 154; varieties of, 34 F"il)rin ferment, 42 Fil)rin()us synovitis, 546 Fibroblasts, 30 Fibro-cellular tumor, 130 Fibro-enchoniiroma, 134 Fibroid polypi of n j^e, 756 ; tumors of uterus, 1 159; recurrent, I42 Filuoma, 130; of bone, 487; of breast, 117S dura mater, 673; jaws, 771 ; larynx, 810 ovary, 1 148 ; sarcoma, I42 ; of scalp, 657 of testis, 1 135 ; within the mouth, 771 Fibrous ankylosis, 618 ; goitre, 842 ; union of fractures, 355 Fibula, fracture of, 439 Fisjure-of-eight bandai^e, 390; suture, 169 Filaria sanguinis hominis, 290 Finger and thumb joints, excision of, 625 Fmgers, amputation of, 1193; dislocation of, 527; enchondroma of, 134; supernumerary, 322 ; webbed, 324 First aid to the wounded, 1204; intention, union by, 158 Fissure of anus, 974; at neck of bladder, 1123 ; of tongue, 783 ; syphilitic, loo Fissured fracture, 634 Fistula, 56; in ano, 976; bi-mucosa, 896; branchial, 814; frecal, 947; recto-vaginal, I168; renal, loil; urethral, II2I; urinary, II2I ; vesico-vaginal, I168 Fistula and phthisis, 9S0 Fitzgerald, 332 Fixation of talipes, 328 Fixed splints for fractures, 374; virus, 123 Flail joints, 621 Flap amputations, 11 88 Flat foot, 336 ; after fracture, 440 ; gonorrhoeal, 566 Flexion in aneurysm, 246 ; in hip disease, 593 Flexor tendons, sprain of, 407 Floating kidney, 9S9 Fluctuation, 48 Fluhrer's aluminum probe, 1212 Foetus, attached, 684 ; parasitic, 129 Folding a hernial sac, 902 Follicular prostatitis, 1084; stomatitis, 763; tonsillitis, 791 Food, as a cause of rickets, 477 Foot, amputation of, 1200 ; dislocation of, 541 ; fracture of, 443 Forcipressure, 211 Forearm, amputation of, 1192 ; dislocation, 519 Forehead, dermoid cysts of, 128 Foreign bodies in air passages, 818; in aneu- rysm, 246; in ear, 800; in the eye, 726, 729; in joints, 571, 614; in larynx, 818; in lung, 819; nose, 745; as a cause of obstruction, I109; in palate, 762 ; in pharynx, 846 ; in trachea, 819; in thorax, 862; in urethra, 1090; in wounds, 162 Fossa duodeno jejunalis, 9II ; intersigmoid, 91 1 ; subcjecal, 911 Fourth nerve, injury to, 649 Fractures, 345 ; of acetabulum, 41 1 ; acromion. 391 ; amputation in, 376, 380, 428 ; of base of skull, 637; bed for, 370; of bones of face, 3S1, 745; of carpus, 410; clavicle, 385; complications, 363 ; by contre-coup, 637 ; of coccyx, 412; coracoid process, 391 ; coronoid process, 409 ; depressed, of skull, 601 ; diag- nosis of, 363; and dislocation, 396, 504; in reduction of dislocation, 518; Dupuytren's 439; of elbow, 401; femur, 413; riliula,439; foot, 443 ; of hyoid bone, 817 ; humerus, 392 into knee joint, 428,434; larynx, 817 ; malar bone, 382 ; maxillx, 382 ; metacarpus, 410 ; by muscular action, 349,429; of nasal bones, 381; of patella, 429; Pott's, 439, 540; of pelvis, 41 1; reduction of, 371 ; of radius, 403 ; of radius and ulna, 408 ; of ribs, 853 ; in sar- coma, 489 ; of scapula, 390; of sacrum, 412 ; into shoulder joint, 396 ; of spine, 687 ; of sternum, 825; of skull, 634; of tibia, 438 ; of tibia and fibula, 435; of trochanters, 419; treatment, 369 ; of ulna, 408 ; of vault of skull, 634 Fragilitas ossium, 348 Friction, as a cause of inflammation, 39 Fringes, synovial, 570, 614 Frog's skin, grafting of, 162 Frostbite, 63 Fumigation in syphilis, 113 Function, impairment of, in inflammation, 32 Functional aphonia, 812; disorders of muscle, 310 Fungi in auditory meatus, 800 Fungus of dura mater, 659 ; of actinomycosis, 89 Furneaux Jordan's amputation, 1193; plaster jacket, 708 Furuncles in ear, 800 Fusiform aneurysm, 235 Gags, 760 Galactocele, 1177 Gall-bladder, diseases of, 951 ; operations upon, 953 Gall-stones, 951 ; as a cause of obstruction, 925 ; of strangulation, 915; treatment of impacted, 9'9 Galvanic excitability, after nerve-section, 293 Galvanism in nerve injury, 296; in delayed union, 358 Galvanopuncture in aneurysm, 247 Gamgee's antiseptics, 378; dressings, 166; splints, 373 Ganglion, 125,315 Gangrene, amputation in, 57 ; in aneurysm, 244, 260; after ligature of artery, 215, 232 ; causes, 59; embolic, 63, 232; in fractures, 368, 379; due to nerve-irritation, 60; in her- nia, 894; in intussusception, 914, 922; hos- pital, 69; moist, 64; senile, 6 v. in spinal in- jury, 690 , symmetrical, 63 ; thrombotic, 63 Gangrenous stomatitis, 746 Gartner's duct, 128 Gastroduodenostomy, 875 Gastrojejunostomy, 875 Gastrostomy, 851 ; for stricture, 874 Gastrotomy, S47, 876 Gelatiniform degeneration of bone, 468 Generalization of sarcoma, 142 Genu recurvatum, 324 ; valgum, 34I Gestation, ectopic, 1 146 Giant-cells in syphilis, 103 ; in tubercle, 93 Gihon cot, 1207 Glanders, 87 1224 INDEX. Glands, caseating, 284 ; excision of,286 ; in ery- sipelas, 81 ; inflammation of, 282; in neck 824 ; tubercular, 284 Glandular enlargements in syphilis, 99; tumors of breast, 1 1 76 Glaucoma, 733 Gleet, 1097, 1 100 Glenoid fossa, fracture of, in dislocation, 518 Glioma, 141 ; of brain, 673 ; of choroid, 734 Globe, rupture of, 728 Glossitis, 779 Glottis, scald of, 821 Glower's suture, 1 70 Gluteal aneurysm, 258; ligature of artery, 275 Godlee, 868 Goitre, S39 Golden Rule of Guthrie, 214 Golding-Bird's dilator, 821 Gonococcns, 1095 Gonorrhoea, 1095 ; complications of, 1098 ; epididymitis, 1129; prostatiti-, 1084; rheu- matism, 337, 565. 1097 Gooch's splint, 397 Gordon on Colles' fracture, 406 ; splint, 407 Gorgas cot, 1207 Gorget, 1054; Teale, 11 17 Gout, 39 ; arteritis in, 224 ; arthritis, 566; iritis, 730; neuritis, 299; orchitis, 11 34; phlebitis, 234; prostatitis, 1085 ; urethritis, 1098 Gowers' tumor of spinal cord, 720 Graafian follicle cysts, 127, 1150 Grafting, bone, 360 ; in bums, 183; frog's skin, 162; mucous membrane, 162; nerves. 297; omentum, 944; skin, 160; tendons, 308; for ununited fracture, 360 Granulation tissue, 29, 158 Granulations, in ear, 802 ; healing by, 159 Granuloma, 31 ; fungoides, 482 Graves's disease, 839 Grawitz on peritonitis, 934 Gray tubercles, 93 Great toe. deformities of, 339 Greenstick fracture, 346 Greig Smith on enterectomy, 941 ; on intestinal strangulation, 919; on peritonitis, 935 Grittrs amputation, II97 Growth, arrest of after fracture, 363, 395, 425, 440 ; in rickets, 475 ; in syphilis, 469 Gum and chalk bandage, 373, 436 Gummata in bone, 104,465 ; brain, 674 ; bursae, 319; in hereditary syphilis, lio; histology of, 104 ; in muscle, 312 ; of skull, 658, 662 ; of testis, 1 1 32 ; tongue, 783 ; treatment of, 1 1 5 ; of sternum, 864 Gums, hypertrophy of, 770 Gunn's rule for dislocation, 508 Gunshot fractures, 12 12; wounds, 1209 Gurjun oil in leprosy, 1 1 7 Guthrie's perineal section, 11 17 Gutta-percha in fracture of jaw, 383 Gutter fractures, 634 Gymnastics in lateral curvature, 717 H Haemarthrosis, 550 Haematocele, 155, 1 143 Ha^matoma, 155 ; anerial, 206, 217 ; auris, 800 ; of chest-wall, 855 Hxmatomyelia, 698 Haematuria, 1019; after spinal injury, 686; in enlarged prostate, 1075 ; in villous tumor, 1065 Haemothorax, 859 Haemophilia, 222 Hc^emoptysis, 860 Hagedorn's needles, 170 Hahn's tampon, 831 Hallus flexus, 339 ; rigidus, 339 ; valgus, 340 Hamilton, irrigation of abscesses, 53 Hammer-toe, 338 Hand, club, 324; fractures of, 410; tendon sheaths of, 315 ; incisions into, 315 ; steriliza- tion of, 184 Hard cataract, extraction of, 740 Hare on cerebral localization, 679 Hare-lip, 742; pins, 169 Harrison's truss, 904 ; whip bougies, loio ; on enlarged prostate, 1074; draining bladder, 1079 Head, injuries of, 631, 655 Healing by fir^t intention, 158; under scab, 159 Heart, failure of, in anaesthesia, 188; wounds of, 857 Heat, in arthritis, 551 ; hemorrhage, 2IO; taxis, 889; a symptom of inflammation, 31 Hectic, 49, 55 Hegars method in extirpation of uterus, 1167 Helplessness in fractures, 362 Hemianaesthesia in railway injuries, 699 Hemorrhage, 201, 214 ; into abscesses, 56 ; in aneurysm, 240 ; as a cause of shock, 149; in cleft palate, 761 ; in chest injuries, 858 ; in cut throat, 814; diagnosed from shock, 150; from ear, 639 ; into eye, 727 ; in fractures, 365, 378 ; intracranial, 648; from kidney, 995; after lithotomy, 1057; in myopia, 724; from middle meningeal, 648 652 ; afier ovari- otomy, 1 1 60; into peritoneum, 871 , after piles, 970 ; into spinal canal, 698; secondary, 201, 243; treatment of, 215 ; subperiosteal in 479 ; in tracheotomy, 830 ; after wound of tonsil, 762, 794; after urethrotomy, 1 114; from varicose veins, 228 Hemorrhagic diathesis, 222 ; exudation, 31 ; in- farct, 76, 233; sarcoma, 127 Hemorrhoids, 957 Hereditarj" sjrphilis, 109 ; laws of transmission, 108 : osteitis in, 487 Heredity in syphilis. 102; in tubercle, 91 Hernia, 877; anatomy of, S77; causes of, 877; cerebri, 672; congenital, 896 ; diaphragmatic, 909; direct inguinal, 896; encysted, 898; femoral, 905 ; inflamed. 