COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD ^^ . HX64060748 RD31 W1 6 1 896 Surgery; its theory Columbia ®mber£iitp )^^c COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by cJjiaj-mAJ^ . /a*- /yx • SURGERY ITS THEORY AND PRACTICE. 20,ooo copies of this book have been sold during the past eight years. This fact is stated here as being the best evidence that could be offered of its usefulness to, and its popularity among, students and physicians. SURGERY ITS THEORY AND PRACTICE WILLIAM JOHNSON WALSHAM, F.R.C.S. Eng. ; M.B. and CM. Aberd. ; SENIOR ASSISTANT-SURGEON, LECTURER ON ANATOMY, AND SURGEON IN CHARGE OF THE ORTHOPEDIC DEPARTMENT, ST. BARTHOLOMEW'S HOSPITAL; SURGEON TO THE METROPOLITAN HOSPITAL; CONSULTING SURGEON TO THE HOSPITAL FOR HIP DISEASES, SEVENOAKS, AND TO THE COTTAGE HOSPITAL, BROMLEY; EXAMINER IN ANATOMY TO THE CONJOINT BOARD OF THE ROYAL COLLEGE OF PHYSICIANS AND ROYAL COLLEGE OF SURGEONS; LATE EXAMINER IN SURGERY TO THE SOCIETY OF APOTHECARIES. FIFTH EDITION REVISED AND ENLARGED THREE HUNDRED AND EIGHTY ILLUSTRATIONS. PHILADELPHIA : P. BLAKISTON, SON & CO., IOI2 Walnut Street. 1896. PREFACE TO FIFTH EDITION. Ix preparing a fifth edition, the Author has endeavored to increase the usefulness of the work by amplifying those sub- jects that seemed to require it, and by describing many condi- tions and operations not mentioned in former editions. This has been done without materially enlarging the book by leaving out such matter as, with the advance of surgical science and practice, has now ceased to be of value. The rapid sale (20,000 copies having been printed in less than eight years) has encouraged the Pubhshers to issue the present edition in a more convenient shape and size ; to im- prove the character and distinctness of the type ; and to lib- erally add to the already numerous illustrations. In the work of revision the Author has received valuable help in the pathological and bacteriological sections from Dr. Kanthack, Lecturer on Pathology, and Dr. DrA-sdale, Casualty Physician, St. Bartholomew's Hospital ; and throughout the rest of the book from Mr. W. G. Spencer, Assistant-Surgeon to the Westminster Hospital. He is further indebted for many hints and suggestions to Mr. W. E. Miles, F.R.C.S., Dr. J. F. Hall, Mr. E. L. Lloyd, Mr. W. Wenmoth Pryn, R. N., and Mr. Percy Furnivall. He has in addition to thank Mr. Furnivall for his kindness in reading the proof sheets. (V) VI PREFACE. Most of the new illustrations were made from drawings by Mr. Prendergast Parker, either from rough sketches by the Author, or from preparations in the Hospital Museum. For others the Author is indebted to Mr. Greig Smith, Mr. Paul, Dr. Macintyre, and Mr. Miles. 77 Harley Street, W. CONTENTS. PAGE SECTION I. General Pathology of Surgical Diseases. Inflammation -------.---17 Chronic inflammation ..-- 33 Suppuration and abscess ---- 34 Sinus and fistula ---------- 43 Ulceration and ulcers ----- 44 Gangrene or mortification 51 Tubercle and tuberculosis ---------58 Struma or scrofula ---------- 63 Syphilis ---.--------65 Haemophilia . . . -^ . 76, Tumors .........--- jy Cysts 98 SECTION II. General Pathology of Injuries. Wounds 104 Contusions or bruises 119 Burns and scalds - 120 Hremorrhage ----------- 123 Constitutional effects of injury 136 Diseases the result of septic and infective processes in wounds - - 141 SECTION III. Injuries of Special Tissues. Injuries of bones ---------- 168 Injuries of joints ---------- 186 Injuries of muscles and tendons -------- 194 Injuries of arteries ----- 196 Injuries of veins -...--.--- 203 Injuries of nerves ---------- 204 (vii) Vlll CONTENTS. PAGE SECTION IV. Diseases of Special T.ssues. Diseases of bone - - - - - -- - - - 209 Diseases of joints ---------- 236 Diseases of muscles ---------- 260 Diseases of tendons ---...--. 261 Diseases of fascias - 264 Diseases of bursae ---------- 265 Diseases of arteries, including aneurysm ------ 267 Diseases of veins - - - - -- - - - - 2P2 Nsevus --..-.--.-.- 308 Diseases of lymphatics 310 Diseases of nerves ---------- 314 Surgical diseases of the skin 320 SECTION V. Injuries of Regions. Injuries of the head 327 Injuries of the face --------- 348 Injuries of the neck, including the entrance of foreign bodies into tlie pharynx, oesophagus, and air-passages ------ 354 Injuries of the back --------- 362 Injuries of the chest ---------- 3G8 Injuries of the abdomen ...----- 376 Injuries of the pelvis ---------- 394 Iniuries of the upper extremity ------- 403 Injuries of the lower extremity -------- 429 SECTION VI. Diseases of Regions. Diseases of the scalp and skull ------- 462 Diseases of the brain, calling for surgical interference - - - - 464 Diseases of the ear --------- 468 Diseases of the eye 482 Diseases of the lips, cheeks, and mouth 509 Diseases of the t(jngue - - - - - - - - -518 Diseases of the uvula, palate, fauces, and tonsils - - - - 527 Diseases of the gums and jaws -------- 533 Diseases of the nose, naso-pharynx and accessory cavities - - 54° Diseases of the pharynx and fjcsophagus ------ 554 Diseases (jf the larynx --------- 560 CONTENIS. IX PAGE Diseases of the parotid gland - - - -•'- - - -• 57^ Diseases of the thyroid gland -------- 577 Diseases of the spine .--. 580 Surgical diseases of the intestines ------- 594 Diseases of the liver, gall-Vjladder, stomach, spleep, and pancreas calling for surgical interference - - - - - - - - -613 Hernia 619 Diseases of the rectum - - - - - - - - -652 Diseases of the urinary organs ------- 667 Diseases of the genital organs - - - - -1- - - 728 Diseases of the female genital organs ------ 749 Diseases of the breast 759 Deformities of the neck, knees and feet ------ 772 APPENDIX. Amputations -- ""." 7^5 Index 793 S/ f»~ ^^^-v^ SURGERY: ITS THEORY AND PRACTICE. SECTION I. GENERAL PATHOLOGY OF SURGICAL DISEASES. INFLAMMATION. Infla]\imation is defined by Dr. Burdon Sanderson as " the succession of changes which occurs in a living tissue when it is injured, provided that the injury is not of such a degree as at once to destroy its structure and vitaUty." Inflammation as thus defined may occur in any tissue of the body, and in whatever tissue or organ it occurs, whether superficial or deep, transparent or opaque, vascular or non-vascular, soft or hard, the pathological process is essentially the same. Gexeral Outline of the Process. — Let us first study the pro- cess as it may be observed by the naked eye, say, in a portion of inflamed skin. The part is uniformly red, hotter than the sur- rounding skin, swollen and painful. The redness momentarily disappears on pressure, and gradually fades away into the natural color of the part around, but later it becomes mottled, and in places of a deeper hue. There is usually some oedema about the inflamed spot, and the neighboring lymphatic glands may be slightly tender and enlarged. If an incision were now made into the inflamed tissues, they would be found fuller of blood than natural, of a bright red color, and infiltrated with serum ; whilst if the lymphatics leading from the part were opened, as has been done in animals, they would be seen to be transmitting more lymph than under normal conditions. The inflammation may now terminate, leaving the tissues apparently normal {resolution), or it may lead to certain changes producing irreparable damage I* 07) lo GENERAL PATHOLOGY OF SURGICAL DISEASES. to, or total destruction of the part. Thus, the process may be- come chronic and the tissues thickened and indurated {fibroid thickening) : or the tissues in the centre of the inflamed spot may soften and break down, forming a creamy fluid called pus (sup- puration and abscess) ; or the more superficial tissues, may un- dergo molecular destruction, leaving a raw surface {ulceration^ ; whilst again the whole of the tissues in the inflamed area may lose their vitality and die "en masse" {gangrene). When the in- flammatory process is at all severe, constitutional symptoms will also be present. Thus, the temperaiure will be more or less raised, the skin dry, the pulse increased in rapidity, the tongue furred, the appetite lost, the bowels confined, and the urine scanty and high-colored — a condition known as inflammatory fever, and due in almost every case to the absorption of some poison {intox- ication). Under some circumstances the constitutional symptoms may be of a more serious character, and secondary inflammations may be set up in internal organs or in other parts of the body ; the patient is then said to be suffering from septic or from infective poisoning, conditions which, as will be pointed out hereafter, are due to poisonous products entering the general blood-stream or the lymph-channels at the primary seat of inflammation. The nmiute changes which occur in the above-described phe- nomena have of late years been very accurately studied in the transparent parts of the mesentery of the frog, rabbit, and dog, and in sections of the cornea and tongue of the frog. They are divisible into (i) the changes occurring in the blood-vessels and their contents, and (2) the changes in the fixed tissue elements. The following is a brief summary of what is observed : I. Changes in the blood-vessels and their contents. — After, in some instances, a momentary contraction, the vessels become dilated, the arteries first, and then the capillaries and veins, and the blood in them flows with greater rapidity {determination of blood or actii^e hyperccmia), whilst smaller vessels which were pre- viously invisible are now seen transmitting blood. Hence the redness of the part. Now, after a longer or shorter period, ac- cording to the kind of irritant used to set up the inflammation, the blood-current slackens at first in the veins, and then in the capillaries and arteries, and leucocytes are seen to drop out here and there from the central stream or axial current, which appears yellowish in color from the red corpuscles being contained in it. 'I'hese truant leucocytes first roll lazily along in the pale or cir- cumferential current, and are joined by more and more as the blood- stream fiirther slackens in speed. Now they adhere to the walls of the veins, and to a less extent to the walls of the capil- laries and arteries, so that the vessels appear as if lined with them. INFLABIjMATION. 19 Soon they begin to pass through the vessel-walls into the tissues around {diapedesis), attracted, according to some writers, to the seat of inflammation by the poison or chemical irritant which has excited it {positive cheniiotaxis). By and by, if the inflammation is very acute, the colored corpuscles, in groups of two to a dozen, also leave the central stream and pass through the walls of the vessels into the tissues, producing those patches of darker redness and the mottling of the surface afluded to above. The central stream next begins to oscillate, flowing onwards during the systole, and slightly receding during the diastole of the heart ; whilst the colored corpuscles show a tendency to adhere to one another. Finally the stream stops, and stasis is said to have occurred (Fig. I). In the meantime the liquid contents of the vessels have also been passing through the vessel-walls into the tissues, and together with the escaped leuco- cytes, account for the swelling and for the serous exudation which can be squeezed out when- the parts are cut into. The serum, fur- ther, soaks into the neighboring healthy tissues, thus explaining the surrounding oede- ma, and is thence, along with some of the leucocytes, taken up by the lymphatics, and so passes back into the circulation, and as we shall presently see, may partly account for the attendant inflammatory fever. If now the cause of the inflammation ceases to act, and the vitality of the tissues has not been too much lowered to per- mit of their recovery, the corpuscles in the middle of the stream in those vessels where stasis has occurred again begin to oscillate and then to move on ; the leucocytes no longer drop out of the axial current, and those that have already escaped into the tissues either break down or pass along with the escaped fluids into the lymphatics, leaving the part apparently uninjured {?-esotutio?i). If the above favorable termination does not take place and stasis is not soon relieved, coagulation of the serum rapidly en- Diagram of the minute changes in inflammation. 20 GENERAL PATHOLOGY OF SURGICAL DISEASES. sues, and the vessels become thrombosed. At the same time, moreover, coagulation of the liquid exudation in the tissues also occurs. The clot thus formed contracts, squeezing out the serum, which is then drained away by the lymphatics, so that if the parts at this stage be cut into, a serous exudation will no longer escape. The original tissues, partly in consequence of the plugging of the vessels, and partly in consequence of the digestive action of the leucocytes and soddening effect of the fluid exudation, become swollen and softened, and finally lose their vitality and disappear, their place being taken by a mass of closely-packed small cells embedded in a very slight amount of intercellular substance. This small-cell-infiltration was formerly thought to be derived entirely from the multiplication of the original tissue elements. More recently it has been attributed to the aggregation of the escaped leucocytes, the tissue elements being beUeved to remain passive or to undergo degeneration ; whilst more recently still it has been ascribed in part to the proliferation of the connective- tissue and other cells in the inflamed area, the leucocytes, though being thought to play only a subordinate part and sooner or later to undergo disintegration or absorption, forming, nevertheless, its chief constituent. From whatever source these small round cells are derived, among them, especially during the stage of repara- tion, may soon be seen numerous dehcate capillary loops, which have been formed from the old capillaries in and around the in- flamed area, or from the young endothelial or connective-tissue cells. To this vascularized tissue the name of inflammatory new formation or granulation tissue is given. When the cells and liquid escape on a free surface, the fibrin with the entangled cells forms a so-called false membrane. 2. Cha?iges in the fixed elements of the tissues. — When the mes- entery is examined after inflammation has existed a short time, the cells of the origmal tissue are found to be proliferating. The nuclei of the endothelial cells divide, and the daughter cells thus produced lose their endothelial characters and become pear- shaped and larger than the escaped leucocytes surrounding them. The connective-tissue cells are believed to divide and proliferate in like manner. Thus, in the earlier stages of inflammation, two kinds of cells may be found — a number of small round cells, leu- cocytes, which have escaped from the vessels, and amongst them larger cells, which exhibit amoeboid movements on a warm stage, and are now looked upon as being derived in the way above mentioned from the original tissue cells. These large cells are believed by many recent pathologists to continue to divide and multiply, and to form in chief parts the cells of the inflammatory new formation or granulation tissue. They are called fibro- INFLAMMATION. 2 1 blasts. The escaped leucocytes are supposed, by the supporters of this view of the formation of granulation tissue, to act the part of scavengers, to eat up and remove effete and dead tissues, and destroy in this way any micro-organisms that may be present {phagocytosis) and then in their turn to undergo degeneration and absorption. By some pathologists the large amoeboid cells formed from the connective-tissue cells are believed to absorb the leucocytes which have already done their part in eating up the devitalized tissues and micro-organisms, and in addition to aid in the destruction of micro-organisms. The large cells are thus called macrophages, the small cells or leucocytes microphages. Terminations of inflammation. — We have already seen that before coagulation has taken place and the tissues have become irreparably damaged, if the cause of the inflammation ceases to act, the process may term.inate and the part resume its normal condition, when resolution is said to occur. Faihng this, how- ever, the following terminations may ensue. Thus, under favor- able circumstances, the cells constituting the inflammatory new formation may gradually become converted into fibrous tissue, producing the condition already referred to of fibroid thickening or scarring. Under less favorable circumstances the intercellular substance in the centre of the mass of closely-packed cells liquefies ; and the cells are then known as pus cells, whilst the liquefied tissues and exuded serum form a fluid {liquor puris) in which'they are contained. Thus pus is form.ed, and suppuration is said to be established. When these changes occur on the sur- face of the skin or mucous membrane, so that the products escape externally, the process, though essentially similar to that of suppuration, is spoken of as ulceration. And lastly, the in- filtrated tissues in the centre of the inflam.ed area may lose their vitality and die en masse, before infiltration with leucocytes and serum has gone on sufficiently long to produce their softening ; mortification or gangrene is then said to result. Causes of inflammation. — The direct cause of the inflamma- tory phenomena is undetermined, but is commonly supposed to be due to some change in the vessel-walls whereby they are rendered capable of behaving towards the blood more or less like dead matter, thus promoting a tendency to stasis and coagulation and the escape of leucocytes and serum in abnormal quantities. This molecular change in the vessel-walls may be brought about by some influence acting upon them, i, from within, through the blood ; and 2, from without, either directly upon the vessel-walls themselves, or indirectly through the intervention of the con- tiguous tissues. Irritants acting in either of these ways may be looked upon as exciting causes, and would appear in some 2 2 GENERAL PATHOLOGY OF SURGICAL DISEASES. instances to be alone sufficient to set up the process. In other cases, however, certain prior conditions such as may be con- sidered to lower the vitahty of the tissues, and to render them less able to resist deleterious influences, appear necessary to render such irritants operative. Among such predisposing causes may be mentioned: i. A deficient supply of healthy blood caused by insufficient or improper food and air, a feeble action of the heart, haemorrhage, anaemia, and the like. 2. The pres- ence of impuriiies or of certain poisons in the blood, such as exist in chronic alcoholism, Bright's disease, diabetes, gout, syphilis, and in lead, mercury and phosphorus poisoning. 3. Deprivation of healthy nerve influence, as from disease or injury of a nerve-centre, or nerve-trunk. 4. Old age. 5. The so-called strumous diathesis. The exciting causes, which are usually spoken of as irritants, may be considered under the following heads : i. Direct violence and physical irritation. 2. Chemical irritants. 3. Micro- organisms — saprophytic and parasitic. Micro-organisms, how- ever, most likely also act by their chemical products. 1. Direct violence and physical irritation. — Under this head are included all forms of mechanical injury ; excessive heat or cold ; electrical stimulation ; the application of strong acids or alkalies, or of irritating products, as croton-oil or mustard ; friction, and tension. All of these are now admitted to be exciting causes. 2. Chemical irritants. — The chemical products of putrefaction would appear to play an important part in the causation of in- flammation. For fermentation or putrefaction to occur, there must be dead animal matter, a sufficiency of water and oxygen, the maintenance of a certain temperature, and the presence of a ferment. This ferment consists of living microscopic organisms, species of bacteria known as saprophytes, which exist in large numbers in the air, water, etc., in short everyvv^here, except per- haps in mid-ocean and above the snow line, and are especially numerous in large cities, hospitals, etc. It is not thought, how- ever, that the inflammation is lighted up by the bacteria them- selves, but by the chemical products which are formed in the process of fermentation or putrefaction, and which soak into the surrounding tissues, acting like any irritant fluid or the poisonous alkaloids. For it has been found that when a fluid swarming with these bacteria {saprophytes) is injected into the blood or connective tissue of a living animal, the bacteria rapidly dis- apjjear without causing inflammation or other ill-effect. Again, if a similar fluid is injected into the peritoneal cavity in such quantities only as to allow of its rajjid absorption, no inflamma- tion ensues. On the other hand, if such a fluid, or even water, is INFLAMMATION. 23 injected in quantities more than can be rapidly absorbed, serum from the blood is effused into it ; and as all the essentials for putrefaction are now present, viz., diluted serum which con- stitutes the dead animal matter, heat, moisture, oxygen, and saprophytic bacteria to act as a ferment, putrefaction ensues. Thus, to sum up, it is inferred from these and s milar experi- ments that the saprophytic bacteria themselves are incapable ^f setting up inflammation ; that they are only able to thrive in dead animal matter, and not in living tissues ; and that it is the pro- ducts of putrefaction, of which they are believed to be the cause, ' that set up the inflammatory process. 