884; inguinal, 896; diagnosis of, 1126: internal, 911; infantile, 898; irreducible, S82 ; oflunp, 861 ; lum- bar, 910 ; Liltre's, 883 ; ol«tructed, 883 ; ob- turator, 909 ; perineal, 910 ; pudendal, 910 ; radical cure of, 900,907 ; sciatic, 910 ; strangu- lated. 885; of testis, 1 134; tunicary of blad- der, 1 104; of joints, 552,572,575; umbilical, 907 ; ventral, 909 Herniotomy, 892,900 Herpes labialis, after nerve-seciion, 293; pre- putial, 97. Hey, 538, 1 201 Hill's, Berkeley, urethrotome, 1113 INDEX. 1225 Hilton's case of gangrene, 60; on opening ab- scesses, 51 Hip : amputation of, 1 193 ; Senn's method, 1 195 ; ankylosis, 603; contusion, 420 ; disease of, 588; and hysteria, 594; and bursitis, 596; and osteitis of femur, 596 ; and sacro-iliac disease, 595, 603 ; stages of disease, 596 ; shape of, 550; dislocations of, 527; con- genital, 322 ; unreduced, 499 ; excision of, 603, 625 Hodj^en's splint, 424, 436 Holt's dilator, 11 13 Homatropin, 722 Horns. 199; on scalp, 657; on eyelids, 737 Horse-hair suture, 168 Horse-shoe fistula, 977 Horsley : on intracranial tumors, 673 ; on te- tanus, 122; on tumors of spinal cord, 720 Hospital gangrene, 69 Hot water bags, in gangrene, 67 Howse on gastrostomy, 876 Howship"s lacunre, 481 Humerus: amputation of, 1190; dislocation of, 508; reduction of, 514; unreduced, 517; fracture of, 392; in reducing dislocation, 518; ununited, 357 ; separation of epiphysis of, 393, 512 Humphry, 529, 614 Hunter's canal, ligature in, 276 ; method of ligature, 243 Hunterian operation for aneurysm, 243 Hutchinson: amputation in gangrene, 58; massage in intestinal obstruction, 1116; on osteitis deformans, 483; teeth, in Hydatid: of brain. 674; breast, 1177; kidney, 997; liver, 950; of Morgagni, 128; and ovarian cyst, 1153 Hydramnios, 1 152 Hydrarthrosis, 546, 554, 575 Hydrencephalocele, 630 Hydrocele, 1139: diagnosis of, 1 126; of her- nial sac, 878; of neck, 289, 826 Hydrogen gas, injection of, 871 Hydronaphthol, 166 Hydronephrosis, 994; spurious, 991 ; and ovarian cyst, 1 153 Hydrophobia, 121 Hydrophobic tetanus, 118 Hydrops antri, 768; articuli, 546, 554, 575 Hydrosalpinx, 125, 1145 Hygroma, congenital, 130, 138, 289, 826 Hyoid, fracture of, 817 Hyolingual canal, 128; cysts, 826 Hyperabduction in reducing dislocation, 516 Hyperseniia of brain, 664 Hyperesthesia of larynx, 81 1; in spinal in- jury, 690 ; in railway injury, 700 Hypermeiropia, 723 Hyperostosis, 469 Hyperplasia and inflammation, 39 Hyperpyrexia in tetanus, I20 Hypertrophic catarrh of nose, 753 ; lupus, 748 Hypertrophy of bone, 444; breast, 1171; in cicatrix, 178; congenital, 289; tonsils, 793 ; of bones of skull. 657 Hypnotic sleep, 700 Hypodermic use of mercury, 113 Hypospadias, 1 124 Hypostatic congestion in spinal injury, 709 Hysterectomy, 1163 Hysteria and hip disease, 595; in railway ac- cidents, 699 Hysterical dysphagia, 848; jsaralysis of a-so- phagus, 848 Ice-bag, for checking inflammation, 380 Ichorous pus, 46 Ichthyosis of tongue, 781 Idiopathic aneurysm, 235 Ileus paralyticus, 895, 917, 926 Iliac abscess, 705; aneurysm, 257; common artery, ligature of, 273; external, 275; in- ternal, 274 Immediate treatment of talipes, 3^0 Immobility in treatment of wounds, 173 Immovable splints, 373 Impacted calculus in ureter, 1002 ; in urethra, 1087; fracture, 346, 361 ; of femur, 418 Impaired mobility in hip disease, 593 Imperfect repair after dislocation, 498 Impermeable stricture, mo Implantation of intestine, 946 Impulse, loss of, in strangulation, 887 Incised wounds, 157 Incisions: on hand, 315; to relieve tension, 67, 73 ; in hydrocele, 1 143 Incomplete fracture, 345 ; dislocations, 497 Incontinence in spinal injury, 695 ; after fistula, 948 ; of urine, 103 1 Incubation of hydrophobia, 121 ; of syphilis, 98; of tetanus, 119; of tubercle, 92 Indian operation for rhinoplasty, 751 Induration of chancre, 98 ; lobular, of breast, "75 Inequality of limbs in scoliosis, 712 Infantile hernia, 898; hydrocele, 1 140; par- alysis, causing talipes, -^-XiZ ; ^s a cause of fracture, 347 ; simulating rickets, 47S ; pseu- doparalysis, no; umbilical hernia, 908 Infarcts, 233 ; in pyaemia, 76 Infected wounds, 1 74 ; pus, 46 Infective arteritis, 223 ; softening of thrombi, 230 Inferior maxilla, fracture of, 382; dental nerve, in fracture, 385 ; section of, 304 Infiltrating scirrhus, 1 180 Inflammation, 30; of bone, 444 ; brain 660, 670; in burns, 180; chronic, 38; diffuse of neck, 823 ; in fracture, 368 ; of hernia, 884; and hyperplasia, 39 ; of joints, 545 ; of men- inges, 660 ; due to poisons, 70; phlegmon- ous, 70; of skull, 658; after sprains, symp- toms of, 30,496; of tongue, 779; varieties of, 34; temperature in, 31 ; treatment of, 35 ; in wounds, 162 Inflammatory ulcer, I94; of leg, 195 Infractions in rickets, 477 Ingrowing toe-nail, 200 Inguinal aneurysm, 257 ; canal in hernia, 902 ; colotomy, 939; glands, inflammation of in chancroid, 97 ; hernia, 896 ; radical cure of, 900; tumors, diagnosis of, 1126 Inhalations, 803 Injection in delayed nnion of bone, 358 ; gon- orrhcea, 1099; hydrocele, 1 142 ; hernia, 901 ; hydrops articuli, 575 ; piles, 962 ; synovitis, 554; syphilis, 113 1226 INDEX. Injury, 25 ; as a cause of arthritis, 547 ; to the head, 631 ; of blood-vessels, 201 ; histological changes after, 29 ; and repair, 25 ; general pathology, 1 50 Innominate aneurysm, 241, 250 ; ligature, 262 Inoculation of tubercle, 92 ; treatment in hydro- phobia, 123 Insanity, traumatic, 654 Inspection in intestinal obstruction, 929 Instrumental compression, 243 Instruments, 1S5 Insufflation in intussusception, 92 1 ; of larynx, 805 Intention, healing by first, 158 Intercostal arteries, wounds of, 858 Interdental splints, 383 Intermaxilla, treatment of in harelip, 744 Intermediary amputation, II88 Intermittent fever, 34 Internal derangement, 537 ; hemorrhage, I go; hemorrhoids, 959 ; hernia, 91 1 ; iliac, aneur- ysm of, 257 ; ligature of, 274 ; mammary, ligature of, 269; wounds of, 859; pudic, hemorrhage from, 21 1, 1056; strangulation, 911 ; urethrotomy, 11 12 Interrupted suture, 170 Intersigmoid fossa, 91 1 Interstitial absorption of neck of femur, 421 ; condensing osetitis, 469 ; emphysema, 853 ; fibroids, 1161 ; gestation, 1 147 ; keratitis, 1 1 1 ; syphilitic osteomyelitis, 465 Interrupted suture, 170 Intestinal anastomosis, 946 ; hemorrhoids, 959 ; implantation, 946; obstruction, 911, 922; symptoms of, 926 ; sutures, 942 ; treatment of, 941 ; toxa'mia, 44; strangulation, 919; evacuation in, 919 Intestines, inflation of, 871; in hernia, 894; malignant disease of, 923; operations on, 936 ; resection of, 942 ; strangulation of, 884; stricture of, 871 ; wounds of, 873 Intoxication, septic, 43 Intra-articular ankylosis, 616; fracture, 352; of femur, 515 Intracranial hemorrhage, 648 ; abscess, 667 ; suppuration, 664; tumors, 673 Intracystic growths, 127 Intradental splint, 383 Intralaryngeal operations, 810 Intraparietal sac, 878, 890 Intrapelvic abscess in hip-disease, 595, 602 Intrathoracic aneurysm, 248 Intrauterine fracture, 346 Introduction of foreign bodies in aneurysm, 246, Intubation of larynx, 833; oesophagus, 85 1 Intussusception, 913; treatment of, 921 ; chronic, 926 ; treatment of, 930 Inunction of mercury in syphilis, 113 Inversion as an aid to taxis, 889 Involution cysts, 126 Iodide of potasli, coryza, 114; eruptions, 114; in syphilis, 113; in aneurysm, 241; in osteitis, 451 Iodine in goitre, 842 ; in hydrocele, 1 142; as an antiseptic, 166 Iodoform in abscesses, 54, 587 ; in fractures, 378; hydrocele, 1 143; after removal of tongue, 789; in synovitis, 554; in syphilitic ulcers, 194; in phagedena, 69; in wounds, 167 ; poisoning, 167 ; in tubercular arthritis, 585, 603 Iridectomy, 739; for glaucoma, 734 Iris, diseases of, 729; in syphilis, 80; after cataract, 741 ; in rheumatism, 730; prolai)se of, 726 Iritis, 730; in syphilis, 102; treatment of, 1 15 Iron in erysipelas, 81 Irreducible hernia, 882; umbilical, 882, 907 Irrigation of joints, 494, 562; of wounds, 165; of abscess cavity, 54 Irritability of bladder, 1030; brain, 642, 662; urethra, 1 108 Irritants, classification of, 25 ; causing gangrene, 60; effect of, 30 ; causing inflammation, 30 Irritation, sympathetic, of eye, 727 ; continued, effect of 30 Irritative fever, 33 Ischiorectal abscess, 973 Italian ojjeration for rhinoplasty. 75 1 Itching of scars, 178 Ivory exostoses, 136,484, Jack-towel in extension, 501, 516 Jaws, closure of, 768; dislocation, 504; exci- sion, 774; of condyle of, 769; fracture of, 382; necrosis of, 446, 765; resection, 757; tumors, 770 Joints, contusions of, 495 ; excision of, and arthrectomy, 586; compound fractures into, 381, 402, 410; dislocations of, 497; unre- duced, 498; examination of, 548; hemor- rhage into, 222; inflammation of, 546; of ankle, 61 1 ; elbow, 608 ; hip, 58S ; knee, 604 ; sacro-iliac, fo3 ; shoulder, 612; wrist. 613; injuries of, 492; in fractures, 36S ; of elbow, 399, 402; of knee, 429, 434; of shoulder, 395; of wrist, 410; irrigation of, 562; loose bodies in, 570, 614; shape of, when inflamed, 550. 552, 558 ; sprains of, 495 ; of spine, 685 ; wounds of, 492 Jordan Lloyd's elastric strap, 1 194 Joubert's suture, 943 Jugular vein, ligature of, in pyfemia, 669; wound of, 815 Junker's inhaler, 817 Jury-mast, 708 K Kangaroo tendon, 213 Keegan on lithotrity, 105 1 Keloid. See Cheloid. Kelotomy, 892 Keratitis, interstitial, ill Kerato-iritis, 730 Key-note position in scoliosis, 716 Key's staff, 1053 Kidney, abnormalities of, 988 ; calculus in, 998; differentiation of secretion of, loi i ; examina- of, 996; floating, 989 ; inflammation of, 1003 ; injuries of, 990 ; operations on, ioi2; solid growths of, 998 ; tumors 096 ; wounds of, 992 ; cysts of, 997 Knee-joint, amputation through, 1 197; arthrec- tomy of, 587 ; aspiration, 431 ; in Charcot's disease, 579; dislocation of, 536; dr.iinage of, 562; excision of, 626; in fiaciured patella, 434; fracture into, 428, 434; internal derange- ment of, 537 ; irrigation of, 562 ; shape of, in INDEX. 1227 synovitis, 550, 552; Thomas's splint for, 609 ; tubercle of, 605 Knock-knee, 341 Knott, 538 Kocher, removal of tongue, 789 ; on fractured ^patella, 433 Koerbele, resection of intestine, 942 Krenig, 581 Kraske, on excision of the rectum, 986 Krohne, mociitied Thomas's splint, 70S Kussmaul, 919 Kyphosis, 710 Labial cysts, 1 168 Lacerated wounds, 157 Lachrymal obstruction, 735 Lactic acid in lupus, 191 Lamellar cataract, 732 Laminated clot, 237, 240 Landry, 122 Langenbeck, 624; nasal polypi, 756; operation for nose, 751 ; resection of maxilla, 758 Laparo colotomy, 939 Laparotomy in intestinal obstruction, 930; strangulation, 919 ; intussusception, 922 ; peri- tonitis, 934 ; perityphlitis, 933 Laryngeal growths, removal of, 811 ; diagnosis, 836; phthisis, 807 Laryngitis, 804 ; erysipelatous, 81 ; from scald, 822; in syphilis, 100, 107 Laryngotomy, 828 ; preliminary, 788 Laryngo-tracheotomy, 833 Larynx, diseases of, 804 ; disorders of sensation, 811 ; excision of, 8315 ; examination of, 803 ; foreign bodies in, 818 ; fracture of, 817 ; intu- bation of, 833; lupus in, 808; muscular paralysis of, 81 1 ; operations on, 828 ; paraly- sis, 811 ; perichondritis, 807 ; phthisis in, 807; spasm of muscles of, 813; syphilitic disease of, 808; tumors, 809; wounds, S15 Latent calculus, looi, 1045 ; fracture of spine, 689 Lateral curvature of spine, 712; lithotomy, 1052 ; sinus, thrombosis of, 669 Lawn-tennis leg, 307 Leather splint for fractured patella, 433 Leg, amputation of, 1 198 ; chronic ulcer of, 195, 228 ; fracture of, 434, 441 Leiter's coils, 36; panelectroscope, iioi Lembeit's sutures, 943 Length of mesentery in hernia, 877 Lengthening in hip disease, 594 Lens, dislocation of, 728 Leontiasis ossea, 482 Lepra cells, 1 16 Leprosy, 116; of the face, 748; laryngeal, 809 Leucocytes, action of in repair, 29 Leucoma, 781 Leucoplakia, 781 Levers for hallux valgus, 340 Lichen, in syphilis, 98 Ligaments, division of, in talipes, 330 ; strain of spinal, 685 Ligature of abdominal aorta, 273 ; in aneurysm, 243,248; of arteries, 212 ; after compression, 242; for inflammation, 380 ; of vein, 229; of anterior tibial, 279; of axillary, 269; of brachial, 270 ; carotid, 263; of common iliac, 273 ; dorsalis pedis, 280 ; of external iliac, 275; facial, 266; femoral, 276 ; gluteal, 275 ; jugular vein in pya-mia, 669; of lingual,' 265 ; internal mammary, 269 ; internal iliac, 274; innominate, 262 ; popliteal, 277 ; pos- terior tibial, 278 ; for piles, 964 ; radial, 27 1; subclavian, 266 ; temporal, 266 ; ulnar, 272 • varicose veins, 229; vertebral, 268 Lime in rickets, 478 Limping in hip-disease, 590 Line of demarcation, 61 Linear osteotomy in osteitis, 452 Lingual artery, ligature, 265 ; nerve, operations on, 784 Lip, malformations, 742 ; epithelioma, 749 Lipoma, 132 ; congenital, 684 ; myxomatous, 133 ; nasi, 748 ; of sacrum, 684 ; of tongue 784 ^ ' Liquefaction of tubercular deposit, 94 Lisfranc's amputation, 1201 Lister's dressings, 54, 165; excision of wrist, 623; tourniquet, 209; sounds, 11 11 Liston's splint, 422 Lithotomy, lateral, 1052; accidents in, 1057 ; cellulitis after, 71; prognosis of, 1058; me- dian, 1058; suprapubic, 1060; compared with lithotrity, 1062 Lithotrity, 1047; accidents in, 1050 ; at differ- ent ages, 1041 ; difficulties in, 1052; com- pared with lithotomy, 1062 Little's shoes for congenital varus, 330 Littre's hernia, 887 ; operation, 939 Liver, abscess of, 949; hydatids, 950; opera- tions on, 950; rupture, 870 Lobular induration of breast, 1175 Localization, cerebral, 678 Locality of pain in hip-disease, 590 ; of leprosy, 116 Longitudinal fractures, 346 Longmore's electric explorer, 1211 Lockjaw, 1 18 Lonsdale's clamp, 385 Loose cartilages in joints, 571, 614 Lordosis, 592, 710 Loreta's case of abdominal aneurysm, 247, 257 ; operation, 876 Lower jaw, fracture of, 382 ; dislocation of, 504 Lucas, 538 Lumbago, 686 Lumbar abscess, 704; colotomy, 937; hernia, 910 ; nephrectomy, 1014; vertebrae, fracture of, 695 Lungs, foreign bodies in, 819, 862; hernia, 861 ; injuries of, 856 Lupus, 92, 189; of face, 747; hypertrophic, 748; of larynx, 808; rectum, 971 ; of tongue, 784 Lupus, erythematosus, 192 Luschka's gland, 683 Luxatio erecta, 509 Lymph, organization of, 158 Lymphadenitis, 282 ; in syphilis, loO Lymphadenoma, 287 Lymphangioma, 138, 289 Lymphangiectasis, 289 Lymphangitis, 281 Lymphatic glands, diseases of, 281 ; in ery- sipelas, 80; inflammation of, in neck, 824; tumors of, 286 Lymphoma, 287 1228 INDEX. Lymphorrhcea, 290 Lymphosarcoma, 141, 288 M MacCormac, 612 MacEwen, 360, 646; chisels, 342; drainage- tubes, 162; intubation tubes, 833; operation for genu- valgum, 343; radical cure of hernia, 902 MacGill, 360, 10S2 McDonald's ambulance lift, 1 208 Mclntyre splint, 424 Marcrocheilia, 2S9 Macroglossia, 137, 289, 778 Macrostoma, 742 Madelung, 939 Maisonneuve's urethrotome, 11 13 Makins' clamp, 943 ; artificial anus, 949 Malar bone, fracture of, 382 Malformations of back, 680 ; of neck and throat, 814; of pharynx and cesophagus, 845; of bladder, 1024; of breast, 117I; of face, 742; of head, 630; of nose, 751 ; of kidney, 9S8 ; of limbs, 322 ; of rectum, 955 ; of tongue, 778 Malgaigne's hooks, 432 ; operation for hare-lip, 743 Malignant disease of thyroid gland, S44 ; stric- ture of intestine, 923 ; stricture of rectum, 983 ; pustule. 84 Metacarpal, fracture of 410 Malignancy, 143 Malignant disease of intestine, 923 ; redema, 84 ; pustule, 84 Malingering, ulcers in, 196 Malnutrition after sprain, 496 ; as a cause of non-union, 357 Malposition of testis, 1127 Malum coxse senile, 570, 575 Mal-union of fracture, 351 Mammary abscess, 11 73; gland [see Breast); glandular tumor, 1 178; ligature of internal, 269 Mammilla. See Nipple Manipulation in aneurysm, 246 ; in dislocation of the spine, 695 ; in CoUes' fracture, 407 ; in lateral curvature, 717 ; in reduction of dis- location, 501, 5J5 Manual examination of rectum, 929, 956 Marriage in svphdis, 108, 1 15 Marsh, 538, 5S5 Martin's bandage, 196 Massage in lateral curvature, 717; in inflamma- tion, 41 ; in intestinal obstruction, 931 ; in nerve-injury, 296, 301 ; in oedema, 234; in sprains, 496; in leno-synovitis, 314; in writer's cramp, 310 Mastitis, 1172; chronic interstitial, 1175 Mastoid cells, suppuration in, 665, 669, 802 Maxilla, fracture of, 382; dislocation of, 504; necrosis of, 452 Maydl's colotomy, 940 Measurement for truss, 881 Mechanical stimulation in delayed union, 358; support in caries, 706; curvature, 718 Meckel's diverticulum, 128, 912; ganglion, ex- cision of, 304 Median lithotomy, 1059; compared with lat- eral, 1059 Mediastinal abscess, 863 ; in Potts disease, 703 Medulla, drainage of, 458; in fractures, 349; oblongata, pressure on in caries, 702 Medullary carcinoma, 148; lesions of brain, 645, 674 ; sarcoma of bone, 4S7 Meibomian cyst, 736 Melanotic sarcoma, 140; choroid, 734 Melon-seed bodies, 313, 320, 614 Meningeal artery, rupture of, 648 Meninges, diseases of, 660 Meningitis, 660; of cord, 718; consecutive to otitis, 666, 802 ; disease of spine, 703; sup- purative, 664; acute traumatic, 718 Meningocele, 630, 631 Meningomyelitis and railway spine, 699, 719 Meningomyelocele, 681 Mental emotion as a cause of shock, 149 Mercier's prostatotomy, loSi Mercurial necrosis, 453; stomatitis, 764, 766; and cataract, 752 Mercury in inflammation, 38, 40, 41 ; in iritis, 731 ; inunction in syphilis, 113, 115 Mesentery, length of, S77; prolapse of, 877 Metacarpal bones, fracture of, 410; tubercular disease of, 472 ; dislocation of thumb, 525 Metastasis in erysipelas, 80 Metastatic abscesses, 49 ; in pyaemia, 74, 75 ; or- chitis, I F29 Meteorism in obstruction, 926 Methylene bichloride, 187 Mickulicz, 612; on peritonitis, 934 Microbes causing gangrene, 62 ; non-infective, 42 ; pathogenic, 45 Micrococcus cyaneus, 47 Micro-organisms of suppuration, 45 ; in pyemia, 74 Micturition in fracture of spine, 693 Middeldorpf 's triangle for fractured humerus, 397 Middle ear, disease of, 801 ; meningeal, rupture of, 648, 652 Military surgery, 1 204 Milk cysts, 1177 Mind-blindness in lesions of cortex, 645 Minor surgery, 184 Mobility, as a sign of fracture, 361 ; in hip dis- ease, 594 Mocmain truss, 8S0 Moist gangrene, 59, 64 Moles, 197 Mollities ossium, 483 ; and fracture, 348 Molluscum fibrosum, 131, 138; on face, 749 Monoplegia, 643 Monospasm, 643 Morbus coxii;, 5 88 Morgagni, hydatid of, 128 Morrant Baker, on excision of tongue, 758 Morris, 529; i)itrochanteric measurement, 415 Mortification. See Gangrene. Morton's fluid, 683 ; club-foot stretcher, 328 Mother's marks, 137 Mouth, inflammation of, 762 ; injuries of, 762 ; lupus, 189; malformations, 759; tumors of, 770 ; wounds of floor of, 815 Movable kidney, 9S9 ; splints, 373 Movement, as a cause of non-union, 357 Mucocele, 735 Mucous lining of nose, inflammation of, 753 ; cysts, 126; of mouth, 770, 773 ; tongue, 784; INDEX. 