3. Micro-organis7ns. — These, which include the various species of micro-organisms, known as pathogenic or parasitic bacteria, play an important role in the causation of most inflammations. But whilst it cannot be admitted that they are the exciting cause of all inflammations, the behef is almost universal that they are important, if not the chief agents in many inflammations, and especially in those inflammations which, because they occur with- out any apparent cause, were formerly spoken of as idiopathic. Thus erysipelas and some forms of osteomyelitis and periostitis appear lo depend upon them, whilst malignant pustule has been proved to do so. They are always found in acute suppurative inflammation. Unlike the saprophytes, the bacteria which are found in all decomposing fluids, and which as we have seen are unable to exist in the living tissues, the parasitic bacteria are not only capable of living in such tissues, but thrive and multiply in them, and whilst doing so give rise to certain irritating chemical products which set up inflammation. Hence their name, infective, parasitic or pathogeiiic bacteria. They not only multiply and spread in the surrounding tissues, setting up inflammation in their course, but also in some instances enter the system by the blood or by the lymph-vessels, where, still multiplying, they poison the body generally, and in consequence of their becoming lodged in the capillaries of various tissues or organs of the body where they further multiply and thrive, set up there a like inflammation. The way in which they enter the body is either by a wound direct, or else by the alimentary or respiratory mucous tract. Where they enter by a wound, it appears that decomposition of the discharge favors their entrance (as in erysipelas occuring in a septic wound), though such is not essential. They or their spores are supposed to exist in the air, water, etc., but in less quantities than the sap- rophytic bacteria, and only occasionally, as, for instance, when a case of specific inflammation to which they give rise is present in the ward, etc. Many micro-organisms, as already mentioned, require oxygen 24 GENERAL PATHOLOGY OF SURGICAL DISEASES. of the air for their development, and are then called aerobic ; whilst others only thrive when protected from access of oxygen and are known as anaerobic. As the various species of bacteria will have to be frequently mentioned, they may be here briefly described. The bacteria belong to the group of protophytes, the simplest of vegetable or- ganisms. They are divided into i, micrococci or spherical bacteria ; 2, bacilli or rod-shaped bacteria \ and 3, spirilla or spiral bacteria. Micrococci are round or oval bodies ; they occur singly or in pairs. When in pairs they are called diplococci, an example of which we find in the gonococcus. Sometimes they form chains, and are then termed streptococci, e.g., streptococcus pyogenes ; or they may occur in grape-like colonies (zooglma masses'), and are then spoken of as staphylococci, the best known being the staphylococcus pyogenes aureus. They multiply by fission or division. Bacilli are rod-shaped microbes ; some of them multiply by spores as well as by fission. Hence a bacillus may at one period of its development be rod-shaped, whilst at another it may be round like a micrococcus. The spores which are developed in the interior of the bacillus are liberated by its destruction, and then if the conditions are favorable, germinate and assume the shape of the fully developed organism. The spores have a greater resistance to external influences, heat and chemicals, than the bacillus from which they are formed. The spirilla are of no surgical interest, and will not be further men- tioned. Both bacilli and micrococci may be divided into {a^ saprophytic, and (/^) parasitic bacteria. {a) The strictly saprophytic bacteria only live on dead organic material or in solutions of the same, and are incapable of thriv- ing in the living tissues. Some species by means of the activity of their protoplasm not only obtain food from the dead organic material and multiply, but cause changes in the fluid in contact with their surface known as fermentation. To this is due the de- composition of serum or of pus retained in a wound, the conver- sion of milk-sugar into lactic acid in the souring of milk in the stomach, and the resolution of urea into carbonate of ammonium and consecjuent production of ammoniacal urine in the bladder. These micro-organisms by their growth and metabolism elaborate substances either within themselves {intracellular poisons) or in the medium in which they are growing, and these substances act as irritants to the living tissues, setting up inflammation, or, if absorbed, give rise to symjjtoms somewhat similar to those pro- duced by the poisonous alkaloids. The short rod-like body always present in myriads in a drop of decomposing fluid was formerly known as bacterium termo, or INFLAMMATION. 2$ the bacterium of putrefaction. More recently it has been shown that not one but many species of micro-organisms were con- founded under the term. Most of these organisms have been but imperfectly investigated and are consequently still unnamed. Other bacteria, instead of setting up fermentation, produce pig- ment, as for example, the bacillus of blue or green pus. (b) The parasitic bacteria reside in living organic material, and derive their food from the fluids of the circulation or from the protoplasm of the living cell. Some of these are only capable of thriving in living tissues {obligatory parasites) ; others, though occasionally found in living tissues, are as a rule found in dead organic material {faciilative parasites). Parasitic bacteria may be divided from a pathological point of view into the non- pathogenic, which exist in the body without doing any harm, and the pathogenic, which produce disease either by their direct in- fluence or by their chemical action. Pathogenic bacteria in- clude : I, those which are capable of attacking a healthy though susceptible organism, as the anthrax bacillus, and 2, those which develop when the life energy of the cells of the organism is de- pressed, or when the tissues in which they live are altered, as the tubercle bacillus. In the former the special properties of the bacteria, and in the latter the predisposition of the organism to attack, are the determining factors. The methods by which bacteria may gain admission to the body and set up inflammation have already been referred to (p. 23). Having gained admission, they may merely affect the tissues at the place of entry, setting up a local inflammation ; or they may extend by the lymphatics to the nearest lymphatic gland, where they may be arrested or pass through it, and thus enter the circulation ; or they may make their way into the small veins, and so gain the circulation at once, and become lodged, according to the nature of the bacteria, in the capillaries of various tissues and organs. Bacteria growing in connection with a mucous membrane may extend along the surface as in diphtheria \ or may be carried from one point to another, as in phthisis, from the lungs to the larynx or intestine. Diseased tissues produced by one kind of bacteria may be secondarily in- fected by another kind ; thus the lung affected by croupous pneu- monia may sometimes be secondarily infected by tubercle bacilU, and the tuberculous tissue by the micrococcus of suppuration. The tissues may be protected against the development of micro- organisms by the normal resistance of the body to the process of disease {natural immunity). Of acquired immunity there have been several explanations offered. Thus it is believed that im- munity may be brought about {a) by the exhaustion of the soil, /. e., the occurrence of a disease once is thought to protect against a 2 26 GENERAL PATHOLOGY OF SURGICAL DISEASES. second attack through the first disease having exhausted the supply of the material which is necessary for the development of the micro-organism of that particular disease ; {/>) by the chemi- cal products formed J>ari passu with the bacteria acting as a poison to the bacteria and preventing their development ; (r) by certain chemical constituents in the blood serum which destroy the bacteria; {d) by the leucocytes collecting around the bacteria, and so killing them; and {e) by the leucocytes and tissue-cells absorbing and destroying the bacteria {phagocytosis). Much has been written of late on the destruction of bacteria by the leucocytes and tissue-cells { phagocytosis) . Metschnikoff and his pupils hold that the leucocytes are endued with a peculiar power of protecting the organism, that they are attracted by the bacteria or their products {chemiotaxis), gather round them, ab- sorb them into their substance, and so digest or destroy them ; and then that the leucocytes {jnicrophages) having thus performed their function of scavengers, are in their turn absorbed by large amceboid cells {macrophages) derived from the tissues, and are in like manner destroyed. Other pathologists hold that the bacteria are first killed or weakened by the chemical products generated by the bacteria or by the disinfecting constituents in the blood- serum, and then only when dead or disabled are absorbed by the leucocytes and tissue cells, and along with the devitalized tissues are in this way got rid of. Amongst the pathogenic bacteria of surgical interest may be mentioned : the anthrax bacillus, the cause of malignant pustule ; the tubercle bacillus found in tubercular disease ; the bacillus of glanders, of leprosy, of actinomycosis, of tetanus, of diphtheria, and of rhinoscleroma : the staphylococcus pyogenes aureus and the streptococcus pyogenes, the organisms found in connection with suppuration ; the streptococcus erysipelatosus and the micrococcus gonorrhoeae. Signs and symptoms of inflammation. — These may be divided into the local and constitutional. The local signs are the well- known redness, heat, pain and swelling, to which may be added disturbance or alteration of function. Except in a typical case, these signs aie not all necessarily present ; on the other hand, the presence of one or more is not always indicative of inflamma- tion. The redness is due to the dilatation of the small arterioles, veins and capillaries, and increased flow of blood to the part ; the darker patches over the general surfiice to the escape of red cor- puscles, and to the blood passing into the veins before the oxyhemoglobin has all been reduced. The redness varies ac- cording to the intensity of the inflammation, being bright in the INFLAJVIMATlON. 2 7 acute, and dull in the chronic variety, and generally assumes a livid hue when suppuration is about to occur. It may sometimes be absent as in inflammation of non-vascular tissues, although present in the vascular area around. It more or less disappears after death. The increased heat is now generally held to be due merely to a greater flow of blood through the part, and not to any generation of heat in the part itself, as the blood coming from it is never hotter than the blood in the left ventricle of the heart. The in- flamed part, however, feels intensely hot and burning to the patient, although the thermometer shows httle actiial increase of heat. The pain, which is due to pressure upon or stretching of the terminal nerve-twigs by the dilated blood-vessels and by the exu- dation, varies in intensity and character, and is nearly always increased by pressure and by the dependent position. It is of a stabbing character in serous membranes, aching in bone, throb- bing when pus is about to form ; more intense when occurring in organs where but slight stretching can occur, as the globe of the eye or the testicle ; and less intense in parts like the axilla, where the tissues are loose. In the eye, as well as pain, there may be flashes of light ; in the ear, noise. The pain is sometimes referred through the nerves to other parts or organs. The swelling, which is caused partly by the increased quantity of blood in the inflamed area, partly by the exudation of leucocytes and serum, and partly by the proliferation of the original tissue elements, is, as might be expected, greatest in lax tissues, as the axilla, and least in the dense and fibrous, as bone or tendon. It is always an important sign in chronic inflammation where there may be but little redness or pain. The disturbance in function, which practically always occurs in an inflamed part, may be illustrated by the inabihty of an inflamed bladder to retain urine, or of an inflamed eye to tolerate light. The constitutional symptoms may be summed up as those of fever. There is a rise of temperature — often preceded by chilU- ness or even a distinct rigor, a quickened pulse, dry skin, furred tongue, loss of appetite, constipation, scanty and high-colored urine, headache, perhaps delirium, and a general feeling of mal- aise. When the inflammation is slight there may be no fever ; but when it is at all intense, or occurs in an important part, the fever is generally considerable, and in septic and infective inflam- mations is by far the most anxious symptom. Inflammatory fever has been divided into the sthenic, asthenic, and the irritative or nervous. In the sthenic the symptoms are acute, the temperature is high (104° or 105°), and the pulse full, strong and bounding. 2 8 GENERAL PATHOLOGV OF SURGICAL DISEASES. In the asthenic the symptoms assume what is called a typhoid character ; the temperature falls, the tongue becomes brown and dry, the lips and teeth are covered with sordes, and the pulse is quick, soft and feeble. . In the irritative there is, in addition to either of the above set of symptoms, delirium, violent in the one case, or low and muttering in others and a general nervous state. The cause of the fever has been variously explained. In simple inflammation it may be due: i, in part to tissue-change caused by the presence in the blood of free fibrin ferment (a substance known to possess pyrogenic or fever-producing properties), which is supposed to be derived from the escaped leucocytes and drained away in the serum from the inflamed part by the lymphatics ; and, 2, in part to disturbance of the heat-regulating centre in the brain, induced either reflexly, through the sensory nerves, as when there is much pain and tension in the inflamed part, or directly, by the action on it of the deteriorated blood. In septic inflammations the absorption of the products of fermentation or putrefaction, as from a septic or ill-drained wound, has no doubt a large share in the production of the fever, which is then spoken of as septic {septic fever, sap?-cEmia) ; whilst in the infective inflammations the presence of micro-organisms is beheved to be the chief factor (see Septiccemia and Pyccmia.') Varieties ok inflammation. — Inflammation may be divided into the acute and chronic according to its intensity and duration ; the acute again into the simple, the septic, and the infective. What has already been said applies chiefly to the acute variety. The chronic is discussed separately later on. Simple or traumatic inflammation is that which remains local- ized to a limited area, and subsides without suppuration as soon as the cause is removed. It is commonly the result of a mechan- ical injury, and may be studied in its simplest form in the healing of an incised wound by the first intention (see Wounds). Should suppuration occur it is now generally held to be due to the presence of certain pyogenic micro-organisms (see Suppwation, p. 38). Septic inflammation depends upon the presence of fermentation or putrefaction in a wound or serous cavity ; it spreads beyond the original seat of injury, and is accompanied by constitutional synii)toms of blood-jjoisoning (septic fever, saprwrnia). The septic j)roducts so'ik into the tissues, where they act like other chemical irritants, and so set up wider and wider circles of inflam- mation, and entering the general blood-stream with the serum which is drained away by the lyiiijjhatics, give rise to septic poi- soning. They do not miilti|)ly in the living tissues, like the micro- organisms producing the infective inflammation to be next de- INFLAMMATION. 29 scribed. Hence as soon as the fermentation or putrefaction can be checked the spreading of the inflammation and septic poison- ing have a tendency to cease. Septic inflammation is often accompanied by suppuration, but this is regarded as a complica- tion depending on the presence of pyogenic micro-organisms (see Suppuration) . Some pathologists include under the term septic all inflammations attended by suppuration and the various specific inflammations, as erysipelas, which are here called infective. The infective variety is also of a spreading character, and de- pends upon the presence of specific micro-organisms {pathogenic bacteria) . Unlike the products of putrefaction these micro- organisms multiply and thrive in the hving tissues and in the blood-stream. They may also under certain circumstances be- come lodged in the lymphatic glands and in the capillaries of distant tissues and organs, where they give rise to inflammations similar to that at the seat of primary inoculation. Like the septic, the infective inflammations are generally accompanied by severe constitutional symptoms. The micro-organisms may enter, it is thought, either through a wound, or through "the respiratory or ahmentary tracts ; and, though not essential, a septic wound favors their admission. (See Infective processes in woujids.) Inflammation also admits of other divisions ; thus it is vari- ously spoken of as traumatic, idiopathic, strumous, syphilitic, gouty, &c., according to its supposed cause ; as adhesive, sup- purative, and ulcerative, according to its termination, &c. The treatment of inflammation may be divided into the Pre- ventive and the Curative. The former will be discussed under the Treat7nent of wounds. Curative treatment. — This must necessarily varj^ according to the character and situation of the inflammation and the type of constitutional disturbance. Here only are given the indications which should guide us in the general management of the case. Our first endeavor where practicable should be to remove the cause. Thus a foreign body in the tissues, such as a thorn in the finger, should be extracted ; tension should be relieved ; a free drain estabHshed for any pent up and decomposing discharges ; exit given to extravasated secretions, as putrid urine and the like ; irritating applications, as strong antiseptics, exchanged for less irritating dressings ; and such constitutional causes as syphihs, gout, &c , treated by appropriate remedies. When the cause can be thus removed and fresh sources of irritation avoided, the inflammation will tend of itself to cease. Where such cannot be ' done, we should in the second place endeavor to prevent the com- plete loss of vitality of the already injured tissues and to restore their healthy nutrition. For this purpose our efforts should be 30 GENERAL PATHOLOGY OF SURGICAL DISEASES. principally directed to controlling the supply of blood to the part, and reducing the blood-pressure in the damaged blood-ves- sels in order to lessen the escape of leucocytes and serum, the pres- sure of which on the vessels and tissues may lead to the death of the part, whilst the tension to which they give rise is a fertile source of fresh irritation and consequently of the continuance of the in- flammation. Further, we should aim at counteracting this inju- rious pressure and tension by facilitating the draining away of the products of inflammation ; whilst we should seek to promote the return of healthy nutrition to the inflamed tissues by endeavoring to remedy such constitutional defects which, as we have seen, by lowering their vitality act as predisposing causes. Thirdly, we should not lose sight of the important indication to relieve pain. And lastly, whilst directing our efl"orts to the treatment of the local inflammation, we must modify our remedies according to the type of constitutional disturbance to which it may give rise. General re?nedies. — The means at our disposal for fulfilHng the above indications are both local and constitutional. In some cases local remedies alone will suffice ; in others constitutional remedies will also be required. t (A) The local may be enumerated as rest, elevation of the part, cold, heat and moisture, local blood-letting, incisions, and astringents. These means should not be used indiscriminately ; those that may at one period be of the greatest benefit, may at another produce the result we are trying to avoid. Rest is one of the most important means we possess in the treatment of surgical inflammation. It should be complete, and as far as possible both functional and physiological. Thus, an inflamed joint should be placed on a splint, an inflamed eye re- ceive no light, etc. Elevation 0/ the />art leWeves swelling and tension by diminish- ing the arterial supply, and promoting venous return, and the draining off" by the lymphatics of the inflammatory exudation. Thus, an inflamed hand should be placed in a sling, an inflamed foot raised on a pillow, etc. Cold, though a most powerful agent in controlling inflamma- tion, is one that requires cautious and seasonable application. It acts by causing contraction of the small arteries, and conse- quently diminishes the supply of blood to the part ; it likewise controls the amoeboid movements of the leucocytes. At the same time when intense it lowers the vitality of the tissues and pro- motes adhesion of the corpuscles and stasis, and as exemplified by frost-bite may destroy the part. It is of the most service in the preventive treatment of inflammation, and for controlling the process in the early stages. Later, when the inflammation is INFLAMMATION. 