1229 tubercle, 198; memljrane, grafting of, 162; patches, loo ; on tongue, 783; polypi, 755 Mucus in urine, 1021 Miiller's ilucls, 128 Multilocular cysts of jaws, 774; ovary, I149 Multifile periostitis, 457 ; fractures, 346 Mumps, 795 ; and orchitis, 1129 Musca; volitantes in myopia, 724 Muscles, rupture of abdominal, S70; diseases of, 306 ; ossification of, 307 ; rupture of, 307, 870 Muscular atrophy, 306, 309 ; after fractures, 369 ; in arthritis, 551,593; after nerve-section, 292 ; sprains, 306; contraction, as a cause of frac- ture, 349, 429; of displacement, 361 ; after nerve injury, 298; in arthritis, 551 ; contrac- ture, 311 ; rigidity, causing talipes, 336; spasm, after head injuries, 644; in swallowr- ing, 848; in tetanus, 120; in stumps, 1203; strain, 686 ; in spinal injury, 685 ; twitching in fracture of spine, 694 ; wasting, as a cause of curvature, 91 1 Musculo-spiral, paralysis of, 293, 398 Mycelium in actinomycos-is, 90 Mydriasis, traumatic, 727 Myelitis, 719 Myeloid sarcoma, 139; of Ijone, 487 Myofibroma, 137 Myolipoma, congenital, 6S4 Myomata, 136 Myopia, 723 Myosarcoma, 141 Myositis, 31 1 Myxoedema, 838 Myxoma, 133 ; of larynx, 810 Myxomatous carcinoma, 147 ; lipoma, 133 Myxosarcoma, 140 N Nsevi, 137, 197,220; of auditory canal, 802 ; of eyelid, 737; of face, 748; of mouth, 770; neck, 826; of scalp, 656 ; tongue, 784 Nails, affections of, 199; after nerve-action, 293 ; ingrowing, 200 Narcotics in neuritis, 301 Nares, tumors of, 755 Nasal bones, fracture of, 381 ; inflammation of, 754 ; passages, tumors of, 755 Nasopharyngeal polypi, 756 Nathan Smith's splint, 424,436 Natiform skull, 468 Neck, cellulitis of, 71, 823 ; cysts of, iio, 128; dislocation of tendons of, 309 ; inflammation of glands of, 823; malformations of, 814; ncevi, 826 ; tumors, 826 ; wry, 824 ; wounds of, 814 Neck of femur, absorption of, 421 ; angle of, 414; atrophy, 4(5; fracture, 417 ; diagnosis, 421 Necrogenic lupus, 190 Necrosis, 59 ; acute, 453 ; after amputation, 462 ; coagulation, 45 ; of cranium, 659 ; of cartilage, 546; exanthematous, 464 ; of jaws, 765; mercurial, 453; of nasal bones, 754; of last phalanx, 314; phosphorus, 452; quiet, 447, 451 ; of scalp wounds, 633 ; of stumps, 1203 Needle, exploring, 41 ; for cataract, 740 Nelaton's line, 415 ; operation for harelip, 743 ; enterostomy, 936 Nephralgia, icoo Nephrectomy, 1014 Nephritis, 1003; causing suppression, 992 Nephrolithotomy, 1012 Nephrorrhaphy, 990 Nephrotomy, 1012 Nerve-bulb, 292 Nerves, anastomosis of, 293; compression of, 208, 294. 367 ; contusions of, 294 ; evulsion, 304 ; grafting, 297 ; inflammation of, 299 ; injuries of, 292, 650; injury of in fractures, 367 ; ir- ritation as a cause of gangrene, 50; of te- tanus, 113; in leprosy, 117; operations on, 302; in syphilis, 107; regeneration of, 292 ; wounds of, 292 Nerve-section in tetanus, I2i ; as a cause of ankylosis, 617 Nerve-splitting in leprosy, 119 Nerve stretching, 302 ; in leprosy, 119 ; tetanus, 121 Nerve-suture, 295 Nervous system, diseases of, in arthritis, 548, 575 ; as a cause of fracture, 347 ; in syphilis, 107 ; in railway accidents, 699 Neuber's drainage tubes, 172 Neuralgia, 301; of scars, 177; stumps, 1203; testis, 1 128 ; nerve section for, 721 Neurectomy, 304 Neurenteric canal, cysts from, 129 Neuritis, 299 ; as a cause of tetanus, 119 Neurofibroma, plexiform, 130 Neuroma, 138, 305 Nine-day spasms, 119 Nipple, affections of, 1171 ; Paget's disease of, 1 172; retraction of, 11 83 Nitric acid in piles, 963 ; in prolapse, 96S Nitrous oxide gas, 186 Nocturnal incontinence, 103 1 Nodes, 446, 465 ; Parrot's, no, 468; periosteal, 464 _ Nodosity of joints, 569 Nodular scirrhus, 1180 Noma, 746 Non union of fracture, 355 ; of lower jaw, 385 . Nose, diseases of, 751 ; hemorrhage from, 752 ; foreign bodies in, 745 ; malformations of, 751 ; plastic sugery of, 751; syphilitic affec- tions of, 106, 109 Nostrils, plugging, 752 Nothnagle's test, 943 Nuclear cataract, 732 Nuhn's gland, 126, 770 Nussbaum, 311, 359 Nutrition, influence of, in repair, 18; lesions in spinal injury, 691, 719 Obesity and ovarian cysts, 1 152 Oblique fractures, 346; illumination of eye, 722 Obsolescence of tubercle, 94 Obstructed hernia, 883; in oblique inguinal her- nia, 896 ; lymphatics, 290 Obstruction, intestinal, 91 1, 922; diagnosis of, 928; symptoms, 925, treatment, 930; after 1230 INDEX. ovariotomy, 1 158; of lachrymal duct, 735; of ureter, 993; of veins, 231 Obturator artery in hernia, 907, 909; internus in dislocation of hip, 529 Occlusion of vessels, effects of, 206 Odontomata, 772 O'Uwyer's tul)es, 834 CEdema, acute, of neck, S24 ; in fractures, 367 ; malignant, 84; solid, 39, 290; of scrotum, I125 (Edematous pile^, 959 Qisophagostomy, J>5i Qisophagotomy, S47 Qisophagus, epithelioma of, 848 ; foreign bodies in, S46 ; inflamm:ition of, 847 ; injuries of, 845 ; malformations of, S45 ; paralysis of, S47 ; stricture of, ^49; tumors of, 848 Ogston, 36, 324, 33S, 343 Old dislocations, 535 Olecranon, fracture of, 408 Olfactory bulbs, injury to, 650 Omentum grafting, 944 ; injuries of, 873 ; strang- ulation of, SS5 ; treatment of, 894 Onychia, 199 Oophorectomy, 1 146; and osteomalacia, 483 Open fractures, treatment, 375 (icv Compound); wounds, 157, 174; dislocations, 497 ; method for treatment of inguinal hernia, 901 Opening of ab^cesse^, 53 Operations on arteries, 261 ; on nerves, 302; for genu-valgum, 343 ; on the eye, 738 ; sub- cutaneous, 174; in shock, 15 1 Ophthalmia, catarrhal, 728 ; sympathetic, 727 Ophthalmoplegia, 107,111 Ophthalmoscope, 722 Ophthalmoscopy, examination, 272 Opium in aneurysm, 243 ; coma and concussion, 647 ; in delirium tremens, 153; in obstruction, 930; strangulation, 918; intussusception, 921 ; peritonitis, 934; phagedena, 196; in senile gangrene, 68 Opisthotonos, 1 1 7 Optic nerve, injury to, 650 Orbit, cellulitis of, 71 ; diseases of, 735 Orbital aneurysm, 253; tumor, pulsating, 737 Orchitis, gouty, 1134; metastatic, 1129; in mumps, 795; syphilitic, 1131; suppurative, 1 134; tubercular, 1133 Ord, on arthritis, 565 Organization of extravasated blood, 29, 155 ; of granulations, 160 ; lymph, 158; thrombi, 230 Organisms, classification of pathogenic, 45 ; in- fective diseases due to, 44; non-infective dis- eases due 10, 42 Origin of calculi, 104I Os magnum, dislocation of, 524 Osseous ankylosis, 627 ; of hip, 603 ; nodes, 465 Ossification of callus, 351 Ossifying myositis, 312 Osteitis, 445, 765; of cranium, 65S; chronic, 451 ; as a cause of cerebral abscess, 667 ; of frac- ture, 34S ; of delayed union, 357 ; deformans, 40, 4S0 ; of femur and hip disease, 595 ; of jaws, 765 ; in knee-joint diseases 606 ; in inflammation of joints, 546; of nose, 727; rheumatic, 471 ; in syphilis, 106, 111,465; tubercular, 472, 558; of vertebrae, 701 Osteo-aneurysm, 31S Osteo-arihritis, 509; and loose cartilages, 614 ; after dislocations, 503 Osteoclasis, 344 Osteocopic pains, loi, 464 Osteoid tissue in rickets, 465 Osteoma, 135. 4S4 ; of skull, 659 Osteomalacia; 483; skull in, 482 ; asacau-eof fracture. 348 Osteomyelitis, 451 ; acute, 453, 462; after am- putation, 463 ; septic, 462; syphilitic, 465 Osteophytes, 571 Osteoplastic resection of ankle, 611 ; in intra- cranial tumors, 676 Osteo-sarcoma, 140 Osteo-sclerosis, 446, 466; rheumatic, 471 Osteotomy, 342; in osteitis, 452, 458 Othematoma, 800 Otis's urethrameter, 1 1 1 5 ; urethrotome, 1 1 1 3 ; as a cause of meningitis, 665 ; suppurative, 671 ; of the spine, 701 Ovaries, cysts of, 130; inflammation of, 1 145; pedicle, twi-.ting of, 1155 ; tumors of, 1 148 Ovariotomy, 1 155 Over-extension, as a cause of ankylosis, 617 Overflow of urine, 961, 1031 ; in enlarged pros- tate, 1075 ; in spinal injury, 693 Overgrowth, 290, 322 Oxalate of lime, 1017 Ox aorta, ligature of, 213 Ozjena, 755 Pads in fractures, 373 Page, railway accidents, 699 Pain in fractures, 362 ; in hernia, 887, 916; in hip-disease, 590 ; in obstruction, 926 Painful subcutaneous tubercle, 131 Palate, clefr, 759 ; deviations of, after injury to brain, 650 ; wounds of, 762 Palatine arteries, hemorrhage from, 211 Palliative treatment of epithelioma of tongue, 786 Palmar arch, wound of, 210 ; fascia, contraction of, 316; section of, 318; ganglion, 315; tendon-sheaths, 315 Palpation in obstruction, 929 Pancreas, cysts of, 954 Panelectroscope, iipi Papillary cysts, 127, I150; synovitis, 460, 570 Papilloma, 143 ; of bladder, 1064; gums, 770; larynx, 810 ; tongue, 784 Paracentesis thoracis, 864 ; pericardii, 868 Parjesthesia of larynx. Si I Paraffin as a splint, 374 Paralysis, ascending, of Landry, 122; cortical, 644 ; as a cause of fracture, 347 ; infantile, 7>Zl)-> 2>Z^ '^ of larynx, 811 ; afier nerve sec- tion, 292 ; of oesophagus, 847, S49 ; reflex, 298; of shoulder, 501, 512; spastic, 662; spinal, 705 Paraphimosis, 1 1 25 Paraplegia in spinal disease, 705, 766 ; in in- jury, 690 Parasitic foetus, 1 29, 684 Parenchymatous goitre, 839 ; prostatitis, 1085 Parker, 325 ; on tracheotomy, 828 ; suction cannula, 830 Paroophoron, 128, 1 151 Parotid, division of duct, 745 ; inflammation of, 794 ; tumor of, 134, I42, 795 ; bubo, 45 INDEX. 1231 Parovarian cysts, 128 Parruis noJes, 1 10, 468, 658 ; pseudo paralysis, 469 Parulis, 766 Pas-ive clot, 237 ; motion in arthritis, 555 ; after di-.locations, 502 ; excision, 620, 625 ; sprains, 496 ; synovitis, 555 Pasteur, 124 Patella, dislocation of, 535 ; fracture of, 429 Pathogenic organisms, classification of, 36 Pedicle of ovarian tumor, 1 155; in hysterec- tomy, 1 165 Pedunculated hemorrhoids, 961 Pegging arch of foot, 338 ; in delayed union, 358 Pelvic cellulitis, 71, 974 Pelvis, fracture of, 411 ; in rickets, 476 Pemphigus, 109 Penetrating wounds of abdomen, 872 Penis, amputation of, 11 25; epithelioma of, I125; gangrene. I118; malformations, 1 1 24 Perchloride of iron, in goitre, 842 ; in erysipals, 81 Percussion in intestinal obstruction, 929 Perforating ulcer, 294, 571 Perforation of appendix, 932 Periadenitis, 283 Periarteritis, 223 ; as a cause of aneurysm, 235 Pericardium, paracentesis of, 868; wounds, 857 Perichondritis of larynx, 807 Pericranium, nodes on, 465 ; separation, 633 Perineal abscess, 1120; cystotomy, 1069; dislo- cation, 534; fistula, I122; hernia, 910; pros- tatectomy, 1082 Perinephritis, loio Perineum, rupture of, I169 Periosteal abscesses of jaw, 767 ; changes in rickets, 474; cysts, 768, 773; nodes, 464 ; sarcoma, 487 Periosteum, division of, in inflammation, 458 ; function of, 349 ; grafting, 360 ; preservation after excision, 619 Periostitis, 445 ; acute, 453 ; of femur and hip disease, 59b ; of last phalanx, 314 ; syphilitic, 101,115; multiple, 457 ^ Periphlebitis, 233 Periproctitis, 973 Peritonitis, 933 ; after taxis, 891 ; herniotomy, 893; after ovariotomy, 1158 ; and strangula- tion, 917 Perityphlitis, 931; and hip disease, 598 ; dis- tinguished trom strangulation, 917 Peronsei tendons, displacement of, 299 Petifs tourniquet, 208 Phagedsena, (39, 115; and chancroid, 97 Phalanges, enchondroma on, 134; strumous nodes, 473 Phalanx, necrosis of last, 314 Pharyngitis, erysipelatous, 81 Pharyngocele, 827, 845 Pharyngotomy, subhyoid, 833 Pharynx, foreign bodies in, 846 Phimosis, 1 1 24 Phlebitis, 230, 233; syphilitic, loi Phlegmasia, alba dolens, 290 Phlegmonous inflammation, 70 Phosphates in urine, 1017 Phosphorous necrosis, 452, 766 Phthisis and fistula, 980 Pick's bandage, 390 Pigeon-breast, 476 Pigmentation in syphilis, loi Piles. See Hemorrhoids Pinning in fracture of patella, 432 Pirogoft's amputation, 1200 Pirrie, 1200 Piriform bone, dislocation of, 525 Pityriasis versicolor. See Tinea Placenta, in ectopic gestation, 1147 Plantar fascia, section of, 328 PlaiUaris, rupture of, 308 Plaster splints, 373, 437 ; in caries of spine, 683 ; in fracture, 696 ; in talipes, 327 Pleura, rupture of, 856; inflammation, 863 Pleurosthotonos, 118 Plexiform neurofibroma, 131 Plugging nostrils, 752 Pneumocele, 862 Pneumonia, 857, 863; in burns, iSo; after ope- rations on tongue, 790; wounds of neck, 817 : Pneumonotomy, 868 Pneumothorax, 860 Poisoned wounds, cellulitis after, 70 Poisons, chemical, as cause of inflammation, 70 Polar cataract, 731 Polk's method of collecting urine, ion Polymastia, 1171 Polymorphism in syphilis, lOI Polypi, 113; of antrum, 767; bladder, 1063; ear, 802 ; mucous, 755; nasopharyngeal, 756 ; rectum, 969 Poore, Vivian, 310 Popliteal aneurysm, 259 ; rupture, 240 ; cysts, 321,575; artery, ligature of, 216; in frac- tures, 36b, 428 Poroplastic jacket, 706; splints, 373, 437 Position in arthritis, 551 ; fractures, 371 ; in in- flammation, 36; in wounds, 168 Posterior staphyloma, 724 ; tibial artery, ligature of, 278; in fractures, 366, 440; wound of, 210 ; tibial tendon, division of, 328 Pott's disease, 700 ; fracture, 439, 540 ; as a cause of flat-foot, 336 ; on fractures of the femur, 425 ; puffy tumor, 635, 665, 660 ; splint, 436 Prjemaxilla, treatment of, in hare-lip, 744 Pregnancy in fibroids, I161 ; and ovarian cysts, 1 152; and osteomalacia, 4S3 Presbyopia, 725 Pressure, 36; in arthritis, 551, 556; in aneu- rysm, 238, 250; hemorrhage, 209; in wounds, 167 Priapism in fracture of spine, 693 Primary amputations, 376,1188; hemorrhage, 201 ; operations in shock, 151 Probangs, 846 Proctitis, 970 Proctotomy, 982 Progressive multiple neuritis, 300 ; myositis, 31 1 Prolapse of anus, 966 ; kidney, 992 ; iris, 727 ; mesentery, 877; piles, 961 ; rectum, 966; excision of, 968 Proliferous cysts, 127, 130 1 Proptosis, 738 Prostate, calculi in, 1087; enlargement of, H04; and atony, 1075; and cathcterism, 1077; inflammation of, 1083 ; gouty, 1085; suppura- tion in, 1087 ; tumors of, 1083 Prostatectomy, 1082 Prostatitis, retention in, 1034 Prostatotomy, 108 1 INDEX. Provisional callus, 351 Pruritus ani, 970 Psainmoma, 142 Pseudo-arthrosis, 355 Pseudo-paralysis, Iio; of infants, 469; in rickets, 47S, 479 ; in strains, 686 Pseudo-strangulation, 917 Psoas abscess in Pott's disease, 705, 709 ; in- rtammation of, and hip-disease, 596 Psoriasis in syphilis, lOO, 109, 1 15 Psorosperms, 11 73 Ptomaines, 42 Pubic dislocation, 534 Pudendal hernia, 910 PudJc aneurysm, 258; artery, hemorrhage from, 211 Puerperal arthritis, 564 Pulleys for reduction of dislocation, 5or, 535 Pulmonary congestion after fracture, 364 Pulsating bronchocele, 839 ; orbital tumor, 737 ; sarcoma and aneurysm, 240, 257, 490; tumor of bone, 490 Pulsation, expansile, 237 ; recurrent, 244, 260 ; of vessels in glauconia, 735 Pulse in aneurysm, 23S, 250 Puncture of bladder, 1034; of kidneys, 1012; of testis, 10S7 ; in delayed union, 358 Punctured fracture of skull, 636; wounds, 157, 174; hemorrhage from, 210, 214; of neck, Pupil in injuries of the sympathetic, 691 Purgatives in peritonitis, 83 1 Purpura and rickets, 479 Purulent exudation, 39; synovitis, 459 Pus, 46; in urine, 1020 Pustule, malignant, 84 Pyaemia, 74 ; and cerebral abscess, 668 Pyaemic arteritis, 223; phlebitis, 234; arthritis, 563 ; suppuration in tendon sheaths, 314 Pyelitis, 1006; calculous, 1002; suppurative, 1006; tuberculous, 1007 Pylorectomy, 876, 946 Pyogenic membrane, 46, 448; organisms, 45, 74 ; in tubercle, 93 Pyonephrosis, 1007 Pyosalpinx, 1 145 Pyramidal cataract, 731 Pyrogenous agents, 33, 154 Quiet necrosis, 447, 451 Quill suture, 169 Quilt suture, 170 Quinsy, 792 Rabies, 121 Radial artery, ligature of, 271 Radical cure of hernia, 899, 906 ; of varicose veins, 230 Radius, dislocation of, 522 ; fracture, 403 ; sub- luxation, 524; and ulna, dislocation of, 520 Railway accidents, amputations in, 476; spine, 687, 699, 719 » Rand, distinction of coils of intestine, 919 Ranula, 126, 770 Rapid coagulation in aneurysm, 245 Rarefying osteitis, 446; of cranium, 658 Rat tail pads, 880 Raynaud's disease, 63 Reaction in concussion, 641 Readjustment in delayed union, 358 Rectal gonorrhoea in women, 1097 ; lever, Davy's, 209 Rectovaginal fistula, 1 168 Rectum, atony of, after piles, 966 ; epithelioma of, 983; examination of, 929,956; excision, 985 ; fistula, 976 ; inflammation of, 970 ; lupus, 971, malformations, 955 ; plugging for hemorrhage, 965 ; polypus, 969 ; prolapse of, 966 ; resection of, 980 ; stricture of, 965, 979 ; ulcer of, 971, 975 ; villous tumor of, 986 Recurrent dislocations, 511 ; fibroid, 142; hem- orrhage, 202, 215 ; pulsation, 243, 260 Reclressment, 343 Red softening of brain, 660 ; of cord, 689, 719 Reduction of dislocations, 501 Reef-knot, 262 Referred pain in hip-disease, 590 Reflex paralysis, 298 ; spasm after nerve injury, 298 Reflexes in spinal injury, 690 Regeneration of nerves, 291 Keid's bandage for aneurysm, 245, 260 Relapsing typhlitis, 932 Reminders in syphilis, 102 Remittent fever, 34 Renal calculus, 998; colic, 998; cysts, 997; fistula, loii ; haematuria, 1020 Repair, action of leucocytes on, 28; of arteries, 203; complications of, 162; of dislocations, 47S ; effect of nutrition on, 28 ; of fractures, 349; epidermis, 159; of nerves, 293; tissue changes in, 28 ; of wounds, 158 Resection, osteoplastic, of ankle, 611 ; in de- layed union, 359 ; in fractured patella, 434 ; of intestine, 943; rectum, 986; ribs, 867; subperiosteal, 458; superior maxilla, 758 Residyal abscesses, 50, 369, 5S7 ; urine, 1073 Resilient stricture, 1103 Resolution of thrombi, 230 Respiration in fracture of spine, 692 ; in scolio- sis, 715 Rest as a cause of ankylosis, 616; compared with arthrectomy, 587 ; in arthritis, 556 ; in caries, 706; after dislocation, 503 ; in inflam- mation, 36 ; in synovitis, 556 Restraint in delirium tremens, 153 Retained testis, 1127 Retention cysts, 126 Retention of urine, 1032 ; in fractures, 364 ; after piles, 965; in stricture, 1109 Reticular lymphangeiectasis, 290 Reticulated urethra, 1104 Retina, in myopia, 724 ; rupture of, 728 ; gli- oma of, 141 Retinochoroidilis, 728 Retromaxillary polypi, 757 Retropharyngeal abscess. 704 Rha'L)dosarcoma, 141 Rhagades, 100, 104 Rheumatic arthritis, 569; gout, 570; inflamma- tion, 39; iritis, 730; nodes, 470; osteitis, 471 ; phlebitis, 233 Rheumatism, gonorrhceal, 565 INDEX. 1233 Rheumatoid arthritis after dislocations, 502 ; compared with fracture of femur, 420 Rhinoscleroma, 748 Ribs, beading of, 476; fracture of, 853 ; resec- tion, 868 Rickets, 474 ; acute, 479 ; as a cause of flatfoot, 336; knock-knee, 341 ; fracture, 347; and scurvy, 479 ; of skull, 475, 482, 657 ; of spine, 711 ; visceral changes, 477 Rider'sbone, 136, 306 Right-angled contraction, 336 Rigidity of jaws, 768 ; of muscles, 336 Rigor, 48, 163; in pyivmia, 76 Risus sardonicus, 120 Rizzoli's operation on jaws, 769 Robson, Mayo, 297 Rodent ulcer, 146 ; on eyelid, 736 ; on face, 74S Rosenmuller, organ of, 127 Roseola, recurrent, 100 ; syphilitic, 99 Rotation in reduction of dislocated humerus, 515 ; in scoliosis, 713 Roth on curvature of spine, 716 Rouge's operation, 754 Roux's amputation, 1199 Reduction en j/iasse, 890 Ruffer, 124 Rules for ligature of arteries, 261 Rupia, 100, 115 Rupture or aneurysm, 240, 259 ; arteries in fractures, 365 ; bladder, 1026 ; ectopic gesta- tion, 1 146; globe, 728; hernial sac, 890 ; muscles, 308; of abdomen, 870; perineum, 1 1 69; stricture, ilil; urethra, 1088; in lithotomy, 1058 Sac, anatomy of hernial, 878 ; in radical cure, 900 ; rupture of, 890 Sacculated aneurysm, 235 Sacculus of bladder, 1037, 1045, 1104 Sacrococcygeal cysts, 1 29 ; tumors, 684 Sacroiliac disease, 603 ; and hip disease, 596 Sacrum, fracture of, 412 Sailors, fractures in, 357 Sal aleni broth, 164 Salicylic creosote plaster in lupus, 191 ; warts, 198 Salivary calculi, 795 ; division of duct of, 745 ; fistula, 745 ; inflammation of gland, 794 ; tumors of, 795 Salivation in syphilis, 112 Salmon and Ody's truss, 881 Saphena vein, varix of, 227 Sapraemia, 43, 163 Sarcoma and aneurysm, 240, 258 ; of bone, 487; of breast, 1 1 79; cysts in, 126; of dura- mater, 660, 673 ; degeneration of, 141 ; as a cause of fracture, 349 ; generalization of, 142; jaws, 772 ; kidney, 998; ovary, 1 148; mahgnancy of, 141 ; skull, 659, 673 ; testes, 1 192; varieties of, 138 Sayre's bandage in fracture of clavicle, 389 ; jacket in caries of spine, 706 ; fracture, 696 Scabbing of wounds, 159 Scalds, 179; of the eye, 726; of glottis, 821 Scalp, cellulitis of, 71, 655; diseases of, 654; cysts of, 128, 656; tumors of, 656; wounds of, 632 79 Scapula, dislocation of, 508; fracture, 391 ; sarcoma, 490 Scarification of larynx, 822 Scarlatinal arthritis, 564 ; inflammation of neck, ^ 823 Scarpa's shoe, 331 Scars, 175 Scliede's dressing, 171 Schizomycetes, 25 Schrapiiell s membrane, 799 Sciatic aneurysm, 258 ; dislocation of hip, 530 ; compared with fracture, 419; hernia, 910 ; nerve, stretching of, 302 Scirrhus, 148, 1180; of intestine, 923 Scissor-legged progression, 592 Sclerosis, 447, 465 Scoliosis, 710 Scott's dressing, 553 Scraping lupus, 190; lymph-glands, 287 tongue, 780, 785 Scrofula, 91 Scrofulous arthritis, 580 Scrotum, diseases of, 1125 ; examination of, 1 126 Scurvy, as a cause of fracture, 348; and rickets, 479 Sebaceous cysts, 126; of scalp, 656 ; of face, 772 Secondary amputation, 380, 11 88; hemorrhage, 201, 243; in fractures, 368, 381 ; after piles, 965 ; in cleft palate, 761 ; treatment of, 216; nodes, 464 Section of spinal cord, partial, 698; perineal, I117 Semilunar cartilages, dislocation of, 537 Semimembranosus bursa, 321 ; cysts, 575 Senile cataract, 732 ; gangrene, 68 ; struma, III; tuberculosis, 585 Senn, amputation of thigh, 1195; on enteror- rhaphy, 944; intestinal anastomosis, 946; omental grafting, 944; injection of hydrogen gas, 871 Sensation in injury to spine, 691 Separation as a cause of non-union, 357 ; of epiphyses, 363 ; of femur, 426, 428 ; of humerus, 393, 521 ; in osteitis, 457 ; of radius, 405 ; osseous union after, 425 ; of tibia, 440 Septic fever, 42, 163 ; infection, 82 ; inflamma- tion in wounds, 162; intoxication, 43 Septicemia, 82 Sequestra after amputation, 462 Sequestrotomy, 461 Serocystic disease, 127, 11 78 Serous cysts of breast, 1176; exudation, 39; iritis, 730 Serpiginous eruptions, 105; ulcers, 194 Sessile hemorrhoids, 961 Shattock, 325 Sheath of arteries, method of opening, 262 Shock, 149 ; death from, 669 ; diagnosis from hemorrhage, 151; in fractures, 365; as a cause of suppression, 992 ; operations during, 151 ; from passage of catheter, 1093 ; in rail- way accidents, 669 Shortening in hip-disease, 594 Shoulder, amputation at, 11 90; dislocation of, 508; unreduced, 498, 527; disease of, 612; excision of, 620; fracture into, 396; fre- quency of dislocation of, 497 ; growing out of, 713 ; osteo-arthritis of, 573 ; paralysis of mus- cles of, 501 ; shape of, in synovitis, 55° 1234 INDEX, Signoroni's tourniquet, 209 Silicate of soda s[)lints, 374 Silk ligatures, 213 Simple caries, 448 Sinus, 56; tliroinbosis of lateral, 669 Size of urethra, 1106 Skin, diseases of, 1S9; grafting, 160 ; trans- plantation, 176 Skull : craniotabes, 657 ; exfoliation from, 459 ; fracture of, 643; inflammation after, 662 ; hypertrophy of, 657 ; nodes on, 464 ; osteoma of, 658, 662 ; in osteomalacia, 483 ; osteitis of, 658 ; in osteitis deformans, 480 ; in rickets, 474, 4S2, 657 ; sarcoma of, 659 ; syphilitic inflammation, 107, 465, 658 ; tubercular dis- eases, 658; tumors of, 659 Sloughing in fracture, 368 ; in intussusception, 914, 922 ; in spinal injury, 690 Smith's gag, 760 ; tubular needles, 761 ; Nathan Smith's splint, 424, 436 Smoker's patch, 105, 780 Snuffles, 109, 753 Soft chancre, 98 Softening of brain, 660 ; of spinal cord, 688, 718; of thrombi, 231 Solid oedema, 39, 290 Solution of calculi, 1003 Sonnenburg, cystectomy, 1070 Sounding for calculi, 1045 Sounds, Bellocq's, 752; bulbous, 1 108; for diagnosis, 1107 Spasm in arthritis, 551, 556; cortical, after head-injury, 644; of larynx, 812; in swal- lowing, 847 ; in tetanus, 118 Spasmodic closure of jaws, 768; contraction after nerve-injury, 299; croup and rickets, 478; stricture, 1102, 1107 Spastic paralysis, 662 ; rigidity, 336 Speculum : anal, 957 ; aural, 799 Spence's amputation, 1189 Spermatic cord, diagnosis of tumors of, 1127 Spermatocele, 127 Spheroidal-celled carcinoma, 147 Spina bifida, 680; false, 680 ; ventosa, 472 Spinal canal, narrowing of, in caries, 702 ; cord, compression of, in caries, 703 ; curvature, 712 ; inflammation of, 718 ; injuries of, 697 ; tumors of, 720 Spine, caries of, 700 ; dislocation of, 687; frac- ture, 687 ; railway, 686, 699 ; in rickets, 476 ; sprains of, 6S5 Splicing nerves, 297 ; tendons, 308 Splint, Bavarian, 438 ; Bryant's, 426, 598 ; Carr's, 407 ; Croft's, 438 ; Desault's, 422 ; Dupuytren's, 440 ; Ellis's, 390; Erichsen's, 393: extemporized, 370; in fractures of the leg, 435; Gamgee's, 373, 438; Gordon's, 407; Hammond's, 3S4; Ilodgen's, 424, 436; interdental, 383 ; leather for fracture of pa- tella, 433 ; Lister's, for wrist, 624 ; Liston's, 422 ; Maclntyre's, 425 ; Middeldorpf's, 397 ; movable, 373, 436; Nathan Smith's, 424, 436 ; plaster, 373, 438 ; poroplastic, 373, 437 ; Pott's, 439; in rickets, 478; for semilunar cartilages, 539 ; in spinal caries, 706 ; in sjMnal fracture, 695 ; stocking, 436; in talijies, 327, 330 ; Thomas's hip, 599 ; knee, 423, 609 ; for jaw, 384 Splinters in fractures, 37S Spontaneous aneurysm, 235 ; cure of aneurysm, 238 ; fracture in sarcoma, 490 ; regeneration of nerves, 292 Sprains, 495 ; of