3 1 fully established, it can only do mischief. Its action should be continuous ; if applied intermittently it tends to increase the in- flammation by the reaction which follows each application. It is best applied in the form of an ice-bag, or by irrigation with ice- cold water, or by Leiter's tubes. Heat and moisture act by causing a general dilatation of the capillaries and free flow of blood through the part. They are especially useful when the inflammation has become fully estab- Hshed, and suppuration is threatened. Under the latter circum- stances they tend to localize the process, and bring the abscess to the surface. They may be applied in the form of boracic or linseed-meal poultices or hot fermentations to which opium and belladonna in some form may be added to soothe and reheve pain. The boracic poultice is made by soaking cotton-wool or lint in a boiling saturated solution of boric acid, or of boroglyceride ( 3j to Oj). The material is then wrung out, applied to the part, and covered by gutta percha tissue, or oil silk. Heat alone may be applied by means of Leiter's tubes, the water being kept heated by Krohne's lamp. Loeal blood-letting xeWtve?, the vessels of the inflamed part, and so removes tension. It may be employed in the form of leeches, wet- cupping, or incisions with a lancet. It is often of great bene- fit, even when not applied directly over the part, as is shown by the relief afforded to an inflamed eye by a leech behind the ear. Incisions are useful in some forms of inflammation, as phleg- monous erysipelas, to relieve tension. They should be made in the long axis of the limb, taking care to avoid miportant struc- tures. Astringents act by constricting the blood-vessels, and are espe- cially useful in inflammations of the mucous membrane of the mouth, nose, urethra, and conjunctiva. (B) Constitutional remedies, like the local, should be used according to the intensity, nature and situation of the inflamma- tion, and the type of the constitutional disturbance. In an ordi- nary case of simple inflammation, beyond a brisk purge, subse- quent regulation of the bowels and secretions by salines, and re- stricting the diet, no special constitutional treatment is required. But when the fever is high, the patient young and vigorous, and the pulse rapid, full, and strong — in short, where the fever is of the sthenic type, antiphlogistic or lowering treatment should be adopted. Where, on the other hand, the patient is weakly or old, or broken down in constitution, and the fever is of a low or asthenic type, a stimulating plan of treatment will be required. Antiphlogistic treatment may be considered under the heads of diet, drugs, and general blood-letting. GENERAL PATHOLOGY OF SURGICAL DISEASES. The diet should be restricted to milk, weak beef-tea, barley- water, arrow-root, and the like. Drugs. — Purgatives determine the flow of blood to the intes- tines, and so relieve the inflamed part. They are not, however, generally employed, except as a brisk purge at the onset of the inflammation, and in gonorrhoea and orchitis, in which they are of considerable benefit. In inflammations of the intestine and peritoneum they should not as a rule be used at all. Diaphoret- ics and diuretics relieve the distended vessels, the former by determining the flow of the blood to the skin, the latter to the kidneys. They are not often employed in surgical inflammations. Aconite in small doses, frequently repeated, is believed to reduce the frequency and force of the heart's action, and is much praised by some. Antimony was formerly much employed, and is still used in inflamed testicle. Mercury, in combination with opium, was once in much favor, and was thought to have a controlling action on the inflammation. It is seldom given at the present day, except in syphilitic inflammation, and as a purgative at the com- mencement of other inflammations. Opium, however, is fre- quently used to relieve pain, and it also seems to have some action in controlling the inflammation. It may be given by the mouth, or in the form of morphia as a subcutaneous injection. Quinine, salicylic acid, and antipyrin are sometimes employed when the temperature is high, as is colchicum in gout, potash and salicylate of soda in rheumatism, perchloride of iron in erysipelas, and hyoscyamus, bromide of potassium, sulphonal, and chloral when there is want of sleep. Bleeding is not often employed in modern surgery, but it is at times beneficial in very acute inflammations in young and pleth- oric subjects. Of late F'G- 2- bleeding has again be- come not so very uncom- mon in the medical wards. I'he surgeon should therefore make himself acquainted with the method of operat- ing. The blood may be taken from one of the veins of the arm, usually the median basilic, as that is the larger vessel, or from the external jugular vein. In bleeding from a vein of the arm {phlchototny), a bandage or tape is carried twice round the arm a little above the elbow, to obstruct the vein, and tied in a Method of holding the lancet in bleeding. {Heath's Minor .Surgery.) CHRONIC INFLAMMATION. 33 bow. Grasping the arm with the left hand, with the thumb steady- ing the vein, the surgeon makes an incision into the vessel, hold- ing the lancet with the blade between his forefinger and thumb, about half an inch from the point, to prevent it penetrating too deeply (Fig. 2). The blood is directed into a graduated bleed- ing-bowl, the flow, if necessary, being increased by the patient making his muscle act by grasping a stick. When sufficient blood has been taken (usually about 10 oz.) the constricting tape is untied, a pad placed over the incision, and the ends of the tape carried across the pad to below the joint, then round the arm, and again over the pad, where they are tied. The stimulating plan of treatment may be considered under the heads of diet, drugs and stimulants. The diet should consist of essence of beef, milk, eggs, milk-puddings, oysters, turtle-soup, and of white fish and minced chops, if solid food can be retained. Of drugs, ammonia and bark, or quinine and iron, will generally be found of most service ; whiht stiniulatits in the form of brandy, the brandy-and-egg mixture, port-wine, champagne, or any other that the patient has been accustomed to take, should be given in divided and measured doses at stated intervals. Stimu- lants increase the force of the heart's action, and so drive the blood through the inflamed part, and maintain the circulation till the crisis has been tided over. The indications for their use are a feeble and frequent pulse, a high temperature, a dry and brown tongue, and general signs of prostration. CHRONIC INFLAMMATION. The pathological process in chronic inflammation is essentially the same as in the acute ; but the dilated vessels appear to lose their tone, and remain dilated for longer periods, and the escape of leucocytes and proliferation of the original tissue elements are continuous. Further, the inflammatory exudation contains less fibrin-forming material and albumen. Like the acute, it may ter- minate in resolution, suppuration or ulceration, but it is much more liable to produce chronic thickening, from the accumulation of the cellular elements in the tissues. It may also terminate in caseation or even calcification. The causes of chronic inflammation are similar to those of the acute, but they appear to act with less intensity and for longer periods. Amongst the predisposing causes must be especially mentioned passive congestion, struma, rheumatism, gout and syphilis. The exciting causes are often very slight and may be altogether overlooked ; whilst secondary causes which may keep up the inflammation for an almost indefinite time frequently come into play. Thus, in chronic joint-disease, though the cause 34 GENERAL PATHOLOGY OF SURGICAL DISEASES. may be but a trivial injury in a rheumatic subject, continual movement, and tension due to the distension of the synovial membrane, may keep up the inflammation for months or years. The presence of miliary tubercle is a frequent exciting cause. Sytiiptoms. — These are also local and constitutional. Of the local signs the redness may be absent, or, if present, may be of a dusky hue, whilst the part is often discolored from pigmentation, due to the disintegration of the colored corpuscles. The pain is less severe than in the acute, often of a dull aching character, and increased on pressure, and sometimes worse at night. The part may be slightly hotter than natural, but at times no increased heat is apparent. Swelling is always a marked sign. Constitutional symptoms may be altogether absent ; generally, however, the patient's health is feeble or below par, or he is strumous, or he has gouty, rheumatic, or syphilitic symptoms. At times there may be some fever when an important organ is affected. Treatment. — The indications are : to remove the cause and all secondary sources of irritation ; to promote the absorption of the inflammatory products ; and to re-establish the normal nutrition o^ the damaged tissues. For this purpose constitutional as well as local means should be employed. Thus, we should endeavor to improve the general health by a careful dietary and the regula- tion of the secretions ; whilst stimulants and tonics should be given where indicated. In the strumous, cod-liver oil, in the syphilitic, mercury or iodide of potassium, in the gouty, colchi- cum, and in the rheumatic, the salts of potash or guaiacum, are especially indicated; whilst residence at the seaside, or at some spa suitable to the diathesis, or a sea voyage should be enjoined. Locally, the means at our command, besides rest of the part are : I, couuter-irritation by blisters, tincture of iodine, and stimulating liniments; 2, friction with mercurial ointment, the oleate of mer- cury or ointments of iodide of lead or cadmium, or by sham- pooing, massage, etc. ; 3, pressure by means of carefully-applied bandages, Scott's dressing, or Martin's bandage, or the ammonia- cum and mercury plaster; 4, the formation oi sctons or issues ; and 5, the application of the actual cautery. Where suppuration threatens, as in chronic inflammation of lymphatic glands, sulphide of calcium may be of service in promoting the rapid breaking down of the caseating mass. It should be given in doses of ]4, to 3/S of a grain. SUPPURATION AND ABSCESS. We have already seen that under some circumstances the in- flammatory process may terminate in the softening and breaking down of the inflamed tissues, infiltration of leucocytes and pro- SUPPURATION AND ABSCESS. 35 liferation of tissue-cells, and consequent formation of pus, sup- puration being then said to be established. This process, whether it occur (i) in the substance of the tissues or organs, or (2) on the free surface of the skin, a mucous or a serous membrane, is practically the same. In the former situation, it is spoken of as circumscribed or as diffuse suppuration, according as it is limited in extent or the reverse ; in the latter situation it is known as purulent exudation or catarrh, or as ulceration, according as the process merely involves the superficial layers of the epithelium, or extends through to the deeper parts. We will first deal with the circumscribed variety of suppuration or abscess, as this is the most familiar example to surgeons. Circumscribed suppuration or abscess. — An abscess may be defined as a circumscribed collection of pus, the result of inflam- mation. It may be acute or chronic. Acute abscess. — ^The formation of an abscess may perhaps best be studied as it occurs in the superficial tissues. We have al- ready seen that an inflamed part is hot, red, swollen, and painful. If the inflammation ends in suppuration, the swelling which was more or less diffuse becomes circuixiscribed and pronounced, the redness localized and more intense, the pain assumes a throbbing character, and a distinct chill or rigor is generally experienced. On pressing lightly with the fingers on the inflamed part a sensa- tion of fluid beneath the skin is felt, and fluctuation is said to be present. If left to nature the abscess makes its way in the direc- tion of least resistance, /. e., generally towards the free surface of the skin, or if more deeply seated, towards a mucous canal, serous cavity, or the interior of a joint. Continuing to take a superficial abscess as our example, one part of the inflamed area becomes more prominent than the rest, and the skin over it red and glazed. The abscess is said to point. The skin will shortly ulcerate or slough, and bursting of the abscess with discharge of the pus will ensue. On the evacuation of the pus either naturally as above, or througJi an incision artificially made, the walls fall more or less together, and the cavity is gradually filled up by granulations till finally only a scar remains. The minute changes concerned in this process are briefly as follows : — The leucocytes which have escaped from the vessels in the way already described, together with the cells resulting from the proliferation of the original tissue elements, aggregate at the focus of inflammation around the micro-organisms, which, if not already present as the cause of the inflammation, have now made their way to the inflamed spot. The tissues, as the result of the devitalizing action of the products of the micro-organisms, undergo what is called coagulation- necrosis, and then softening and liquefaction, and finally disap- 36 GENERAL PATHOLOGY OF SURGICAL DISEASES. Fig. 3. pear among, or are absorbed by, the leucocytes and proliferated tissue-cells which now completely replace them in the form of a mass of small round cells. Some of the cells in the centre of this dense mass being cut off from their nutrient supply by the destruc- tion of the vessels, partly as the result of over-stimulation or over- work in their battle with the micro-organisms, and partly as the result of the action of the metabolic products of the latter, in their turn degenerate and die, and are now found floating in a fluid formed by the liquefied tissues and serous exudation infiltrat- ing the part. The leucocytes and proliferated tissue-cells are known as piis-corpiiscles, the fluid as liquor puris. Thus a cavity is formed containing pus. Meanwhile around the cavity the leucocytes and tissue-cells continue to aggregate and thus form a barrier to the advance of the microbes. New vessels now grow into the mass of small round cells and the abscess-cavity becomes surrounded by a layer of vascular granulation-tissue {the pyogenic zone). The accompanying wood-cut (Fig. 3) illustrates diagram- matically the appear- ance that would be presented by a section through an abscess and the surrounding tissues. In the centre is the abscess-cavity ; around this in the upper half of the diagram are zones representing the inflam- matory changes in vari- ous stages of progress. ' When an abscess en- Jlarges it is simply by the extension of the inflammatory proces-s from zone to zone. The central cavity (Fig. 3) increases by the suc- cessive degeneration of the small round cells, which fall into the cavity and become pus-corpuscles, whilst what was formerly the zone of thrombosis is now converted by the aggregation of the leucocytes and proliferated tissue-cells into the zone of small round cells, the zone of dilated vessels and retarded flow into the zone of thrombosis, and so on to the circumference. Such at least occurs when an abscess spreads uniformly in all direc- tions. Usually, however, it makes its way in the direction of least Diagrammatic representation of the minute changes in the formation and healing of an abscess. The upper half shows abscess enlarging; the lower half abscess healing. SUPPURATION AND ABSCESS. 37 resistance, these changes then occuring chiefly at that part. If an abscess is not opened the tension and the presence of the pus keep up the inflammation, but when the pus is evacuated and all sources of irritation are removed the circulation in the vessels around resumes its normal state. The walls in consequence of the pressure of the surrounding tissues fall more or less into con- tact, and what remains of the cavity is gradually filled up by the growth of the granulation-tissue. The granulation-tissue is de- veloped into fibrous tissue, which in its turn contracts, obliterating the blood-vessels, and is converted into dense cicatricial tissue. In the lower half of the diagram (Fig. 3) are zones representing the various changes in the process of healing. Character of pus. — Pus from an acute abscess in an otherwise healthy person is a thick, creamy, opaque, yellowish-white, shghtly alkaline fluid, with a faintish smell, saltish taste, and a specific gravity of about 1030. If a drop is examined under the micro- scope it is found to consist of a fluid (the liquor puris) and cor- puscles (pus-cells). Some of these corpuscles are globular, slightly granular, and measure uAtj of an inch in diameter, whilst some contain two or three nuclei which are made more evident on the addition of acetic acid to clear up the granular matter. Amongst them may be seen other corpuscles indistinguishable from leucocytes, and exhibiting when examined on a warm stage amoeboid movements. The latter are living leucocytes and tissue- cells, the former leucocytes and proliferated tissue-ceUs which, have undergone death and degeneration. The proportion of dead to living pus-cells varies with the duration of the inflammation. The liquor puris consists of water, albumen, and salts, of which • chloride of sodium is the chief. It coagulates on boiling. Though probably derived in chief part from the exudation of the serum through the vessels, it differs from serum in that it does not coagu- late spontaneously. In acute abscesses the pus contains granular material derived from the rapid degeneration of the tissues, and various species of micro-organisms, usually cocci. If allowed to stand or to decompose in an imperfectly drained abscess cavity, it will be found moreover teeming with the bacteria of putre- faction. Varieties of pus. — Pus is variously spoken of as sauious when it contains blood, curdy when portions of coagulated fibrin are seen floating in it, ichorous when of a watery consistency, viuco- pus when mixed with mucus, and infective when containing path- ogenic micro-organisms. In some instances it has been observed to have a bluish-green color (blue pus), due to the presence of the bacillus pyocyaneus. The Cause of inflammation terminating in an acute abscess. 3S GENERAL PATHOLOGY OF SURGICAL DISEASES. may briefly be said to be the presence of tlie pyogenic micro- organisms in tissues whose vitality has been lowered by the per- sistent action of an irritant. The micro-organisms which appear to be chiefly concerned in the process of suppuration are the Staphylococcus pyogenes aureus and the Streptococcus pyogenes. The Staphylococcus pyogenes aureus is found in inflammations running on to suppuration and abscess, and is always present wherever necrosis of tissue is taking place. The organisms are found gathered in grape-like (Fig. 4) masses, and the growth in an artificial culture is commonly golden-colored, but there are varieties in which the culture is white or lemon-colored {staphylo- coccus alb us, citreus). These organisms occur in suppurating wounds, in pustular inflammations of the skin, in suppuration in bone, in suppurating joints, in acute periostitis and osteomyelitis, in purulent peritonitis and in empyaema and other deep abscesses. They may extend from a wound either by the lymphatics or by the veins and give rise to metastatic abscesses (pyaemia), or they may enter the system through ulcers of the respiratory or digestive tract. The exact point of entry in acute periostitis and osteo- myehtis, ulcerative endocarditis and empysema is uncertain. Fig. 4. Fig. s. Staphylococci. '•' 950. (After Sternberg.) Streptococci, v 1000, (After Sternberg.) The Streptococcus pyogenes is more especially found in suppura- tion attended by phlegmonous or purulent tjedema with a tendency to spread. The organisms occur in chains (Fig. 5). The sup- purations in which they appear to be chiefly concerned may start in a septic wound of the skin, or the puerperal uterus, or on a mucous or serous surface in contact with decomposing substances. The absorption of the chemical products produced by these organisms is very liable to occur, giving rise to general septic SUPPURATION AND ABSCESS. 39 poisoning (septicaemia), or if the micro-organisms themselves also gain access to the circulation, they may become lodged in the capillaries and produce metastatic abscesses, so that the toxic symptoms produced by the absorption of the chemical products may be accompained by metastatic {pyemic') abscesses. The two foregoing micro-organisms, though the chief, are not the only ones associated with suppuration ; other forms of micrococci and even of bacilH may also at times be found in pus. The Strep- tococcus erysipelatosus and the Micrococcus gonorrhoece., which are closely allied to the Streptococcus pyogenes, are referred to under Erysipelas and Gonorrhoea. The Symptoms of an acute abscess are at first those of inflamma- tion, followed, whilst pus is forming, by a chill or rigor and by throbbing pain in the part. The pain, however, usually ceases when suppuration is fully established. The local signs, when the abscess is superficial, are pointing, central softening, and when about to burst, a red and glazed appearance of the skin with sepa- ration of the cuticle. Deep suppuration is often difficult to detect ; deep-seated fluctuation, oedema, subcuticular mottling and tenderness on pressure are then the chief signs ; but puncture with a grooved needle will clear up any doubt. Treatment. — The chief indications are to remove the pus with as little injury to the tissues as possible, to ensure a sufficient drain, and to maintain the parts aseptic. When it is evident that suppuration must ensue, it should be promoted by moist warmth in the form of a large boracic poultice sprinkled with opium or hot poppy fomentations. As soon as fluctuation is detected the abscess should be opened by making a free incision in the most dependent part or where it is pointing, of course taking care to avoid blood-vessels or other important structures in the neigh- borhood. The pus should generally be allowed to flow out of its own accord. To ensured, thorough drain, and to prevent any ten- sion from re-accumulation, the opening should be free and a drain- age tube should be inserted. If the abscess is large a counter opening may be necessary, or the abscess-cavity may degenerate into a sinus. If the drainage is efficient, no harm will ensue if a poultice, the favorite treatment of the older surgeons, be applied. But if the abscess is deep and the aperture small, and there is thus danger of the pus becoming retained and undergoing de- composition, antiseptic dressings or boracic fomentations should be used, as under these circumstances the retained discharge will probably be under some degree of tension, and the granulation- walls of the abscess hence inefficient to prevent absorption. Al- though it is a rule in Surgeiy to open an abscess as soon as fluctuation clearly shows that pus has formed, there are some in- 46 g£ner.\l path(>logy of surgical diseases. stances in which this is especially imperative. Thus an abscess should be opened at once when it is situated in the perineum, the abdominal or thoracic walls, the sheath of a tendon, under deep fasciffi or the peritoneum, in the orbit, near a joint, and in the neck if attended by dyspnoea ; when obstructing some passage ; when caused by the infiltration of urine, fseces, &c., and when a spontaneous opening would produce deformity. Hilton's method, as it is called, of opening an abscess, is very useful when the abscess is situated deeply and amongst important structures, as at the root of the neck or in the axilla. It consists in making an incision through the skin and fascia, and then work- ing gently in the direction of the pus with a director. As soon as pus presents, a pair of dressing-forceps is slid along the groove of the director into the abscess-cavity, the director removed, and the blades of the forceps separated so as to stretch the opening and make a free exit for the pus. The complicatio7is of acute abscess are: i. Haemorrhage from the involvement of a large vessel. 2. The implication of some important part, as the peritoneal cavity, the interior of a joint, (Sec. 3. Degeneration into a sinus or fistula. 4. Blood-poison- ing {saprcEmia, pycBtnia ) . A chronic abscess differs from an acute in that it is formed slowly, is unattended by the ordinary signs of inflammation, and does not necessarily depend upon the presence of the pyogenic micrococci. The contents, moreover, are usually thin and curdy, not thick and creamy like the pus from an acute abscess. In some situations, however, as in the chronic abscess in the sub- cutaneous tissue so familiar to the surgeon, the contents may differ very litde to the naked eye from ordinary pus, and, when the result of tubercular disease, may contain the tubercle bacillus. A chronic abscess is generally formed in connection with carious bone, joint disease, a caseating lymphatic gland, or tubercular de- posit. At times no cause can be discovered. IVheii due to spinal caries a chronic abscess has a tendency to burrow in the tissues, especially in the long axis of the body ; and its walls often be- come condensed and thickened, and lined with a layer of smooth granulations, which give it a velvety and mucous membrane-like appearance, or they may become coated with a thick layer of caseating tuberculous matter. The symptoms are very various, and differ according as the abscess is found in connection with carious bone, a diseased spine, &c., and will be again referred to under the head of Suppuration in Bone, Psoas Abscess, &c. Here it may be stated generally that the chief signs are a fluctuating swelling, often unattended with any sign of inflammation, and the presence of some affection, as spinal caries, that is known to be SUPPURATION AND ABSCESS. 4 1 often associated with abscess. Before a chronic abscess is opened, there are usually no constitutional symptoms ; but subsequently saprophytic bacteria or pyogenic micrococci may gain admission, and long-continued suppuration attended by hectic fever or lardaceous disease of the viscera is very liable to ensue and terminate fatally from exhaustion, renal disease, diarrhoea or hepatic mischief. Diagnosis. — A small chronic abscess in the subcutaneous tissue maybe mistaken for a fatty tumor, an hydatid or other cyst, a blood-extravasation, or a soft solid tumor, and it may be quite impossible to arrive at a correct diagnosis without puncture with a grooved needle. The diagnosis of chronic ab- scess connected with the spine, joints, &c., will be further alluded to in the section on diseases of regions. Terminatiojis. — A chronic abscess, after remaining quiescent for a long period, may take on increased action, and burst either externally, or into a mucous canal, a serous cavity, &c., or the watery portions of the pus may be absorbed, leaving behind a caseous mass, which may either dry up or undergo calcification ; or it may remain in its caseous state for years, and then break down, and set up fresh in- flammation around, and produce what is called a residual abscess. Treatment. — Small chronic abscesses unconnected with diseased bone, joints, &c., may be freely incised and then scraped and sewn up or drained antiseptically. Large abscesses, especially when the result of spinal disease, require very careful manage- ment. If free drtiinage and antiseptic precautions are neglected, and the pus is allowed to undergo putrefaction or fermentation, or pyogenic micrococci gain admission, long-continued suppura- tion and attending, hectic generally follow and frequently termi- nate fatally. Hence, many advise that thi- opening of a chronic abscess should be delayed as long as posssble — /. xtravasation cysts. A. Exudation cysts are formed by exudation or by excessive secretion into cavities which have no excretory duct. Under this head are included Bursse, Ganglia, Cystic Bronchoceles, and Cysts in the ovary due to the dilatation of Graafian follicles. They will be further referred to under Diseases of Bursjc, Ganglia, etc. B. Rkten'I'ion cysts are formed by the retention of the normal secretion and the consequent dilatation of the ducts or acini of the affected gland. They are lined with epithelium ; their walls be- come thickened by fibroid changes ; and the natural secretion is altered by inspissation or by exudadon from the cyst-wall. Three forms are described : i, atheromatous or sebaceous cysts due to RETENTION CYSTS. 99 the dilatation of the sebaceous glands ; 2, mucous cysts formed by the dilatation of mucous glands ; and 3, cysts produced by the distension of special ducts, as the sahvary, lacteal, hepatic, and renal ducts, and tubules of the testicle. 1. Atheromatous or sebaceous cysts (vaefis) occur mostly on the scalp or face, but may be met with on any part of the body, and are often multiple. They do not contain hair follicles, papillae, or other skin elements, thereby differing from the der- moid cysts which they otherwise resemble. Those on the scalp are sometimes hereditary. S(^ns. — They form smooth lens- shaped, semi-fluctuating, movable swellings, often adherent to the skin. They may be distinguished from a fatty tumor by not slipping from under the finger on pressing the edge of the swell- ing, and from an abscess by the absence of signs of inflamma- tion. A small black punctum, the obstructed orifice of the seba- ceous follicle, may, except in cysts of the scalp, generally be discovered on the surface. Secondary changes. — i. The contents of the cyst may undergo decomposition and become extremely offensive. 2. The cyst-wall may become inflamed and suppu- rate, and be thus cured ; or a portion of the wall may escape, and a sinus ensue ; or the wound may heal and the cyst refill. 3. One part may give way, and the sebaceous matter exude, become hardened, and be pushed up from below, and take the form of a horny growth. 4. Granulations may spring up from the interior of the cyst, and exude as a fungating mass resembling an epithe- lioma. 5. They may degenerate into an epithehoma. 6. Their walls may undergo calcification. Treatment. — They may be re- moved by — (a) Dissection, (b) Splitting them, squeezing out the sebaceous matter, and seizing the cyst-wall with forceps and pulling it out. Care should be taken not to leave any of the wall behind, or a troublesome sinus will remain. i^c) Dilating the orifice with a probe, and squeezing out the contents. They are apt, however, to refill when emptied in this way, unless the cyst- wall is also squeezed out or sufficient inflammation is set up to destroy it. 2. Mucous cysts are formed by the dilatation of mucous glands. They occur in the lips, mouth, labia, and other situations where mucous glands exist. In the mouth they constitute one form of ranula. The so-called dropsy of the antrum is generally believed to be due to the dilatation of one of the mucous glands of the lining membrane of that cavity, and the cysts met with at the en- trance of the vagina to a dilatation of Bartholin's glands. The walls of mucous cysts are thinner than those of the sebaceous variety ; the contents are viscid and mucoid in character, and- cholesterine is at times present. Treatment. — Excision of a 100 GENERAL PATHOLOGY OF SURGICAL DISEASES. piece of the wall, and touching the interior with nitrate of silver or other caustic will generally cure them ; if not, the cyst must be dissected out. 3. Cysts formed by the dilatation of special ducts. — As exam- ples of these may be mendoned, dilatation of Wharton's duct {ratiitla), of a lacteal duct {galactocele), and of a tubule of the testicle {encysted hyd?-ocele). For a further account, see Dis- eases of Regions. C. Extravasation cysts are formed by extravasation of blood into closed cavities, as the tunica vaginalis of the testicle {Jiaina- tocele), etc. II. Cysts of New Formation. These are divided into — A. Serous cysts ; B. Blood-cysts ; C. Proliferous compound cysts ; and D. Parasitic cysts. A. Serous or simple cysis are thin-walled cysts, lined with a single layer of endothelium, and containing a sticky serous fluid. They are supposed to be formed by the accumulation of fluid con- sequent upon irritation, pressure, etc., in the lymphatic spaces of the connective tissue, these spaces subsequently becoming fused into a single cavity. Their walls consist of fibrous tissue formed by the condensation of the surrounding connective tissue by the pressure of the fluid. As examples of serous cysts may be men- tioned : adventitious burs?e developed over prominences of bone, some forms of ganglion, and simple cysts in the breast, neck, etc. By some pathologists, however, the serous cysts found in the neck are regarded as congenital formations. Those in the median line are undoubtedly formed by the enlargement of pre-existing bursae, e. g., those about the hyoid bone. B. Blood-cysts or h^ematomata may be subdivided into — i. True blood-cysts, which are most commonly met with in the neck, and consist of thin-walled cysts containing pure blood. Their mode of origin is doubtful, but they appear to have some connec- tion with the veins, since if tapped they often bleed very freely, 2. Cysts, formed by condensation of the tissues around a mass of ex- travasated blood. In such the blood may become absorbed or organized ; or it may break down and disintegrate, or deposit fibrin upon the wall of the cyst ; or suppuration may occur and an abcess ensue. They are common in the scalp {cephalhannatoma) , and on the ear \hcemat07na airris), but may occur in any situation after injury. The extravasation of blood into serous cavaties and into solid tumors is also by some included under Hsematoma ; but such a classification is misleading (see Hcematocele, Sarcotna). C. Proliferous compound cysts are cysts containing growths. PARASITIC CYSTS. lOI They are most common in the breast and ovary, and will be found more fully described under Diseases of the Breast. These cysts are developed in connection with the growth of solid tumors, and must be distinguished from cystic degeneration, which, as has already been shown, is very common in some forms of tumor. In the one case, the cysts, which may be regarded as primary, con- tain growths sprmging from their walls or projecting into them from the growths around. In the other case, the cysts are second- ary, and are produced by the degeneration and softening of the tumor-elements, or by the extravasation of blood into the sub- stance of the tumor. D. Parasitic cysts are such as are formed in the tissues around a parasite. Hydatid cysts only are here described ; for an account of other parasitic cysts, the student is referred to a work on Pathology. Hydatid cysts may occur in any of the tissues or organs of the body, but are most often met with in the liver. They are the cystic stage in the development of the cestode worm, known as the TcBnia echinococcus. This worm in the mature form inhabits the intestine of the dog. Thence the ova may accidentally contaminate food or water, and so gain admission to the human intestine. The ova is then hatched, and the embryo may make its way by the portal vein to the liver, or by other channels to some other part of the body, where it becomes converted into a cyst. The cyst is formed of an external latninated elastic layer and of a lining mem- brane, a parenchymatous layer, composed of cells, granules, and muscle-fibers, and a water vascular system. Around the cyst a fibrous capsule is formed as the result of the irritation of the con- nective tissue. The cyst is filled with a clear or slightly opalescent watery fluid containing a trace of sugar but no albumen. As the cyst enlarges, vesicles or brood capsules are developed from the lining membrane, and in them scolices, or small cyst-Hke bodies fur- nished with four suckers and a crown of booklets, are formed. From the brood-capsules secondary or daughter cysts may be developed, having the same structure as the primary or mother cyst, and in them again tertiary or granddaughter cysts. At times the mother cyst does not contain any vesicles or brood-capsules, and is then called sterile. At other times, as in the shafts of bones, there may be no mother cyst, a condition known as muliilocular hydatids. The cyst may (i) cease to grow, die, and be converted into a putty or mortar-like mass of tissue undergoing in places calcifica- tion ; (2) it may suppurate, or (3) burst spontaneously. The signs of an hydatid cyst of course vary according to the situation of the cyst. All that can be here said is that, when the cyst is in an ac- cessible situation, it gives rise to a tense, elastic, more or less 102 GENERAL PATHOLOGY OF SURGICAL DISEASES. globular fluctuating swelling, of slow growth, in which on percus- sion a peculiar thrill may be felt, the so-called hydatid fremitus. The treatment should be preventive and curative. Preventive treatment. — Seeing that the dog is infected by eating the offal of the sheep and pig, in which the worm resides in its cestode state, and that man is infected by food or water contaminated by the dog's excreta, which contain the ova of the tinea, the dog should be prevented from having access to such food, and an attempt should be made to destroy the worm and its ova. Thus, dogs should be purged and given anthelmintics, whilst their kennels should be scalded, and the excrement buried or burnt. All green food, as water-cress, that runs the risk of being fouled by dogs, should be well cleansed before it is eaten. Curative Treatment. — The cyst should be removed entire where practicable. Where this is impossible, it should be incised, the contents evacuated, and the cavity drained, or better, the true cyst-wall should be shelled off the fibrous capsule, and the latter left to granulate. Aspiration or puncture is highly dangerous, especially in the case of abdominal hydatids. Although many cysts have been thus cured, sudden death, secondary infiltration of the peritoneal cavity with the hydatids, peritonitis, and other accidents have fol- lowed this treatment. When the cyst has suppurated, it should be opened, washed out and drained. III. Cysts of Congenital Origin. Congenital cysts may be formed in various ways : — i. By the inclusion of a portion of the epiblast within the mesoblast {dermoid cysts). 2. By the distension in after life of some loetal structure which has not become obliterated in the course of normal develop- ment ; for example, encysted hydrocele of the spermatic cord developed in an unobliterated portion of the funicular process of the tunica vaginalis, and certain broad ligament cysts developed from the parovarium. (See Testicle, qt'c.). 3. By the inclusion of a blighted ovum in a part of the embryo. Such at least is the origin ascribed to certain cysts containing pieces of bone, cartilage, teeth, etc., occasionally found in connection with the ovary and testicle. Another form of congenital cyst, known as the cystic hygroma, is not uncommon. It consists of dilated lymphatic spaces with a varying amount of fibrous, fatty and naevoid tissue around, being almost solid or quite cystic according to the proportion of the solid elements. Hygromata occur in the neck, axilla, scrotum, etc. Their origin has not at present been satisfactorily explained. Of the congenital cysts, the De?-moid only are described here. Dermoid cysts are cysts in the walls of which are found all the structures constituting the true skin and its appendages, such as DERMOID CYSTS. 103 hair, hair-follicles, sebaceous glands, etc. The contents, which resemble sebaceous matter, consist of the secretion of the glands in the cyst-wall, and of epithelial debris, and frequently of hair. They are often quite unconnected with the skin, and their origin is attributed to the inclusion of a portion of the epiblast in the mesoblast, an explanation which in the region of the neck and face is probably correct, as these cysts are usually formed about the outer angle of the orbit, and in other of the situations at which in the embryo a cleft or fissure exists between the processes from which the face or neck are developed. In some dermoid cysts of the ovary teeth also are occasionally found. The origin of these, as of the dermoid cysts of the testicle, are not so obvious. Signs. — The dermoid cyst so common near the outer angle of the orbit forms a smooth, tense, globular tumor, generally freely movable on the parts beneath. It is always congenital, grows slowly, and though generally small may attain a considerable size. Treatment. — The cyst should be dissected out by an incision through and parallel to the eye -brow, in order that the scar may be as much as possible hidden. At times these cysts send pro- cesses beneath the eyelid, or into the orbit, and they have even been known to perforate the bone and extend into the interior of the skull. Care, therefore, is necessary in their removal. I04 GENERAL PATHOLOGY OF INJURIES. SECTION II. GENERAL PATHOLOGY OF INJURIES. WOUNDS. Wounds are divided into two great classes, the open and the subcutaneoiis. Open wounds. — A wound has been defined as " a solution of continuity in any part of the body, suddenly made by anything that cuts or tears, with division of the skin." Here our attention will be confined to the general pathology and treatment of wounds of the soft tissues. Wounds of special tissues, as bone, muscle, blood-vessels, nerves, etc., will be further referred to under those heads. The PROCESS OF repair in open wounds of the soft tissues differs according as the wound is incised, lacerated, contused, or punctured, and according as it is, or is not, kept aseptic, properly drained, and protected from infective processes. The healing process will, moreover, be influenced by the patient's state of health previous to the wound, and the hygienic conditions under which he is subsequently placed. Let us first take a general view of the process of repair as it occurs in a simple incised wound in a healthy subject. Immediately the wound is inflicted there will be free hemorrhage varying in amount according to the vascularity of the part, probably a spouting of blood in jets from a few larger arteries, and a more or less general oozing from the smaller vessels and capillaries. The hemorrhage from the larger arteries having been arrested, and that from the smaller having ceased spontaneously, the wound, if accurately closed, and kept aseptic and at rest with its surfaces in contact, will unite without suppuration by a process of simple or adhesive inflavimaiion. Thus, the edges of the wound for the first day or two may present a very faint blush of redness extending for a few lines to perhaps in a large wound half an inch or so beyond the incision ; whilst they may be slightly swelled, a little hotter than natural, and ten- der on pressure, but cjuite devoid of pain. I'he redness, swelling and heat, however, may be so slight as to be almost impercepti- ble, or indeed may be said in some instances not to occur. If an attempt were now made to draw the edges apart, they would be found adherent to each other, and a few days later firmly united. PROCESS OF REPAIR IN WOUNDS. IO5 All trace of redness and swelling about the edges will by this time have disappeared, a red streak only remaining to mark the line of the wound. This streak grows paler and paler, till ultimately a thin white line, which in course of time may become hardly perceptible, alone indicates the site of the injury. The above- mentioned process, which should be attended by little or no con- stitutional disturbance, is known as healing by the first intention, and is the one which, other things being equal, is always aimed at by the surgeon in the treatment of wounds. Should, however, the wound not admit of its surfaces being placed wholly in contact, or should it be improperly drained and not kept aseptic, the inflam- matory redness and swelling of the edges, instead of subsiding and disappearing in a few days, will increase and extend for some distance around ; the parts then become tense, there may be throbbing pains, union fails, and suppuration is set up. In the meantime the patient may have a chill or even a distinct rigor; the temperature rises ; the pulse is increased in frequency ; the tongue becomes coated, the skin hot and dry, the urine scanty and high colored, and the bowels confined ; he complains of headache and loss of appetite, and there may be restlessness and want of sleep and perhaps slight delirium {septic traumatic fever). If now a free exit is established for the pus, and further septic changes are prevented, the constitutional disturbance subsides, and the surface of the wound becomes covered with granulations. The granulations gradually fill up the wound, and when the level of the skin or mucous membrane is reached, epithelium slowly spreads from the edges of the wound over the granulations till they are completely covered in. A red scar is thus left at the seat of the former wound, and though this in the process of time assumes a white color, and becomes smaller from the contraction of the fibrous tissue into which the granulations are at length converted, it is of a permanent character. The above method of repair is known as healing by the second intention, or by granula- tion. In wounds where there is loss of substance, so that the edges of the skin cannot be brought into contact, healing by the second intention is the normal method of union. The surface after the hemorrhage has been stopped becomes glazed over, and a reddish serum slowly escapes ; granulations appear, first here and there, and finally over the whole surface of the wound, which is then gradually filled up as described above. In lacerated wounds the same process occurs, the dead portions of the lacerated tissues, howeverj being first thrown off in the form of sloughs. In flap wounds where adhesion by the first intention has- failed, after the surfaces of the flaps have become covered by granulations the two io6 GENERAL PATHOLOGY OF INJURIES. layers of granulations in contact may unite, a mode of healing known as secondary adhesion or union by the third intention. Yet again, when a wound has been sealed by blood or discharges, it may unite either by adhesive inflammation or by granulation, the process being hidden by the scab of hardened blood and dis- charges, on the separation of which the wound is found soundly healed. It is the common method of healing among animals, and is known as healing under a scab, or as it was humorously described by Sir James Paget in his lecture on Surgery, as union by no intention at all. Thus a wound may heal, i, by adhesive inflammation, or by the first intention ; 2, by granulation, or by the second intention ; 3, by secondary adhesion, union of granulations, or by the third in- tention ; and 4, under a scab. These methods of healing may now be studied more in detail. I. Healing by the first intention, or by adhesive inflammation. — Chiefly as the result of the injury inflicted on the tissues by the in- strument making the wound, and to a less extent as the result of exposure to the cold air and it may be of the irritation of strong chemical antiseptics, a simple traumatic inflammation is set up Fig. 22. Fig. 23. ■la* Wir?