back, 685 ; of flexor tendons, 408 Spur formation in artificial anus, 947 ; in col- otomy, 948 Staff in lithotomy, 1054, 105S ; Syme's, III5; Wheelhouse's, II 17 Stages of hip disease, 598 Staphylococci, 25, 45, 74, 163, 454 Staphyloma, jiosterior, 724 Starch in rickets, 477 ; for splints, 373 Starting pains, 556 Stasis, 27 Stephen Smith's amputation, 1197 Stercoral ulcers, 923 Sterility and varicocele, 1138 Stemo-mastoid, division of, 825 ; induration 825 Sternum, injuries of, 855 Sthenic fever, 33 Stiffness after dislocations, 503 Stimson, 524 Stimulants in delirium tremens, 153; in gan- grene, 66 ; gout, 568 ; hemorrhage, 204 ; in- flammation, 40, 73, 81 ; intestinal strangula- tion, 917, 921 ; shock, 151 Stirrup for fracture of femur, 422 Stocking splint, 436 Stokes, 338 ; amputation, 1197 Stomach, operations on, 874 Stomatitis, 746, 763 Strabismus, 724 Strangulation by bands, 911 ; in hernia, 884 ; internal 91 1 ; of peritoneum, 888 ; of piles, 961 ; symptoms of, in hernia, 885 Strangury, 1038 Strapping, 168; of testis, 1131 Streptococcus, 26, 45, 69, 163, 454; erysipelatis, 79 Stretching nerves, 301, 407 Stricture of intestine, 923 ; after hernia, 895 ; as a cause of strangulation, 915 Stricture of cesophagus, 849; of rectum, 980; after piles, 967 ; of urethra, 1 102 ; cure of, 1 108; dilatation of, II09; division of, IIII ;• effects of, 1103 ; electrolysis in, 1118; exci- sion of, 1 118; locality, 1 103; measurement, 1 108; retention in, 1033; rupture of, nil; symptoms of, 1105 ; treatment, 1089 Struggling in ancesthesia, 371 Strumous arthritis, 580 ; lupus, 1 7 1 ; osteitis, 472 ; and syphilitic nodes, 470 Stumps, diseases of, 1203; hemhorrage from, 216; neuralgia of, 301 Styes, 735 Styptics, 214 Subarachnoid hemorrhage, 642, 649 Subastragalar amputation, 1201 ; dislocation, 544 Subciecal fossa, 912 Subclavian aneurysm, 245, 254 ; artery, com- pression of, 268; ligature, 266; and carotid arteries, ligature of, 245 Subclavicular dislocation. 510 Subcoracoid dislocation, 509 Subcranial hemorrhage, 648 ; nodes, 465 ; sup- puration, 664 Subcutaneous nerve-stretching, 302 ; urethro- tomy, 1 II 5 INDEX. 1235 Sulnlural abscess, 669 ; suppuralion, 664 ; hemorrhage, 642, 64S Subglenoid dislocation, 509 Sul)hyoid cysts, 129; pharyngotomy, 825 Subbngiial bursa, 771 ; cyst, 129 Subluxation, 497 ; of clavicle, 505 ; humerus, 510 ; lower jaw, 505 ; radius, 523 Submammary abscess, 1 175 Submaxillary tumors, 796 Submucous fibroids, I161 Suliperiosteal cysts, 773 ; excision, 620 ; hem- orrhage in rickets, 479; resection, 458 Sub]ieritoneal fatty hernia, 909 ; fii)roids, 1 161 ; lipoma, 132 Subsi:)inous dislocation, 510 Subungual exostosis, 485 Suction cannula for tracheotomy, 830 Sugar in urine, 1020 Suggestion, 700 Suicidal wounds of throat, 814 Sulphide of calcium, 193 Superficial glossitis, 780 ■ Superior maxilla, fracture of, 382 ; resection, 756 Supernumerary fingers, 322 Supports in caries of spine, 706 ; in curvature, 718 Suppression of urine, 1033 Suppurating bubo, 97, 283 Suppuration in aneurysm, 239, 244; in antrum, 766; in burns, 180; in compound fractures, 353; catarrhal of joints, 550; diffuse, 46, 5 1; and embolism, 50; after extravasation of blood, 156; and hemorrhage, 216; intra- cranial, 664; of scalp, 657 ; in spinal caries, 703, 709 ; symptoms, 46 ; in syphilis, 102 ; in wounds, 158, 163 Suppurative arthritis, 495, 559 ; arteritis, 222 ; bursitis, 320; fever, 49; meningitis, 664; microbes, 45; orchitis, 11 34; osteitis, 456; of skull, 658, 462; otitis, 671; parotitis, 795 > peritonitis, 934 ; phlebitis, 233 ; pyel- itis, 1002, 1007; prostatitis, 1084; tenosyno- vitis, 313 Supra-coracoid dislocation, 509 Suprapubic cystotomy, 1062; lithotomy, 1060 ; prostatectomy, 1082 Supraspinous dislocation, 535 Supravaginal hysterectomy, 1163; amputation of cervix, 11 66 Surgical emphysema, 861 ; kidney, 993, 1008 Sutures, 168; of bladder, 1028; after cystot- omy, 1061, 1069; Czerny's, 945; Greig Smith's, 945 ; in fracture of patella, 432 ; Joubert's, 943 ; Lembert's, 943 ; of nerves, 295 ; in scalp wounds, 632 ; of tendons, 308; of urethra, 1089; in wounds of neck, 815 Sweep's cancer, 1125 Sycosis, 735 Syme's amputation, H99 ; gluteal aneurysm, 258; staff, 1115; tenotomy, of posterior tibial, 330; urethrotomy, 11 15 Symmetrical gangrene, 80 Symmetery in syphilis, loi Sympathic irritation, 727 ; ophthalmia, 727 ; paralysis, 691 Syncope from catheters, 1093 Synovial fringes, hypertrophy of, 460, 567, 614; hernise, 552, 572; pouches, 552; sheaths of tendons, arrangement of, in palm, 315; in- flammation of, 312 Synovitis, 545, 549; after injury, 493 ; hem- orrliagic, 222; in osteoarthritis, 570 ; papil- lary, 571 ; in syphilis, 611 ; tubercular, 580 Syphilis, 95 ; acquired, 97 ; as a cause of frac- ture, 348 ; duration of contagiousness, I02 ; of hereditary transmission, 102, 108; erup- tions, lOI ; on the face, 747 ; hereditary, 1 10 ; intermediate, 33 ; lupus, 190; mifcarriage'in, 109 ; and phagedaiia, 69 ; prognosis of, 107 ; second attacks of, 108; secondary, 99; teeth in hereditary, no; tertiary, 103 Syphilitic arteritis, 224; as a cause of aneurysm 236; caries, 449; epididymitis, 1 1 29; glos sitis, 782 ; laryngitis, 808 ; neuritis, 299 orchitis, 1131 ; osteitis, 465, 467, 658; phle bitis, 234; pemphigus, 109; stomaiitis, 764 synovitis, 608 ; ulcers, 193; of rectum, 971 urethritis, 1098 Syringocele, 682 ' Tagliacotian operation, 751 Tait, on operations on the gall-bladder, 953 Talipes, 325; acquired, 332; arcuatus, 334; calcaneus, 325, 334; equinovarus, 326 ; equi- '^"s, T,T,}) ; plantaris, 334; relapsed, 331 ; valgus, 325, 334 Tampon for rectum, 965 ; Buckston Browne's, 1057 ; laryngeal, 831 Tapping the bladder, 1035 ; hydrocele, 114I; ovarian cysts, 1 155 Tar in lupus, 192 Tarsectomy, 331 Taxis, 889; accidents from, 889 ; duration of, 859 ; for inguinal hernia, 898 Teale's amputation, 1 188, II9S Teeth in hereditary syphilis, no; in rickets, 475 . ^ Temperature in cortical lesions, 646; in fracture of spine, 693 ; after nerve-section, 294 Temporal artery, ligature of, 266 Temporo-maxillary articulation, ankylosis of, 769 Tendo-Achillis, contraction of, 336; rupture of, 307 ; section of, 330, 427, 436, 440 Tendons, dislocation of, 309 ; section of, 329 ; splicing, 308 ; suture, 308 ; union, 329 Tenosynovitis, 330 Tenotomy, 174, 330; of palmar fascia, 317 ; in fractures, 371, 427, 439; of sterno-mastoid, 825 ; for strabismus, 739 Tension of eyeball, 733; as a cause of inflamma- tion, 39, 155, 172 Teratomata, 129 Tertiary nodes, 465 Testis, dermoid cysts of, 129 ; enchondroma of, 135; hernia,' 1134; inflammation, 1129; malformations of, 1127; puncture of, 1131; sarcoma of, 141 ; strapping, 1131 ; tumors of, 1 135; undescended, with hernia, 900 Tetanus, 118, 299 ; hydrophobicus, 118 Thecal abscess, 313 Thiersch amputation of penis, 025; dressing for wounds, 165; extroversion of bladder, 1026; method of grafting, 160 Third nerve, injury to, 650 i2i;6 INDEX. Thomas' boot for flat-foot, 337 ; diagnosis of hip-disease, 591 ; splint for hip, 599 ; jaw, 384 ; knee, 423, 610; double, for spine, 708; wrench, 600 Thompson's bladder-forceps, 1068 Thoracic duct, wounds of, 281 Thoracoplasty, 867 Thorax \Sei Chest) ; deformity in caries, 702 ; in curvature of spine, 715 Thorburn, injuries of spine, 690, 700 Thrill in aneurysm, 237 Throat, scald of, 82 1 ; wound of, 762 Thrombosis, 27 ; of arteries, 225 ; in fractures, 364 ; of lateral sinus, 253, 669 ; in pycemia, 74; traumatic, 217 ; of veins, 228 Thrombotic abscesses, 75 ; gangrene, 63 ; piles, 959 Thrush, 763 Thumb, amputation of, 1 192; avulsion of, 307; dislocation of, 525 Thyroarytenoid muscles, paralysis of, 812 Thyroid gland, cysts of, 827, 839; accessory ones, 841; enlargement of, 839 ; fibrous degenera- tion, 839; inflammation, 838; malignant, disease of, S44 ; operations on, 884 Thyroid dislocation of hip, 533 Thyro-lingual canal, 826 Thyrotomy, 833 ; for carcinoma, 809 Tibia, fracture of, 438 ; with fibula, 435 ; in rickets, 476 ; separation of epiphysis of, 441 ; s}-philitic disease of, 469 ; tubercular 65. Tibial arteries, ligature of, 27S; wounds of, 212 366, 477 ; tendons, dislocation of, 309 ; divi- sion, 329. Tic, 301 Tilleman, 297 Tilting of pelvis, 592 Toes, amputation of, 1202 ; deformities of, 328 Tongue, hypertrophy of, 778 ; inflammation, 779; leucoplakia, 781 ; malformations, 778; operations on, 787 ; syphilis of, 783 ; tubercle of, 784; tumors of, 784; ulceration, 780 Tonsillotome, 793 Tonsils, calculi in, 794 ; excision of, 793 ; hypertrophy of, 792 ; inflammation, 791 ; sup- puration, 792; tumors, 794: wounds, 214, 265 Tophi, 567 Torsion of arteries, 212 ; of hernial sac, 901 Torticollis, 824 Tourniquets, 20S; Jordan Lloyd's, 1194; for reduction of dislocated jaw, 505 Trachea dilator, 