- mr^ Diagram representing a simple incifed wound, immediately af- ter the incision has been made. Diagram representing an incised wound a few hours after the incision. A. Area of thrombosis — leucocytes mak- ing their way to tlie cut surface. B. Area of dilated capillaries — leticocytes escaping from the vessels into the tis- sues. C. Normal tissues. in the layer of tissue bounding the incision (Fig. 22 and Fig. 23). As a consec|uence, stasis and coagulation of the blood is induced in the divided smaller vessels and capillaries, and thus the hemor- rhage from them spontaneously ceases (Fig. 23). Immediately around there is dilatation of the vessels with retarded flow, and proliferation of the connective tissue cells, escape of leucocytes and liquor sanguinis. These infiltrate the tissues adjacent to the incision, and pass through the cut lymph-spaces on to the raw sur- PROCESS OF REPAIR IN WOUNDS. 107 face of the wound. There coagulation occurs, the fibrin and the entangled corpuscles forming a layer of coaguable lymph between the surfaces of the wound, whilst the serum, at first red from the presence of red corpuscles but subsequently becoming colorless, drains gradually away. It is this coagulable lymph which causes the surfaces of the wound after the first few hours to adhere, or to become glazed if the wound is kept open for some time before the edges are approximated, as was formerly a not uncommon prac- tice. A little further from the line of incision there is the usual inflammatory phenomenon of dilated vessels with accelerated flow (Fig. 23), thus accounting for the faint blush of redness and the slight swelling about the edges of the wound. The coagulable lymph uniting the surfaces of the wound, together with the tissues immediately adjacent to the incision, next become softened and finally replaced by the infiltrating leucocytes and proliferating connective tissue cells which now form a layer of small round cells, welding as it were the surfaces of the wound together (Fig. 24) . The inflammation, like all inflammations of traumatic origin, tends to cease as soon as the cause is removed. Thus in a day or two it subsides, and if a section of the parts were now made, the uniting layer of small round cells could be seen permeated by Fig. 24. Fig. Diagram of an incised wound a day or two after the incision. The sides of the wound united by small round cells. Diagram of an incised wound, a few days after the incision. Loops of capillaries growing out from the old capillaries and making their way amongst the small round cells unit- ing the cut surfaces. A_t the lower part of the figure a loop has united with one from the opposite side. delicate new capillaries stretching across from one side of the wound to the other (Fig. 25). They are generally believed to be produced by loops growing out from the old capillaries, and unit- ing with others similarly produced, and growing out from the capillaries on the opposite side. This vascularization of the uniting layer of cells accounts for the redness of cicatricial line, and for the slight hemorrhage which now occurs if the edges of io8 GENERAL PATHOLOGY OF INJURIES. the wound be drawn forcibly apart. As the capillary circulation is established, the edges of the wound become pale from the col- lateral vessels being now no longer overcharged. The granula- tion-tissue thus formed is at length developed into fibrous tissue, which, like all new fibrous tissue, contracts, obliterating many of the newly-formed vessels. Hence the gradual paHng of the cicatrix, which now becomes practically non-vascular. Healing by the first intention may be prevented by — i. Much contusion of the edges of the wound, with consequent death of the tissues bounding the incision j 2. The presence of aseptic foreign body in the wound ; 3. A greatly lowered vitahty of the tissues, as from broken health, abuse of alcohol, diabetes, bad hygienic surroundings, bruising of the parts, rough sponging, or use of too strong antiseptics ; 4. The parts not being kept at rest, with the surfaces of the wound in accurate apposition; 5. Inefficient drainage, whereby the serum squeezed out from the coagulating material is allowed to collect in the wound and cause tension ; 6. Neglect of antiseptic precautions and consequent de- composition of the serum, or the infection of the wound by some of the specific micro-organisms introduced either at the time it was inflicted or subsequently. Under any of the above circum- stances the inflammation may be kept up, the pyogenic micrococci may gain a footing, and further infiltration of leucocytes and pro- liferation of tissue-elements take place ; the small-cell-exudation uniting the wound then breaks down into pus, the flaps separate, and suppuration is established. Supposing the cause of the in- flammation to be now removed, healing by the second intention will ensue. 2. Healing by second intention. — New vessels grow out among the layers of small round cells forming the exposed surface of the wound, and granulation-tissue is thus formed (Fig. 26). The growth of granulations, other things being equal, exceeds the breaking down of the superficial layers of cells, and the wound is gradually filled up. Epithelium derived from the old epithelium at the edges of the wound gradu- ally spreads over the surface of the granulations ; but new sweat and sebaceous glands, hair folli- cles, papillae and lymphatics, are not formed. The cicatrix, at first red from the abundance of the capillaries in the granulation tissue, becomes pale as these are obliterated by the contraction of Fig. 26. ^^^mm^ Uiagram of Granulating Wound. TREATMENT OF WOUNDS. 109 the fibrous tissue into which the granulation-tissue is converted, and though in the course of time, in consequence of the fibrous contraction, it becomes smaller, a permanent scar will remain. In wounds attended with loss of substance, in which healing by the second intention is the normal process, a traumatic inflam- mation is set up in the tissues immediately adjacent to the surface of the wound, and the conditions for healing being otherwise favorable, a coagulable material, as described above, is formed over the surface, and the serum drains away. Loops of new capillaries, derived from the old, spring up amongst the cells, re- placing the coagulable exudation and softened adjacent tissues, and the wound heals and cicatrizes, as has just been described. Where there is much laceration or contusion of the surface of the wound, the dead tissues are cast off by ulceration in the way men- tioned under gangrene. 3. Healing by the third intention. — When the two layers of granulations covering the flaps of the wound are placed and kept in contact, the capillaries in the one layer meet with those in the other, and so establish a vascular connection between the two flaps, and the heahng of the wound then proceeds in the way de- scribed under union by the first intention. 4. Healing tinder a scab. — The minute changes of healing under a scab require no special description. Treatment of wounds. — The general principles which should guide us in the treatment of wounds will be considered under the following heads : i. Arrest of haemorrhage; 2. Cleansing of the wound and removal of foreign bodies; 3. Drainage; 4. Closing the wound and keeping it subsequently at absolute rest; 5. Pre- vention of putrefaction, fermentation, and infective processes ; and 6. Constitutional treatment. 1. The arrest of hcemorrhage is considered separately at p. 128. 2. The cleansing of the wound and removal of foi'eign bodies, should be done with all gentleness, so as not to bruise the tissues more than can possibly be avoided, their vitality being already lowered by the incision through them. Thus the wound should not be sponged or nibbed more than is absolutely necessary, but a stream of water previously boiled, or if preferred, containing some mild antiseptic, allowed to run through it to wash away any blood-clot, or in the case of accidental wounds any dirt or other foreign substance that may have gained admission. If the wound is deep or irregular, it should be irrigated, care being taken when the skin wound is small, not to cause any forcible distension, for fear of driving the fluid into the interstices of the tissues, where it may act as an irritant and set up inflammation. Foreign bodies, as glass, splinters, bullets, etc., if lodged in the wound, should be picked out by forceps or other suitable instrument. no GENERAL PATHOLOGY OF INJURIES. 3. Drainage. — Where a wound is quite superficial, and in some situations where the parts are very vascular, as about the face, and for moderate-sized wounds, in which the surfaces can be kept in contact by pressure, drainage is not necessary. Such wounds may be completely closed if clean cut and moderately small, or a stitch may be omitted at one end ; or a loop of pewter wire in- serted, but only deep enough to keep the edges of the skin apart at that place. If, however, the wound is large or irregular or lacerated, and the surfaces cannot be kept in contact, efficient drainage of the wound is of the greatest importance. Its object is to promote the free escape of the serum, which, as we have seen, is squeezed out during the first twenty-four hours from the coagulable exudation formed upon the surface of the divided tis- sues as the result of the traumatic inflammation. If this serum is allowed to collect in the deeper parts and irregularities of the v,'ound, it not only mechanically separates the surfaces, and gives rise to tension, a cause in itself of the continuance of inflamma- tion, and hence of the non-healing of the wound, but it is also liable to undergo decomposition and putrefaction, and forms a suitable nidus for the growth of pyogenic micro-organisms. Now the coagulable exudation, being living tissue, resists the agents which determine putrefaction. Not so the serum. In this we have a fluid containing dead animal matter, and as the other con- ditions favorable for decomposition are also present, viz., a tem- perature of about 100°, and a sufficient supply of water and oxy- gen, the addition of a ferment only is required to set it up. If decomposition or fermentation then is suffered to take place through not keeping the wound aseptic, or the pyogenic micro- cocci are allowed to enter, the freshly divided tissues, not as yet sealed by traumatic inflammation, permit the products of decom- position or of the micrococci to soak into the tissues around, set- ting up locally a septic or spreading inflammation, whereby the coagulable exudation, temporarily holding the surfaces of the wound in apposition, is destroyed, and healing by the first inten- tion is prevented. In the meantime the products of decom])osi- tion may pass into the blood, and give rise to the constitutional state known as septic traumatic fever, or if the dose of the poison is large, to saprsemia or septic intoxication ; and this is the more likely to occur if the wound has been closed, so that the decom- ])osing serum is pent up under some degree of tension. If there- fore the wound is very large, and deep or lacerated or irregular, a drainage tube or tubes should be placed in it, and brought out at the most dependent part, the incisions, if the wound is made in an operation, being so planned as to allow as much as possible of a dependent drain. For smaller wounds it may be sufficient to TREATMENT OF WOUNDS. Ill place in them a leash of horsehair or catgut, a piece of gutta- percha tissue, or a strand or two of pewter wire. The drain-tube, if kept in too long, will act as a foreign body, set up inflammation, and give rise to a suppurating sinus along its track. It should therefore be withdrawn as soon as the serum ceases to be squeezed out from the coagulating material — /. e., in from twenty-four to forty eight hours, according to the size of the wound. In large and deep wounds it is better not to remove the tube all at once, as the superficial part of the wound may then heal, and the dis- charge or pus collect in the deepest part ; but to shorten it grad- ually, allowing the wound to soundly heal as it is withdrawn. The drain-tube should consist of red-rubber tubing, varying in calibre according to the size of the wound. It should have lateral holes cut in it to facihtate the escape of the discharge, and should be made thoroughly aseptic by being sterilized or boiled, and then kept in some antiseptic fluid. It had better be passed through the first layer of dressing, and its mouth surrounded by some ab- sorbent material to take up the discharges. Where the wound is deep, the tube should be secured by a safety-pin or by an aseptic thread, lest it slip in, and becoming lost in the depths of the wound, subsequently act as a foreign body. Tubes of decalcified bone have been used in the hope that they would become absorbed, and so prevent the necessity of disturbing the dressings ; but they do not appear to have had the desired effect. Recently a reaction seems to have set in against the use of drains of all kinds. Where they are dispensed with the skin wound is not as a rule tightly closed, and the deeper parts of the wound are maintained in close apposition by means of buried or deep sutures and the application of firm pressure over a thick layer of absorbent and antiseptic dressing. 4. Closure of the wound. — The surface should be placed in contact, and the edges accurately united by suture, strapping, or a bandage. Where the wound involves diff"erent layers of tissue, muscle and fascia should be united, each to each, by aseptic sutures. In uniting the edges of the wound, care should be taken to see that the skin is neither inverted nor everted, and that the sutures, whatever form is used, are only tied sufficiently tight to keep the edges in apposition. All tension should be avoided, as this in itself is a fertile cause of inflammation. The sutures may consist of silver-wire, silk, catgut, silkworm gut, or horse-hair. All kinds have their advantages and disadvantages, and are var- iously required in different cases. Thus, silver-wire is unirritating and perfectly non-absorbent, but causes pain on removal, and, as it is quite unyielding, is apt, from the swelling of the parts, to cause tension and inflammation if left in too long. Catgut is useful in that its deeper parts become absorbed, and therefore does not 112 GENERAL PATHOLOGY OF INJURIES. require removal. For this reason it is often inapplicable, as it gives way too soon. Catgut when chromicized resists absorption for many days, and forms an admirable suture. It is difficult, however, to ensure it being aseptic, and is therefore abandoned completely by many surgeons. Horse-hair is non-absorbent, and is also non-absorbable ; it has the additional advantage of being slightly yielding as well as sufficiently supporting. It is very use- ful when a dehcate suture is required, as in wounds about the face. Silk forms a strong suture, but possesses the disadvantage of being absorbent and thus of becoming saturated with the discharges, so that, if decomposition takes place, it will act as an irritant. Further, unless tied tightly, in which case it is apt to produce tension, it yields too much. At the present day, however, fine silk or china twist is, on the whole, the favorite suture. Sutures may be made aseptic by boiling or by soaking for twenty-four hours in I in 500 perchloride of mercury solution. They should then be kept in absolute alcohol 3 parts and perchloride of mercury solution (i in 200) 2 parts, or they may safely be kept in carbolic lotion (i in 20). The sutures are introduced by various forms of surgical needles, curved and straight, bayonet-spear and probe-pointed (Fig. 27), Fig. 27. Fig. 28. ^^ II - ■■ mil— » Convenient needle- 'Cf Surgical needles and hare-lip pin. the needle being conveniently passed by one of the many forms of needle-holder (Fig. 28). The methods of applying sutures are very numerous. The two chief forms of suture used in ordinary wounds are the interrupted, the suture being tied or twisted at each stitch and cut off short, and the coiitiui/oits, one suture being used throughout without being cut. Among the special forms may be mentioned the twisted, the button, the quilled, the Lembert, the Jobert, the Gely, and the Czerny, which are referred to under those wounds where they are specially indicated. The other methods of closing wounds, as by styptic colloid, iodcformed collodion, and collodion, are useful in wounds about the face, and where the wound is small. Having closed the wound, the parts should be placed as far as is possible at absolute rest, and sup- TREATMENT OF WOUNDS. II3 ported by firm but elastic pressure to insure the deeper surfaces being in apposition. 5. Preveiition of pt(t7-ef actio n^fermeniation, and infective processes occurring in the tvound. — Putrefaction and fermentation are best prevented by thorough asepsis, or by efficiently draining the wound, or by keeping the surfaces in contact by firm pressure, as there is then no material present in the wound wherein decomposi- tion can occur. Antiseptics, viz., agents that are supposed to destroy septic and infective organisms, are adopted by many sur- geons as an extra precaution, and are especially necessar}' where thorough asepsis cannot be insured, or drainage or efficient pres- sure, as in some forms of compound fracture, wounds of joints, etc., cannot be employed. It is questioned by some pathologists, however, if our so-called antiseptics are efficient destroyers of micro-organisms or their spores, unless used so strong that they endanger the vitality of the tissues ; some surgeons trust therefore merely to asepsis, /. e., absolute cleanliness, and have abandoned all antiseptics. But we have to guard, not only against the decomposition of the discharges, but also against the entrance of infective micro- organisms, conveyed by instruments, sponges, the surgeon's or nurse's hands, or by the air when an infectious case is in the ward. The greatest cleanliness therefore is necessary. All instruments should be carefully cleansed after use before they are put away, and before being used again they should be sterilized by boiling them in water or in a one per cent, salt solution, or by passing them through the flame of a spirit lamp, or placing them in the steam sterilizer. Whilst in use they should be placed in some antiseptic solution, as carbolic acid (i in 20) or lysol (2 per cent.). Sponges except new ones had better not be used at all, but Gamgee's absorbent pads, or dabs of cotton-wool, which can be destroyed immediately after the operation. New sponges after cleansing should be kept in carbolic acid (i in 20). The hands of the surgeon should be scrupulously cleaned by thoroughly washing in soap and water, his nails, previously well pared down, being cleansed with an aseptic nail brush. They should be then further purified by dipping them into carbolic acid (i in 40), or corrosive sublimate (i in 1,000). Previous to the operation, the part should be shaved, if necessary, and washed with soap and water for some distance around where the wound is to be made, and afterwards with carbolic acid (i in 20), or corrosive subli- mate (i in 1,000), and where greasy, with ether. An antiseptic dressing should then be applied and kept on till the patient is on the operating table. Before the dressing is removed, towels wrung, out in warm carbolic lotion (i in 20) should be arranged around 5* 114 GENERAL PATHOLOGY OF INJURIES. the 4)art where the wound is to be made, so as to prevent the clothes coming into contact with the wound ; the wetting of the patient's clothes being prevented by placing aseptic mackintosh cloths beneath the carbolized towels. In place of carbolic towels, towels fresh from the sterilizer are preferred by some surgeons. On the removal of the dressing the parts should be again sponged with the antiseptic — carbolic lotion (i in 40), or corrosive sub- limate solution (i in 500). The carbolic spray is now abandoned, and irrigation with corrosive sublimate (i in 5,000), carbolic acid (i in 40), or even boiled water substituted for it. In a work of this character, it would be impossible to attempt any description of the numerous methods of dressing wounds which have been, or are at the present day, in use, and to ade- quately discuss the advantages claimed for them, and the disad- vantages which all of them to a greater or less degree possess. The objects aimed at in the selection of a dressing are : i, that it should be absorbent, so as readily to soak up the discharges drained off from the wound ; 2, that it should promote the drying of the wound ; 3, that it should be antiseptic or aseptic ; and, hence 4, that it should not require frequent changing, since such necessarily disturbs the wound and therefore deprives the tissues of that rest which is so important in promoting physiological re- pair. The materials most frequently used are gauze or cotton- wool, impregnated with sal alembroth or the double cyanide of mercury and zinc, or simply sterilized by dry heat or superheated steam. My own plan is to dress the wound with several layers of moist sal alembroth gauze, over which is placed dry gauze and a thick layer of dry sal alembroth wool. Where the skin is very irritable a layer or two of iodoform gauze is placed next to it beneath the other dressing. Firm compression with a bandage is then applied. The wound is now left absolutely at rest till healing is thought to have taken place. The temperature and pulse are, of course, carefully watched ; and should they indicate any abnormality in the process of healing, or should there be local pain or uneasiness, the wound is looked at and the dressings re-applied. 