821, 830; exploration of, 820 ; foreign bodies in, 819; ulceration after tracheotomy, 833; wounds of, 815 Tracheotomy, 828; for foreign bodies, 820 ; in goitre, 843 ; for scald, 822 ; tubes, 830 Transfusion in hemorrhage, 204; in shock, 151 Transmissibility of syphilis, 102 Transplantation of bone, 359 ; frog's skin, 162 ; muscle, 307 ; mucous membrane, 161 ; nerves, 298 ; skin, 162, 176 Traumatic aneurysm, 205; in fractures, 366; treatment of, 217, 248; cataract, 726 ; mydri- asis, 727; delirium, 153; epilepsy, 654; fever, 42, 154, 173; gangrene, 65; insanity, 654; nodes, 451 ; stricture of oesophagus, 850 ; urethra, 1088 ; synovitis, 493 ; ulcers, 196 Traumatopncta, 856 Travois, 1207 Tremor in delirium, 152 Trendelenburg's operation for ectopia, 1026 ; tampon, S31 ; on amputation of thigh, 1194 Trephining, 675; for cerebral abscess, 671; hemorrhage, 653 ; tumor, 675 ; the chest, 865 ; in chronic meningitis, 670 ; for epilepsy, 654 ; for fracture of skull, 636 ; for insanity, 654 ; in osteitis, 451, 458, 559, 61 1 ; for rup- ture of middle meningeal, 652 Trephining the spine, 720 ; for disease, 709 ; for injury, 697 Treves on intussusception, 920 ; obstruction, 925; splint, 286; on strangulation, 918; typhlitis, 932 Tripier's amputation, I20I Tripolith, 374 Trismus, 118, neonatorum, 118 Trophic lesions after nerve-section, 294 ; in spinal injury, 691, 718 Trusses, 880 Tubage for dyspnoea after tracheotomy, 832 ; of larynx, 834 ; oesophagus, 851 Tubercle, anatomical, 91 ; bacillus of. 9I; in- fection by, 92 ; in lupus, 189; painful sub- cutaneous, 130 Tubercular abscesses, treatment of, 5S7 ; adenitis, 284; of neck, 824; arthritis, 5S0, 588; bur- sitis, 320; caries, 449, 474; of skull, 658; of spine, 700 ; disease of brain, 673 ; of bone, 558,588,606; of choroid, 734; of chest wall, 830; of larj-nx, 807; of tendons, 314; of tongue, 785 ; peritonitis, 936 ; prostatitis, 1085 ; pyelitis, 1007 ; sequestra, 587 ; stoma- titis, 765 ; ulceration of skin, 1 95 ; of intestine, causing stricture, 923 ; of rectum, 971 ; ureth- ritis, 1098 Tubercular leprosy, 116 Tuberculosis, senile, 585 Tubes, tracheotomy, 830 Tubular lymphangeiectasis, 290 Tufnell's treatment of aneurysm, 241 Tumor albus, 605; of bladder, 1064; brain, 673; bone, 4S4 ; choroid, 734 ; jaws, 770; kidney, 99S; larynx, 809; mouth, 770; men- inges, 673; nares, 755 ; orbit, 737 ; salivary glands, 795; scalp, 656; skull, 673 ; spinal cord, 720; scrotum, 1 125; testis, 1 135; tongue, 784 ; tonsils, 793 Tying-in-catheter, 1094 Tympanitic abscesses, 51 Typhlitis, 931 Typhoid, arthritis after, 564 ; necrosis, 464 Twisted suture, 170 Twisting of ovarian pedicle, 1 155 U Ulcer, 193; atheromatous, 225; of bladder, 1038; cancerous, 148; of duodenum, 181 ; face, 748, 750; intestine, 923 ; leg, 194,229; perforating of foot, 294, 57S ; of rectum, 971 ; rodent, 146; on eye, 736; of scars, 177; syphilitic, 105, 194; of tongue, 780; varie- ties, 58, 193 Ulceration, 58 Ulcerative endocarditis, 223, 233 ; stomatitis, 763 INDEX. 1237 101 1 ; impaction, dilatation of, in Ulna, dislocation of, 519 ; fracture, 408 ^ Ulnar artery, ligature of, 272 Umbilical hernia, 907 Union of epiphyses, 394, 426, 441, 447 ; pre- mature in rickets, 475 ; in syphilis, 469 ; by first intention, 158; by second and third intention, 159; by granulations, 159; under a scab, 159 ; of fractures, 349 ; delayed, 354 ; failure of, 355 ; fil)rous, 355 ; of neck of femur, 416; of patella, 430; of skull, 605 ; of nerves, 292 Unna, 191 Unreduced dislocations, 498; of elbow, 522 ; femur, 535 ; radius, 522 ; shoulder, 578 Ununited fracture, 355 ; of patella, 433 Urachus, cysts in, 128 Uraemia and concussion, 646 Urate of soda in gout, 567 Urea, amount of, 1017 Ureter, catheterization of, 1002 Ureterotomy, 1002 Urethra, calculus in, 1090 stricture, 1 104 ; of female, 1069 ; diseases of female, li 22 ; effect of catheters on, 1091 ; foreign bodies in, 1090 ; inflamma- tion of, 1095; irritable, H08 ; rupture of, 1088 ; in lithotomy, 1058 ; stricture of, 1 102 ; suture of, 1089 ; tying catheter in, 1094 ; traumatic stricture of, 1088 ; washing out, 1099 Urethral arthritis, 564 ; caruncle, 1 123 ; epididy- mitis, 1129, fistula, 1121; fever, 1093; hematuria, 1020 ; prostatotomy, 1081 Urethrameter, 1106 Urethritis, retention in, 1024 Urethrocele, 1123 Urethroscope, iioi Urethrotomy, 11 12 Uric acid, amount of, 1017 Urinary abscess, 1119; fistula, loil, 1121 Urine, deposits in, 1021 ; examination of, 1015 ; extravasation of, 11 18; from kidney, 990; incontinence of, 1031 ; organisms in, 1022 ; reaction of, 1016; retention of, 1032; after piles, 965 ; secretion of, in fractured spine, 693; specific gravity, 1015 ; suppression of, 992 ; surgical aspect of, 1015 ; variations in quantity, I015 Uterine appendages, removal of, 1146,1162; and ovarian tumors, diagnosis of, 1 153 Uterus, cancer of, 1165 ; cervix, amputation of, 1 1 66; laceration of, 1168; extirpation of, 1 166; tumors of, 1 1 59 Vagina, affections of, 1 1 68 Vaginal hydrocele, 1139 Valsalva, method of inflating ear, 797 Varicocele, 1 138 ; diagnosis of, 11 26 ; operation for, 1 1 39: in syphilis, 102; and wasting of testis, 1 138 Varicose ulcer, 229 ; vein, 227 Varioloid eruption in syphilis, 100 Varix, aneurysmal, 217 ; arterial, 221 ; of in- ternal saphena, 227 ; of lymphatics, 290 Varus, spurious, 328, 335 Vascular growth of urethra, 1122, 1 168 Vault of skull, fracture of, 634 ; sypliilitic, causes of, 466 Veins: diseases of, 227 ; entry of air into, 219 ; injury of, 218 ; ligature of artery and, 218 ; ligature in pyamia, 669 ; ruptured, in frac- tures, 367 ; varicose, 227 Velpeau, dislocation of clavicle, 507, 508 Venereal wart, 198 Venous angeiomata, 220; hemorrhage, 201 ; hemorrhoids, 960 ; noevi, 143, 220 ; pulsation in glaucoma, 733; obstruction, 231 Ventral hernia, 909 Verneuil, 958 Verrucse, loi, 143 ; necrogenic, 189 Vertebrae, rotation of, in curvature, 713 Vertebral artery, ligature of, 268; wound, 215, 816; column. 6"^!? Spine. Vesical calculus, 1041 ; ha^maturia, 1020 Vesico- vaginal fistula, 11 23 Vesicular eruptions after nerve section, 294 Vessels, formation of, 29 ; injuries, 201 ; occlu- sion, 206; of neck, wounds of, 815 Villous cancer, 127; growths, 143; tumor of bladder, 1064; of rectum, 986 Virus of hydrophobia, 123 Viscera, abdominal, rupture of, 870 ; wounds, 872 Visceral changes in rickets, 477 ; congestion in burns, 180 Volvulus, 912; after hernia, 895 ; treatment of, 920 Vomiting in anesthesia, 187; in hernia, 887, 916; after herniotomy, 895 ; in obstruction, 926 Vulcanite splints in fracture of jaw, 384 Vulva, affections of, 1168 W Wall of thorax, injuries of, 853 Walsham's shoe, 337 Walton-Wells cot, 1208 Wardrop's method of ligature, 245 Waring in ununited fracture, 359; of jaw, 384 Warmth in arthritis, 551 ; in inflammation, 36 Warts, 198 Washing out bladder, 1039; in enlarged prostate, 1079 ; urethra, 1099 Wasting after ligature of arteries 215 ; after in- flammation of joints, 551, 571, 593 Water cushion in fracture of femur, 417 Watson's canula, 1080 Wax in ear, 799 Weakness as a cause of spinal curvature, 713 Webbed fingers, 324 Webbing straps for fracture of jaw, 383 Wedges in reduction of dislocated jaw, 505 Wet-cupping in inflammation, 37 Wharton's duct, cyst from, 126 Wheelhouse's perineal section, I117; on pro- lapse, 968 Whip bougies, I no Whitehead : on excision of tongue, 787 ; on piles, 965 ; tracheotomy, 828 Whitehead's varnish, 790 White swelling, 606 Whitlow, 313; after nerve-section, 293 Wilson's cystometer, 679 I23S INDEX. Wire, introduction of, in aneurysm, 246 ; splint for fracture of jaw, 3S4 Wirin>j in fracture of jaw, 384 ; in delayed union, 359 Wolffian cysts, 127 WoUler's method of grafting, 162 Wood's operation for ectopia vesicie, 1024 ; pads, 880 Wood-wool, 168 Wool-sorter's disease, 84 Wool truss for inguinal hernia, 882 Wounds of abdomen, 872; air-passages, 815; arteries, 207 ; brain, 647 ; chest, 855 ; cord, 698; cellulitis after jioisoned, 70 ; decom- position in, 162; drainage of, 171 ; dressings for, 167 ; of the eye, 726; face, 745 ; in con- nection with fractures, 378; of heart, 857; infected, 165, 171 ; inflammation in, 159, 162; inoculated by tubercle, 92 ; of joints, 492 ; of kidney, 992; lung, 856; of nerves, 292; neck, 814; palate, 762; protection of, 173; repair of, 158; of scalp, 632 ; of spinal cord, 698; treatment of, 164; varieties of, 157, 174; of veins, 218; of viscera, 841 Wrenches of back, 685 ; Thomas's 600 Wrist, dislocation of, 524; excision of, 623; fracture into, 410; tubercular disease of, 613 Writer's cramp, 310 Wry-neck, 824; and spinal caries, 601 ; as a cause of scoliosis, 713 Zygoma, fracture of, 282 ¥^ .';';»>v>.^\A',:,*.vv'.'A'.- ,•?.•>•-..".. -.1 i II •,-!■■. -v-nn.--^ 1 ■;>:•;• s\. •■■v.;; '; \