6. Constitutional treatment. — Whether the wound is received accidentally, or is inllicted in the form of an operation, much of the surgeon's success will depend upon j\idicious constitutional after-treatment ; and, indeed, in the latter case, in great measure also upon the preparation of the patient. Where the wound is large and there has been much haemorrhage, the condition known as shock, and the constitutional symptoms depending upon severe loss of blood, will probably ensue (see Shock and Hcemon-hai^c). For the wound to do well it is important that the patient should VARIETIES OF OPEN WOUNDS. II5 be placed under the best possible hygienic conditions. He should have an abundant supply of fresh air, the secretions should be regulated, and the diet carefully supervised. Thus, he should have at least fifteen hundred cubic feet of air, and this should be changed by efficient ventilation at least three times every hour. The windows, in addition, except in very severe weather, should be opened at regular intervals, in order to thoroughly flush out the room ; but draughts must be avoided, and the temperature of the room maintained at a uniform degree of about 60° F. A horsehair mattress should be employed, and a draw-sheet placed on the bed. The room or ward should be scrupulously clean ; there should be no curtains to the bed and windows, or planned carpet on the floor, and nothing under the bed to interfere with the free circulation of air. The bowels should be kept regular by small doses of confection of senna, or of the compound liquorice powder, or by one of the laxative mineral waters ; the secretion of the skin promoted by washing, which may be done without un- duly exposing or wetting the patient ; and sleep induced, if necessary, by bromide of potassium, bromide of ammonium, paraldehyde, urethane, chloral, sulphonal, or opium, or by sub- cutaneous injections of morphia. The patient must be kept cheerful by books, newspapers, etc. The diet for the first few days should be limited to milk, weak beef-tea, or chicken-broth, and gradually increased if the temperature remains normal, and as the digestive functions regain their power. Where the strength has been much reduced previous to the operation, or the opera- tion has been severe, or the shock marked, or haemorrhage free, or suppuration has ensued, stimulants, varying in amount accord- ing to the state of the pulse, temperature, and tongue are indi- cated. The treatment necessary for the various complications that may attend the heaUng of wounds is given under Inflamma- tion, Suppuration, Erysipelas, etc. As regards the preparation for operation, where this is not one of emergency, the patient should be placed at rest for a few days, and kept cheerful and in good spirits, and put on nourishing but unstimulating diet. In the meantime his digestive, alvine, renal, and cutaneous functions must be regulated by appropriate means, the bowels being cleared the day before the operation by a dose of castor oil or other mild purgative. Where his strength is much reduced by long-con- tinued suppuration or chronic disease, efforts must be made to improve his general health by nourishing diet and the judicious employment of stimulants. Varieiies of OPEN WOUNDS. — Open wounds are divided into incised, lacerated, contused, punctured, and poisoned. Incised wounds are such as have their edges evenly divided and Il6 GENERAL PATHOLOGY OF INJURIES. their surfaces smoothly cut. They are usually inflicted by sharp instruments, and are those commonly made by the surgeon in operating. The danger which is particularly liable to attend them is haemorrhage. Healing is generally accomplished by the first intention, provided the proper means are employed. Treat- ment. — What has been said under the treatment of wounds gen- erally, applies especially to this variety. Lacerated wounds are those in which the tissues forming the surface and edges of the wound are irregularly torn. They are commonly caused by machinery and by the goring and bites of animals. There is usually but little hgemorrhage, in consequence of the vessels being torn rather than cut across. The chief dangers are profuse suppuration, tetanus, saprsemia, erysipelas, and extensive scarring. Healing is generally accomplished by the second intention, the dead portions of the lacerated tissues being first thrown off by ulceration in the way described under Gan- grene. In some situations and under favorable conditions, how- ever, a large part of the wound may heal by the first intention. Treatment. — Special attention should be paid to the cleansing of the wound and establishing a free drain. Any portions of the tissues which have obviously lost their vitality should be cut away. Sutures should not as a rule be applied, but the wound should be dressed by one of the methods before described, and the parts placed at rest. Contused wounds are those in which the tissues forming the surface and edges are extensively bruised. They are usually made with blunt instruments, or with such agents as distribute the force over a large surface. There is commonly considerable ex- travasation of blood amongst the bruised tissues, though usually but little external haemorrhage. The chief dangers are extensive inflammation and sloughing, secondary haemorrhage on the sepa- ration of the sloughs, spreading gangrene, erysipelas or diffuse cel- lulitis, tetanus, and, later, scarring. A combination of laceration and contusion is frequently present. Healing is generally accom- plished by the second intention. The Treatment is similar to that of lacerated wounds. Any portions of skin which have not lost their vitality should be preserved, especially if the wound in- volves the face or scalp. Punctured wounds are those in which the depth is much greater than the breadth. They are usually ])roduced by sharp-pointed instruments, bayonet or sword-thrusts, and stabs. The chief dangers are haemorrhage, penetration of important cavities, as the thorax, abdomen, or a joint, injury of a large blood-vessel or nerve, and subsequently deep suppuration in consequence of the retention of the discharges in the deep portion of the wound. POISONED WOUNDS. II 7 Punctured wounds usually unite by the second intention, owing to the difificulty of keeping the deeper parts of the wound in contact and of preventing the collecting of serum and later of pus. Treatment. — If deep, a drainage-tube should be passed to the bottom of the wound, and gradually shortened as the wound heals. If there is severe arterial haemorrhage which cannot be controlled by carefully applied pressure, the wound must be con- verted into an incised one, and the bleeding vessel treated in the way described under wounds of arteries, veins, etc. For the special treatment required where a joint or visceral cavity has been penetrated, see Injuries of Regions. Poisoned wounds. — Dissection and post-mortem wounds. — Dis- section wounds are of frequent occurrence, but seldom give rise to any serious trouble, unless the body from which the poison is received is fresh, when the risks are similar to those attending wounds received in making post-morte?7i examinations. Fost- jnortem wounds appear to owe their virulence to inoculation with infective micro-organisms which are capable of multiplying in the tissues or in the blood, and so setting up true infective inflamma- tion and blood-poisoning. The micro-organisms are replaced, as the decomposition of the corpse sets in, by the bacteria of putre- faction. Hence, the longer the body has been kept the less dan- gerous the wound, as these bacteria are merely capable of induc- ing a local inflammation, and not a true infective process. The most dangerous wounds are those received whilst examining bodies in which death has recently resulted from septicaemia, pyaemia, diffuse or puerperal peritonitis, and erysipelas. The effects of a wound received in dissection, or in post-mo?'tem inspection, will depend in some degree upon the health of the operator ; if strong and vigorous he is better able to resist the toxic effects than when debilitated by prolonged study or work in a hospital ward. On the other hand, persons acchmatized to the dissecting or post- mortem room are less liable to be affected than those who have but recently been engaged there. The signs, as might be expected from what has been said above, vary considerably, depending, as they do, upon the nature of the poison received from the corpse, and the previous state of the operator's health. Thus : i. A pustule may form at the seat of inoculation, and, after breaking and scabbing, leave a raised, indolent, painful red sore, which may exist for months in spite of treatment. 2. The scratch or wound may become inflamed, the superficial, and, perhaps, the deep lymphatics implicated, and the axillary glands enlarged and painful, this condition being attended by sharp constitutional disturbance, often preceded by a rigor. Suppuration generally occurs at the seat of inoculation, and some- Il8 GENERAL PATHOLOGY OF INJURIES. times also in the axillary glands. The prognosis is usually good. 3. With or without the local signs of the preceding form, severe constitutional symptoms may set in, preceded by a rigor, and rapidly assume a typhoid character. Diffuse suppuration occurs in the axillary glands, and may spread to the neck and side of the chest. The prognosis is very unfavorable, the patient often dying in from one to three weeks, or only recovering after a tedi- ous convalescence, and then, probably, wdth a broken constitu- tion. 4. Diffuse cellular, or cellulo-cutaneous erysipelas, may be set up at the seat of inoculation, attended with the usual constitu- tional symptoms of these affections, and may rapidly spread up the limb and terminate in gangrene and death. The axillary glands in this form are not usually affected. 5. In addition to the local suppuration, a pytemic state, with the formation of metastatic abscesses in various tissues and organs, sometimes occurs. Treatment — Immediately on its infliction the wound should be sucked, and cleansed by a stream of cold water, and bleeding encouraged and absorption prevented by tightly binding the part above the wound. Where the corpse is recent, and death is known to be the result of some infective disease, the wound should be washed in strong carbolic or corrosive sublimate lotion (some recommend its cauterization with caustic potash, or nitrate of silver), and then dressed and protected from further infection. If a wart or indolent sore form, it should be destroyed by nitrate of silver, acid nitrate of mercury, or other caustic, and the patient's health improved by tonics and change of air. If an infective in- flammation be set up, the wound should be freely incised, and any abscess that may form in the axilla, or elsewhere, opened early ; indeed, if there is much tension or brawniness of the parts, inci- sions should be made before pus has formed. The bowels in the meantime should be cleared by a brisk purge, and the strength supported by nourishment and stimulants. Siini^s of insects sometimes cause troublesome local inflamma- tion, which is occasionally of a diffuse character, and where a large extent of surface is stung, as by a swarm of bees, may be attended with symptoms of severe depression. Stings of the throat occasionally occur from swallowing a wasp, and are liable to be followed by oedematous laryngitis. Ti-eatment. — The appli- cation of ammonia will at once relieve pain. Where there is severe depression, ammonia or alcohol must be administered. Scarification, intubation of the glottis, or even laryngotomy, may become necessary in severe stings of the throat. Snake-bites. — The bites of poisonous snakes, other than the adder, are fortunately rare in this country. The bite of the com- CONTUSIONS OR BRUISES. II9 nion adder is seldom fatal. It is attended with much collapse, nausea or vomiting, great pain in the part, swelling of the affected member, subsequent discoloration from blood extravasation, and occasionally inflammation and suppuration. The treatment con- sists in sucking the part where practicable, applying a bandage tightly above the bite to prevent absorption of the poison, and the internal administration of stimulants. The local application of liquor potassse or permanganate of potash, the injection of ammonia into the veins, and excision of the bitten part, are recommended. For an account of the more serious symptoms attending the bite of the cobra and other venomous serpents of tropical countries, a larger work must be consulted. Subcutaneous wounds. — A wound, whether it be of the con- nective tissue, bone, muscle, tendon or other structure, is said to be subcutaneous when the skin or mucous membrane remains intact. Such wounds differ from the open in that they heal by adhesive inflammation v,'ithout suppuration, since as long as the skin or mucous membrane covering the wounded part is un- broken, septic processes are effectually prevented. Moreover, they are attended by but little, if any, constitutional disturbance. They will be further described under Ritptiwe of muscles and tendons, Simple Fractures, etc. Diseases of cicatrices. — The cicatrices left on the healing of a wound are liable to certain affections, which may be enumerated as: — I, painful cicatrix; 2, depressed or contracted cicatrix; 3, warty cicatrix ; 4, thin cicatrices ; 5, ulceration ; 6, keloid, and 7, epithelioma, and more rarely sarcoma. See Ulceration, Tumors, etc. contusions or bruises. Contusions are subcutaneous injuries, occasioned by a crush- ing, pulping or tearing of the tissues, combined with extravasa- tion of blood consequent upon the rupture of the capillaries and smaller vessels of the part. In their slighter forms they constitute the common injury known as a bruise. The effused blood gen- erally makes its way in the cunnective-tissue planes towards the skin, giving rise to the characteristic purplish-black appearance, and, as it later breaks dovvn and becomes absorbed, to a change of colors from bluish-black through dark red to yellowish-green. In severe cases the cuticle is raised into bullge by the eflusion of blood-stained serum beneath it. These bullae, together with the black color of the part, may occasion a close resemblance to gan- grene, from which, however, a contusion may be distinguished by there being no loss of heat or of sensation in the part, and by the buUpe being fixed, and not changing their position on pressure, as. I20 GENERAL PATHOLOGY OF INJURIES. in gangrene. In very severe and extensive contusions, however, the tissues may be so injured as to lose their vitaUty, and gan- grene actually ensue ; whilst in other instances inflammation and suppuration may occur. When the contusion is localized, blood to a considerable amount may be poured out at the injured spot, forming a fluctuating swelling known as a hcematoma. Contusions of muscle, bone, blood-vessels, and nerves, and contusions of the viscera, are considered separately under Injuries of Special Tissues and Organs. Treatment. — Beyond placing the part at rest, and applying an evaporating or a spirit lotion, nothing more as a rule is required, as the extravasated blood presses upon the injured vessels, and so prevents further haemorrhage. Should a hsematoma form, it should on no account be opened, as the blood will usually become absorbed ; whilst, if air be admitted, suppuration will probably ensue. Aspiration, however, when the hsematoma is very large, may occasionally be done with advantage. BURNS AND SCALDS. Burns and scalds vary in their effect according to their depth, extent, situation, and the age of the patient. An extensive though superficial burn on the trunk, head, or face, especially in a child, may be more serious than a deeper but limited burn on the ex- tremities. A burn is usually said to be more severe than a scald, as the fluid producing the latter generally quickly cools and runs off. A scald, however, owes its severity to the large extent of surface usually implicated, and when produced by molten metal or boiling oil, which adheres to the part, is generally very serious. Burns and scalds, when severe, give rise to constitutional as well as local effects. The local effects may be considered under Dupuytren's division of burns into six degrees. These degrees, however, may be variously combined in the same burn. 1ST DEGREE. — Simple erytliema, due to increased flow of blood through the dilated vessels. No tissue destruction ensues, and no scar is left. 2ND DEGREE. — Vesication, due to the exudation from the dilated capillaries of the cutis, causing the superficial layers of the epithe- lium to be raised from the deeper in the form of blebs. No scar is left, as only the superficial layers of the epithelium are de- stroyed, and these are soon reproduced from the deeper layers. Some slight staining of the skin, however, may subsequently re- main. 3RD de(;ree. — Destruction of the cuticle and part of the ti'ue skin. — The epithelium around the hair-follicles, in the sweat- glands, and between the papillae, escapes, and rapidly forms new BURNS AND SCALDS. 121 epithelium over the granulating surface left on the separation of the sloughs. A scar results, but as it contains all the elements of the true skin, the integrity of the part is retained, and hence there is no contraction. It is the most painful form of burn, as the nerve-endings are involved but not destroyed. 4TH DEGREE. — Destruction of the whole skin. — The sloughs are yellowish-brown and parchment-like, and their separation is at- tended by much suppuration. As the nerve-endings are com- pletely destroyed, the pain is much less than in the former degree of burn. The epithelium which covers in the granulating surface is only derived from the margins of the burn, and the resulting scar consists of dense fibrous tissue. Hence the extensive con- traction and great deformity which often result. 5TH DEGREE. — Penetration of the deep fascia and implication of the muscles. — Great scarring and deformity necessarily follow. 6th DEGREE. — Charring of the ivhole limb. — The parts are sep- arated by ulceration in the same way as in gangrene. Constitutional effects. — When the burn is superficial and of small extent, there may be no constitutional symptoms ; and even when it is deep, but limited to one of the extremities, as the foot or hand, they may also be slight. When, however, the burn is extensive, and especially when it involves the chest, abdomen, or head and neck, even although it is only of the first or second degree, the symptoms may be severe, more particularly when the patient is a child. The constitutional effects may be divided into three stages : — i. Shock and congestion. 2. Reaction and inflam- mation. 3. Suppuration and exhaustion. 1ST STAGE. — Shock and congestion. — The shock is often very great, especially when the burn is extensive, and involves the trunk, or head and neck. The patient is pale and shivering, the pulse feeble and fluttering, and the extremities are cold ; he suffers little or no pain, and sometimes passes into a state of coma and dies, the chief post-mortem appearances being congestion of the internal organs, particularly the brain. 2ND STAGE. — Reaction and inflammation. — Reaction comes on from twenty-four to forty-eight hours after the burn. The pulse is full, strong, and rapid, the temperature rises, and there are other symptoms of fever. Inflammation is set up around the burnt part, and there is now danger of the absorption of the septic products derived from the putrefaction of the sloughs which are beginning to separate. The congestion of the internal viscera, so common in the former stage, may run into inflammation ; and pleurisy, pneumonia, peritonitis, or meningitis may supervene and prove fatal. Perforating ulcer of the duodenum, which is generally situated near the head of the pancreas, may now occur, and is said 6 122 GENERAL PATHOLOGY OF INJURIES. to be most frequently met with about the tenth day. It would appear to be more rare, however, than has been generally supposed, since no case has occurred at St. Bartholomew's during the last nine years. It has been attributed to Brunner's glands taking upon themselves the function of the injured glands in the burnt skin, and to the irritation of the vitiated products secreted in the bile and discharged into the duodenum at the bile papilla. 3RD STAGE. — Suppui'ation and exhaustion. — During this stage, which sets in on the separation of the sloughs, there is still a dan- ger of the patient succumbing to inflammation of the viscera, especially the thoracic ; or he may be worn out by hectic and ex- haustion from long-continued suppuration. He is also exposed to the risks of secondary hsemorrhage on the separation of the sloughs and to blood-poisoning from the absorption of septic products, unless the greatest care is exercised to prevent the decomposition of the discharges. On cicitrization occurring, hor- rible deformity may ensue from the contraction of the newly- formed fibrous tissue in the scars. The Treatmeiit must be both local and consdtutional. Local t7-eatment. — The clothes should be removed with the greatest care, so as not to tear off the cuticle ; but undue exposure should be avoided. In burns of the first and second degree the part should be protected from the air and changes of temperature by smearing it with carron oil or vaseline and wrapping it in cotton-wool, the blisters being pricked to reheve tension and to let out the serum. The cuticle, however, should not be removed, as it serves as the best protective. In burns of the third degree, the parts may also be protected by cotton-wool till the sloughs begin to separate. Decomposition of the discharges should then be prevented as much as possible by mild antiseptic dressings. Thus, the surface may be dusted with iodoform ; or eucalyptus oil, boracic lotion, and the like may be applied. Some surgeons put on a charcoal or even linseed-meal poultice. Carbolic acid should not be used, as not only is it too irritating, but there is danger of its being absorbed when the burn is very extensive. When the sloughs have separated, and granulation sets in, the wound may be treated as described under simple ulcer, redundant granula- tions being repressed by nitrate of silver. Skin-grafting is often usefiil in the fourth degree of burns. The fourth and fifth degrees re([uire the same treatment as the third, l)ut during cicatrization, contraction must be as far as possible i)revented by the use of elastic tension, extension-apparatus, sjjlints, etc. Later some forms of plastic operation to overcome the effects of the contraction will often be required. \w the sixth degree, amputation, if a limb is affected, will probably sooner or later be called for. HEMORRHAGE. I23 Constitutional treatment. — If the shock is severe, stimulants in the form of brandy or ammonia should be given according to the state of the pulse, the patient covered with blankets, hot bottles put to the feet, and undue exposure whilst removing the burnt clothes and applying the dressings as much as possible avoided. Opium should be given, especially if there is much pain. As soon as the patient can bear it, fluid nourishment should be substituted for stimulants, as the latter, if given in large quantities, only tend to produce excessive reaction and inflammation. During the second stage, little can be done beyond regulating the bowels and secretions ; lowering treatment is not well borne, at any rate when the burn is extensive and deep, as the patient will then require all his strength to sustain the drain on his system during the casting off of the sloughs and the long suppuration following. The inflam- matory fever, moreover, generally assumes, if it is not so from the first, a low type. A stimulating plan of treatment, rather than a depressing, is therefore necessary. In the third stage, the patient's strength should be supported by abundant nourishment and stimulants. Lightning- and Electric-stroke. — Death may be instantaneous, or the stroke, beyond causing temporary unconsciousness, may do no harm. In some instances, superficial or deep burns, or paralysis of certain nerves, as the optic, auditory, etc., have been produced. Of late effects similar to those produced by lightning- stroke have occurred from contact either with wires through which electric currents of high intensity were passing, or with electro- motor apparatus. Death from contact with such may be due to actual tissue destruction, or to arrest of respiration and asphyxia. In the first case the subject is beyond recovery ; in the latter case death may be only apparent, and artificial respiration continued for some hours may lead to recovery. The treatment consists in applying warmth, artificial respiration, and stimulants whilst the patient is in a state of shock or suspended animation. Rythmical tractions and relaxations of the tongue (the Laborde method of treating asphyxia) should be practiced by seizing the tongue, drawing it out of the mouth and letting it fall back, the process being repeated about fifteen or twenty times a minute. The functions of the nerves if paralyzed have sometimes been restored by galvanism. hemorrhage. In speaking of the treatment of wounds it was stated that our first care should be to staunch haemorrhage. This requires dif- ferent measures according as it is arterial, venous, or capillary. It is therefore first necessary to be able to distinguish between T 24 GENERAL PATHOLOGY OF INJURIES. these varieties. Usually it is quite easy. In arterial h(zmorrhage the blood escapes in jets, the force of which is increased at each systole of the heart, and is of a bright scarlet color. In venous hcemorrhage the blood wells up from the wounded vessel usually in a continuous stream, and is of a dark purplish-red color. In capillary hcemorrhage the blood appears to ooze from all parts of the wound, trickhng down its sides to the deeper parts, where it forms a little pool. In some instances, however, as where arterial blood escapes from a deep and devious wound, it may resemble venous blood in that it flows continuously instead of in jets, and when the patient is partially asphyxiated, as from too large a dose of an anaesthetic, it becomes of a dark color. On the other hand, venous blood exposed to the air in its passage from a deep wound may undergo oxygenation and become bright like arterial. Bleeding from the corpus spongiosum and corpora cavernosa of the penis, or from like tissues consisting of cavernous blood- spaces or numerous small arteries and veins, is sometimes spoken oi 2J=> parenchymatous iiceniorrhage. When haemorrhage occurs in a visceral cavity, as the pleura or peritoneum {internal hcznior- rhage), or into the substance of the tissues of the trunk or ex- tremities {extravasation) , it is known by special signs, and is treated of elsewhere. Constitutional effect of hcemorrhage. — The effect upon the con- stitution of course varies according to the amount of blood lost, and is more marked when the blood is rapidly poured out from a large artery than when it escapes slowly from a small artery or from a vein. In the former case the patient may die in a few minutes of syncope. When the bleeding is less severe the face and general surface become blanched and cold, and the lips and mucous membrane pallid. The pulse is feeble, fluttering and rapid, and at length only to be felt in the larger vessels. The skin is bathed in profuse perspiration, the respiration is sighing, and the mind wanders. These symptoms may end in syncope, convulsions, and death, or the patient may slowly recover, or may suffer from anaemia or functional disturbances for years. If he is old, some secondary disease is apt to be engrafted on this state of anaemia, of which he may die. Children bear the loss of blood badly, but recover rapidly ; the old stand the loss better, but the effect on their constitution is more permanent. Constitutional treatment of hcemorrhage. — When the bleeding has been severe, immediate steps must be taken to prevent fatal syncope ; and after this danger has been tided over, we must then seek to counteract the remote effects produced upon the whole system by the loss of blood, i. Immediate treatment. — Our ef- forts must first be directed to arrest, or at any rate to temporarily HAEMORRHAGE. 1 25 control, the hemorrhage by some of the local measures to be presently described. Having done this, the chief indication is to prevent fatal syncope by ensuring a sufficient supply of blood to the brain to excite the cardiac centre in the medulla oblongata. Thus, the patient should be laid on his back with his head low, his body warmly covered up, and hot bottles placed at his feet and about his trunk ; or if the pulse does not improve, stimulants in small quantities should be administered, by the mouth if he can swallow, otherwise by the rectum or by subcutaneous injection ; whilst in severe cases the legs and arms should be held up, or an Esmarch's bandage apphed to them in order the better to drive the blood to the brain. As a last resource, infusion of a saline solution should be practiced. Where the bleeding is internal or cannot be arrested, stimulants should be avoided, inasmuch as the syncope into which the patient has fallen tends temporarily to stop the bleeding by inducing clotting of the blood in the wounded vessels. If the heart be again roused to action by stimulants and the vessels in consequence become dilated, the clots may be dis- placed, the bleeding re-started, and the last flickering spark of life put out. 2. To counteract the remote ejfects of the loss of blood, fluid nourishment should be given in small quantities, and then eggs, fish, and finally meat. Iron is required to restore the loss of hsematin, and a sea-voyage or prolonged residence in the country is beneficial in overcoming the ansemia. Transfusion of blood and infusion of saline solution into the veins. — Transfusion of blood has long been employed in cases where death is threatened from excessive haemorrhage. It is, however, a dangerous procedure, in that the transfused blood may form clots and thus lead to the plugging of some of the patient's vessels, with possibly fatal consequences. Moreover, it appears that blood is of no more value than an equal amount of any bland fluid, since it has been recently shown that the transfused blood is merely destroyed and absorbed and the blood-pigment passed with the uiine. On the other hand, the infusion of a saline solu- tion has all the advantages of transfusion of blood without its dis- advantages and dangers. A normal saline solution (common salt •7^) ; water Oj) at 99° F. is the most easily prepared, and is best infused into the median basilic vein. The vein is exposed, liga- tured below, compressed above by a clamp, opened, and a glass cannula introduced and secured in situ by a ligature. The cannula is next connected with an irrigator by a rubber tube, and all air having been carefully excluded the clamp is removed from the vein, and several pints (2 to 5) of the solution allowed to flow in. A clean Higginson's syringe connected with the cannula by a rubber tube, will answer the purpose on an emergency very 126 GENERAL PATHOLOGY OF INJURIES. well. The object of the infusion is to raise the blood-pressure in the arteries sufficiently to enable the patient to rally. The pulse should therefore be watched, and the infusion be continued till the object is attained. I have seen the most marvellous effects follow this treatment, and many successful cases have now been reported. It may be repeated if necessary after a short interval. Where the apparatus is not at hand and the case is urgent, a pint of warm water should be injected into the rectum and prevented from escaping. The fluid is rapidly absorbed from the rectum and acts in a similar manner to infusion into the veins, only some- what more slowly. A half-ounce packet of common salt, /. e., sufficient to make four pints of saline fluid, a Higginson's syringe, a glass cannula, and a length of rubber tube, are desirable ad- ditions as suggested by Mayo Robson to the surgeon's bag when severe haemorrhage is likely to occur at an operation. The local treatmeni' of haemorrhage may be considered under the heads of arterial, venous, and capillary haemorrhage. Arterial hemorrhage is spoken of as (i) piimary, (2) re- actionary or recurrent, and (3) secondary. I. Primary hcemorrhage is that which occurs at the time an artery is wounded, whether by accident or surgical operation. 2. Reactionary or recurrent hcemorrhage is that which occurs on the patient recovering from the shock of the wound or operation after the primary haemorrhage has stopped, and may be regarded as a failure in the process for the temporary closure of the vessel. The term recurrent, therefore, should only be applied to haemor- rhage occurring within twenty-four hours of the injury. 3. Secondaiy hcemorrhage is that which occurs any time after the first twenty-four hours, and is due to the failure of the process for the permanent closure of the vessel. The treatment in each case is different. (i) Primary artkrlal h/f.morrhage. — The older Surgeons resorted to very barbarous methods of controlling haemorrhage, such as plunging stumps after amputation into boiling jMtch, or operating with a red-hot knife, and it was not till Nature's method of arresting bleeding had been intimately studied, both in the human subject and by experiments on animals, that the local treatment of haemorrhage was placed upon a scientific basis. It may be best, therefore, first to consider Nature's method of con- trolling hcBmorrhage before describing the surgical measures which have been founded upon it. When an artery of small or moder- ate size is comjjjetely divided, the cut end, in consequence of the injury stimulating the muscular fibres in the middle coat, con- tracts, thus lessening the size of the orifice, and, in the case of the small arteries, com])letely closing it. At the same time, the TREATMENT OF HEMORRHAGE. 127 cut end, owing to the normal elastic tension of the artery, retracts within its sheath, leaving the surface of the latter rough and uneven. The diminution in the size of the orifice retards the escape of blood. The slower current passing over the divided wall of the artery, and the roughened internal surface of the sheath, in con- sequence of this multiplication of points of contact and exposure to the air, coagulates, gradually blocks up the orifice, and fills the sheath around and beyond the retracted end of the artery, form- ing what is called the external clot. The stream having been thus slowed or stopped, the blood inside the vessel also co- agulates, and the coagulation spreading from the clot that blocks up the orifice to the first collateral branch, forms what is called the internal clot (Fig. 29). When the hemorrhage has been severe, two other factors favor the formation of these clots, viz., (i), the enfeeblement of the heart's action induced by the tendency to syncope, and the consequent diminished force with which the blood is propelled from the divided vessel; and (2) the increased ten- j' dency of the blood to coagulate owing to an altera- tion in its composition caused by the absorption of watery fluid from the tissues to make up for the amount of blood lost by the hperaorrhage. Thus the haemorrhage is arrested, and still presuming that the vessel be of a small or medium size, it may not recur, and Nature will permanently close the wounded ves- sel in the way to be presently described. It is only, however, when the vessel is small, that Nature can be thus trusted. When a large vessel is wounded, she is quite impotent to prevent an immediate fatal issue ; whilst if the vessel is of medium size, as the syncope passes off, and the heart again begins to act with vigor, the clots may be washed away and the bleeding recur till fainting once more ensues. In this way bleedings, alternating with tem- porary arrests, exhaust the patient's strength, till he finally suc- cumbs to fatal syncope. The method by which nature permanently closes the vessel is as follows : The clot between the artery and the sheath prevents the artery from dilating on the cessation of the contraction of the muscular fibres of the middle coat \ whilst the internal clot acts, so to speak, as a buffer, and thus prevents the force of the blood- stream being exerted to its full on the end of the vessel while healing is taking place. The injury inflicted on the coats of the vessel by its division sets up a traumatic inflammation. Leucocytes and serum escape from the vasa vasorum of the divided vessel- walls and tissues about the cut end of the vessel, whilst there is Diagram of a wounded ar- tery closed by clots. 128 GENERAL PATHOLOGY OF INJURIES. proliferation of the endothelial and connective tissue cells from the margin of the torn coats of the vessel. The cells thus formed gradually permeate both the internal and external clots so that the end of the artery in a few hours becomes surrounded by a small mass of coagulable lymph. The artery at the same time contracts on the internal clot, which gradually loses its red color as it is invaded by the inflammatory exudation. New vessels grow out from the vasa vasorum of the arterial wall, and from the granulation tissue about the cut end of the vessel, and invade the inflammatory exudation, which has now replaced the internal clot. Thus the internal clot, instead of as at first being merely adherent by its base to the end of the divided artery, is now intimately blended with the arterial walls, forming a plug of vascular granu- lation tissue. The granulation tissue is next converted into fibrous tissue, which gradually contracts and obliterates the newly- formed vessels, till finally the internal clot together>vith the artery is converted as far as the first collateral branch into a firm fibrous cord. Similar changes, in the meanwhile, occur in the external clot, and it is finally blended with the scar-tissue formed by the healing of the wound of the soft parts around the injured artery. When an artery is divided in its continuity, the healing of the distal end is accomplished in a similar manner, except that the internal clot in the distal end is often less perfectly produced, and may not be formed st all. Consequently, secondary haemor- rhage is more frequent from the lower than from the upper end of a ligatured artery. The above description applies chiefly to a complete division of an artery. When an artery is merely punctured, the arrest of haemorrhage will depend upon the size of the vessels, and the size and direction of the puncture. A wound, however small, of the aorta, or vessel next removed in size, will probably be fatal. In a vessel of less magnitude, when the puncture is small, a clot ' forms of an hour-glass shape, thus blocking up the wound, and healing occurs by adhesive inflammation. A somewhat larger wound, when made longitudinally to the artery, may heal in the same way ; but when made transversely to the axis of the vessel, it assumes a diamond shape, in consequence of the elastic tension of the coats, and the haemorrhage will probably not be arrested. The sur(;ical mei hods of arres'j ing HyicMORRHAGE may be con- sidered under the heads of temporary and permanent methods. I. Tempo7'ary methods. — The surgeon, if the bleeding point is within reach, need never fear haemorrhage, as mere pressure with the finger will control it, whatever the size of the vessel, till he can obtain the means of permanently arresting it. The pressure may be made directly on the bleeding point, or between the SURGICAL METHODS OF ARRESTING HEMORRHAGE. 129 wound and the heart ; in the former situation with the finger, Spencer Wells' pressure- forceps (Fig. 30) or the tourniquet;- in Fig. 30. Spencer Wells' pressure-forceps, modified by Morrant Baker. the latter situation with the finger or the tourniquet, the pressure being then made in such a direction as to press the artery against some resisting structure, as a point of bone. The tourniquets employed are various (Fig. 31 and Fig. 32). The rubber tube of the Esmarch's apparatus perhaps answers the best. An im- promptu tourniquet may be made by tying a pocket-handkerchief loosely round the limb, and twisting it up tightly with a walking- FlG. 31. Fig. 32. Signoroni's Tourniquet. Petit's Tourniquet. Stick or umbrella. These temporary means, however, should only be trusted to until more permanent methods can be applied. 2. Permanent methods. — The agents employed for permanently arresting haemorrhage are — i. Cold, 2. Heat, 3. Pressure, 4. Styptics, 5. Cautery, 6. Ligature, 7. Torsion, 8. Acupressure, 9. Forcipressure. I. Cold is only applicable to stopping hemorrhage from small vessels. It acts by causing the muscular coat to contract, thus promoting the coagulation of the blood in the arterioles and ' 130 GENERAL PATHOLOGY OF INJURIES. capillaries. It is frequently employed in the form of cold water or ice to arrest bleeding from the smaller vessels in operation wounds, and is a well-known domestic remedy for checking epistaxis, etc. 2. Heat in the form of hot water is now often employed in place of cold water in large operation wounds, as cold applied to a large surface tends to increase the shock of the operation. The water must be hot (110° to 120°) ; warm water merely en- courages the haemorrhage by washing away the coagula blocking the vessels. Heat, like cold, acts by stimulating the muscular fibres of the vessel to contract. 3. Pressure as a temporary means of arresting haemorrhage has already been mentioned. Firmly apphed to the flaps covering a wound, it is an efficient method of controlling the bleeding from the numerous small vessels necessarily divided in operations. In the form of a plug or tampon it is the best means at our com- mand in certain situations where the artery cannot be secured by more reliable methods, as the rectum, vagina, tonsil, nose, socket of a tooth, interior of bone, etc. It is, moreover, frequently em- ployed to stop haemorrhage from a moderate-sized artery where such can be pressed against a bone, as in the scalp ; whilst in the form of a graduated compress it is especially applicable to wounds of the palmar arch. Pressure acts mechanically by closing the vessel. 4. Styptics arrest haemorrhage by inducing the coagulation of the blood. Those most in use are perchloride of iron, hamamelis, and nitrate of silver. Of the perchloride of iron, the strong liquor and the solid form are the most efficient preparations. Styptics may be most usefully employed in conjunction with pressure in cases where the latter alone has proved ineffectual. The objec- tion to their use is that they are apt to cause inflammation and sloughing of the tissues, and consequently secondary haemorrhage is liable to occur on the separation of the slough. A few years ago a case came under the care of a colleague in which two inches of the median nerve were destroyed by the sloughing fol- lowing the application of perchloride of iron to a wound of the brachial artery. Styptics should never be used where more effi- cient and safer means of arresting haemorrhage can be adopted. A new styptic, consisting of a solution of fibrin ferment (i to 10) to which calcium chloride 1 p. c. has been added, is said to act only on the blood, not on the tissues, and to be perfectly aseptic. It was found by Mr. Wright to be effectual in arresting haemor- rhage after the division of all the veins except the common jugular in a dog's neck. 5. The cautery arrests bleeding in part by causing the muscu- SURGICAL METHODS OF ARRESTING HEMORRHAGE. I3I lar coat of the artery to contract, in part by inducing coagulation of the blood, and in part by charring the tissues and so producing an eschar which checks or prevents the flow of blood. The wound should be first dried by pressure with lint, and then imme- diately touched lightly with the cautery, which should be at a dull red heat, as, if used hotter than this, it simply destroys the tissues without producing the above effects, and the htemorrhage con- tinues. It may be applied in the form of the cautery-iron, which is simply heated in the fire ; but Paquelin's benzoHne cautery and the galvano-cautery are much more convenient. The chief ob- jection to the use of the cautery is that it causes destruction of the tissues around, and on the separation of the resulting eschar secondary haemorrhage is liable to ensue. The cautery should never be used in a clean-cut wound. 6. Ligature is the most reliable method of permanently arrest- ing hsemorrhage, and is the one most frequently employed. Silk, China-twist, whipcord, carbolized and chromicized catgut, kanga- roo-tail-tendon, and ox-aorta are the materials chiefly used as ligatures. Of these chromicized catgut, if rendered aseptic in the way mentioned at page 94, answers admirably for securing the cut ends of arteries in amputation and other wounds. For the ligature of arteries in their continuity, the choice of ligature is still open to question, and will be referred to again under ligature of arteries. Whatever form of ligature is used it should not be too thick, or the internal and middle coats will be unevenly divided or may escape division altogether. At the same time it should be strong enough to resist absorption or softening till the artery is securely sealed. It should be tied tightly till the internal and middle coats are felt to yield, but not so tightly as to cut through the external coat. Messrs. Ballance and Edmunds, as the result of an experimental enquiry on the Hgature of the larger arteries in their continuity, have advocated that two ligatures should be applied so as merely to occlude the lumen of the vessel, without dividing the internal and middle coats. These observa- tions, however, can hardly apply to the ligature of the cut end of arteries in wounds, as unless the ligature is applied tightly to such F"=- 33- there is, obviously, danger of its slipping. An artery is tied in an open wound by seizing the cut end Artery forceps. with nibbed forceps (of which Fig. 33 is one of the best forms), drawing it gently from its sheath, throwing a ligature round it, and then tying the ligature in a reef- knot (Fig. 34, A). Both ends of the ligature are then cut off short. 132 GENERAL PATHOLOGY OF INJURIES. Effects of ligahire. — When a ligature is properly applied the internal and middle coats are evenly and transversely cut through by its pressure. Their cut edges retract and curve within the canal of the vessel, and the external coat, crumpled up and tightly embraced by the hgature, retains the two inner coats in Fig. 34. A. The reef-knot versus B, the granny-knot. Diagram of a liga- tured artery. E. External; M. Middle; and I. Internal coat. L. Ligature. contact with each other (Fig. 35). A clot of conical shape forms in the vessel, extending from the seat of ligature to the first collateral branch, and subsequently becomes adherent by its base to the wall of the vessel. The cut ends of the internal and middle coats unite by adhesive inflammation. When an aseptic ligature is used, and the wound runs an aseptic course, the ligature be- comes embedded in the granulation tissue, and, if of animal material, absorbed, or in the case of silk, encysted. The per- manent closure of the artery is accomplished by the process already described under Nature's Method of controlling hcemor- rhage (p. 126). 7. Torsion consists in seizing the artery firmly with the torsion- forceps (Fig. 36), drawing it gently from its sheath, and twisting it sharply several times in its long axis till the internal and middle coats are felt to yield. 'I'he process resembles the tear- ing across of an artery, such as occurs in the avulsion of a limb. When torsion is successfully jjcrformed, the internal and middle coats are ruptured and bent upwards into the lumen of the Fk;. 36. I'orsion-fortx-ps. .^===> RECURRENT HEMORRHAGE. 133 artery, and the external coat is twisted up into a cone (Fig. 37). A clot then forms, and the artery heals permanently in the way already described. It appears to be a rehable method, but takes a longer _ ^"^" ^''" time in its performance than ligature. XrnnJr 8. Acupressure consists in secur- . /'f — | ing the end of the bleeding artery ^' by pressing it between an acupres- I MWkTwlstccl end sure needle (which resembles a ^^^9 ^-^'^^'y' hare-hp pin) and the tissues, or between the needle and a wire twisted over the needle. This method is scarcely ever used now. Effect of torTion on an artery. 9. FoRciPRESSURE consists in seiz- ing the bleeding artery, and the surrounding tissues if the vessel is small, with Spencer VVells' pressure-forceps, leaving them on a few minutes and then very gently withdrawing them. It is a means often used to control the haemorrhage during an operation, and will even permanently arrest it in the case of the smaller vessels, which are often found not to bleed when the forceps are removed. It is sometimes employed for arresting hseraorrhage from a vessel which from its depth or other cause cannot be tied. In such a case the forceps are left on from twelve to twenty- four hours, and at the end of that time are very gently removed so as not to re-start the bleednig. (2) Recurrent, reactionary, or intermediary HiEMORRHAOE is that which may come on within the first twenty-four hours after a wound as the patient gets warm in bed, and the shock of the operation or injury has passed off. It may be regarded as a fail- ure in the process of the temporary closure of the vessel. It should be noted that the term recurrent is by some authors applied to what is here called secondary haemorrhage. Causes. — I. Slipping of a ligature or displacement of a clot from a vessel, consequent upon the wounded parts not being kept at rest. 2. V/ashing out of a clot from a vessel which it has temporarily plugged, by the increased force of the circulation as the heart re- gains power on the passing off of the syncope or shock. It is not uncommon in large wounds to have some oozing of blood through the dressings ; but this should not be considered as recurrent haemorrhage unless it occurs in unusual quantities, and only then calls for treatment. The soiled dressings having been covered with fresh layers of the antiseptic gauze and wool, the part should be firmly but gently bandaged and then elevated. This failing, the dressings must be removed, and the flaps in the case of an amputation separated, the clots washed away with cold or hot 134 GENERAL PATHOLOGY OF INJURIES. water containing an antiseptic, and any vessel found bleeding, tied. The wound should be then re-dressed and firm pressure applied. (3) Secondary hemorrhage is that which occurs after the period of reaction has passed in consequence of the failure of the process for the permanent arrest of haemorrhage. Cause. — Secondary haemorrhage is due either to the defective formation of the internal clot, or to the failure of union of the in- ternal and middle coats. Either of these, again, may be {a) the result of some fault in the surgical means taken to arrest the primary hccmorrhage, and then in some measure may be said to be preventable ; or {b) the result of some disease of the vessel or constitutional state of the patient, and then may usually be re- garded as non-preventable. These causes may be considered under the following heads : — 1. Defect in tJie ligature or in its application. — {a) An improp- erly prepared animal ligature may become absorbed too soon. {I)) A non-absorbable ligature, if chosen, may be too thick or tape-like, and hence not divide or unevenly divide the internal and middle coats. ('acii{^u^s- ^ ■ i.ood. j^ ^jy^e in time the patient usually recovers. Some merely scrape with a Volkmann's spoon ; others cauterize the wound, after excision or scraping, with chloride of zinc or carbolic acid. Dusting with ipecacuanha powder is highly spoken of by some surgeons. When constitutional symptoms have developed the strength must be supported by fluid nourishment and by stimulants when indicated. Sulphide of soda in ten-grain doses has been recommended on account of the beneficial effect it exercises in splenic fever in animals. Actinomycosis is an infective disease depending upon the pres- ence in the tissues of a micro-organism, the actinomyces. Cause. — 'J'he disease, which is prevalent in cattle, may be trans- mitted to man either directly from the diseased animal, as some- times occurs in cowmen, or indirectly through the mcdimn of un- cooked meat or milk. It may also a])])arcntly be transmitted l)y cereals. A grain of barley has been foimd in several growths. The commonest site of inoculation is through a carious tooth, but the parasite may also gain admission by the alimentary and respi- ratory tracts. ACTINOMYCOSIS. 153 ctinoinj ces — the ray fungus Pathology. — The actinomyces, having entered the tissues, sets up a progressive inflammation leading to the formation of granu- lation-tissue, connective tissue and pus. The pus contains pale yellow, or sometimes white or brown grain?, which are visible to the naked eye when the pus is spread out in a thin layer, the larger grains being about the size of a pin's head. These grains are seen, on microscopical examination, to be made up of fine threads of mycelium, with radiating club-shaped bodies at the periphery. The " clubs " are at times absent and are believed ^'<^ by some, who regard the organ- ism as a species of cladothrix, to be involution forms and not essential to the disease (Fig. 41). - In cattle, the disease affects chiefly the lower jaw, but it has also been met with in the upper jaw, the tongue, the respiratory and alimentary tracts, and in the subcutaneous and intermus- cular tissues. It was formerly included under the names of osteosarcoma, wooden tongue, bone cancer, tubercle, etc. Symptoms. — In the lower jaw it is commonly met with about the socket of a carious tooth. A great deal of thickening occurs in the surrounding bone, and abscesses are formed in the neigh- boring connective tissue. On the opening of the abscesses sin- uses are left leading to the swelling, which is found to consist in part of tough fibrous tissue and in part of soft vascular granula- tion-tissue filling cavities in the bone. The escaping pus contains the grain-like masses of the fungus which are characteristic of the disease. When the disease occurs in bones other than the jaw, it gives rise to a growth with characters similar to those mentioned above. When it begins in the lung it may spread to the pleura and then extend widely in the chest walls. From the intestine it may invade the peritoneum and abdominal walls. In whatever situation it begins, however, it steadily spreads until it kills either by exhaustion or by involving some vital organ. Diagnosis. — The disease perhaps most resembles tuberculous ulceration or a fibro- or myxo-sarcoma attended by profuse sup- puration. The presence of the parasite in the pus will clear up any doubt as to the nature of the disease. Treatment. — The only efficient treatment is the complete re- moval of the growth, whilst it is still local, by excision and scrap- 154 GENERAL PATHOLOGY OF INJURIES. ing. In the lower jaw this has been attended with complete success. When the disease is too extensive to admit of removal, free drainage and antiseptics should be used as palliatives, and iodide of potassium given internally. This drug has been found of great value, especially in cattle. General Infective Diseases. Septic.^isiia OR SEP lie INFECTION. — The term septicaemia is here restricted to the condition known as septic infection ; septic in- toxication, which has hitherto been included under the term sep- ticaemia, has been already described under the head of saprasmia. Septicaemia, in this sense, is an infectious disease due to inocula- tion with a specific virus which multiplies in the blood and is probably of the nature of a micro-organism. Cause. — The essential cause is the introduction of the specific virus into the blood. The virus may be derived from the body of another patient who is suffering from or has died of the disease, and may be conveyed by the hands of the surgeon or nurse, or by imperfectly cleaned instruments, sponges, etc. 'i'he minutest quantity of the poison appears to be sufficient. Pathology. — The post-mortem appearances are similar to those of sapraemia. There is a like condition of congestion of the nerve- centres, gastro-intestinal tract and viscera, with petechiae beneath the serous membranes, and staining of the vessels and tissues. Micro-organisms, both micrococci and bacilli, however, are found in the blood. The serous cavities often contain blood-stained serum, and pleurisy and pneumonia may at times be present. The spleen is generally greatly congested and enlarged. The symptoms are also similar to those of sapraemia ; indeed, it is often impossible to differentiate between them. Septicaemia, however, may be suspected when there is evidence of infection from some source, or the wound is of such a size as to render it impossible for the amount of septic matter necessary to set up septic intoxication to be formed in it. It would, moreover, appear probable that the two diseases may at times coexist in the same subject. Septicaemia begins with a distinct rigor, which may be repeated, followed by a temperature of 103° to 104° or higher. The symptoms, the chief of which are headache, nausea, vomiting, deliiium, and sometimes diarrhaa, may run the same rapid course as in sapraemia, the patient passing into a state of collapse ; or they may be more chronic and less severe in degree though similar in kind, whilst leucocytosis and petechial eruptions of the skin, or bronchitis, pneumonia, pleurisy, or pericarditis may supervene. py^pMiA. 155 Treatment. — Little can be done in the way of curative treat- ment beyond preventing the introduction of more poison by taking the same local means to disinfect the w^ound as were men- tioned under saprsemia. The same good effects, however, must not be expected, as the poison once introduced multiplies indefi- nitely, and hence the disease is almost invariably fatal. Large doses of quinine or salicylic acid or sulphite of potash, however, may be given, whilst the strength should be supported by fluid nourishment and stimulants. Pyemia is distinguished from septicaemia by the formation of secondary {?netastatic) abscesses in various tissues and organs of the body. It received its name on the erroneous supposition that it was due to the entrance of pus into the blood, seeing that it generally originates in connection with a suppurating wound, and is later attended with purulent collections in various parts of the body. By some it is still regarded as a later stage of septi- caemia, as previous to the formation of the abscesses the two dis- eases are often clinically indistinguishable. Recent investigations, however, point to pyaemia being a disease distinct from both septicaemia and sapraemia, and have further made it appear prob- able that the train of symptoms known as pyaemia are due to several different pathological processes. Cause. — The immediate cause is no doubt the entrance of a poison into the blood, and since pyogenic micrococci have been found in the wound, the thrombosed veins leading from the wound, in the blood, the tissues, and the metastatic abscesses, it is now held that these organisms are essential factors in the pro- duction of the condition known as pyaemia. Pyjemia, however, is seldom developed except where the patient is exposed to un- favorable hygienic conditions, amongst which may be especially mentioned overcrowding in ill-ventilated and badly-drained hos- pitals, particularly where a large number of suppurating and foul wounds are congregated together in the same ward ; whilst the general debility induced by insanitary dwellings, poor living, town life, and the abuse of alcohol, in that it lowers the resisting power of the tissues, further predisposes to the disease. Pyaemia is generally developed in connection with a wound which has reached the stage of suppuration and has not been properly drained and kept aseptic. It is probable, therefore, that the septic products entering the system with the pyogenic micrococci further lower the resisting power of the tissues. The micrococci having gained admission to the wound, infect the thrombi, filling the veins leading from it, and are carried away with detached portions of the thrombi into the venous circulation. The emboli become lodged in the capillaries of the tissues and organs, and 156 GENERAL PATH(JLOGY OF INJURIES. being infected with the pyogenic organisms and impregnated with septic ptomaines from the wound, set up suppuration in the tissues around the vessels in which they lodge. In other instances it is believed that the pyogenic micrococci may enter the circula tion in such masses that they are sufficient in themselves without the presence of any clot to plug the small vessels, and here in like manner to cause secondary suppuration. There appear to be, therefore,, two chief elements at work, the pyogenic cocci giving rise to the disseminated suppurations, and the septic ptomaines developed in the wound or generated by the cocci themselves, poisoning the whole system. Pyaemia is especially common after wounds involving bone, owing to the liability of the large patulous veins of bone to become filled with purulent thrombi, portions of which are readily carried away by the blood- stream. Hence the frequency of pyaemia after injuries of the cranium involving the diploe, compound fractures, amputations, and excisions, when antiseptics and drainage are neglected. Again, the poison may be developed in decomposing portions of the placenta left after childbirth, and may then enter the blood by infecting the thrombi in the uterine veins. Or it may be formed in connection with operations on the genito-urinary tract, on account of the difficulty of keeping such wounds aseptic. Pyaemia, moreover, is especially frequent after infective osteo- mychtis and infective periostitis, even before the suppurating cavity is opened and exposed to the outer air. It may also occur in connection with erysipelatous wounds, diffuse cellulitis, and hos- pital gangrene, and sometimes after gonorrhoea, ulceration of the intestines in typhoid fever and dysentery, and ulcerative endo- carditis. Very occasionally pysemia follows the most trivial operation or injury, as the subcutaneous division of a tendon or a portion of fascia. Here it is probably the result of the introduc- tion of micro-organisms at the time of the operation. At times no local source of infection can be discovered ; the disease is then spoken of as idiopathic pycemia, and it is believed that the pyogenic micro-organisms gain admission, as in infective osteo- myelitis, ])eriostitis, and ulcerative endocarditis, through a mucous surface. f'atlwloi:;^}'. — 'j'he post-mortem appearances are similar to those in se[)tic?e:nia, f>/us purulent collections in one or more situations, or disseminated through the body as multiple small abscesses. Thus, there is the same rapid tendency to ])utrefaction, disinte- gration of red blood-corpuscles, staining of the vessels and tissues, minute extravasations {petechice) beneath the serous membranes and in the skin, congestion of the viscera, enlargement of the spleen, and in many cases the presence of micro-organisms in the PY/EMIA. 157 Fig. 42. blood and various tissues and organs. The body is emaciated, and the skin yellowish and earthy in appearance. The purulent collections may be found in the serous cavities, in the viscera, in the joints and indeed throughout the body gener- ally. There may be one or more moderate-sized collections of pus ; or an organ, as the lung, may be riddled by a number of small abscesses varying in size from a pea to a nut. The visceral abscesses are most common in the lungs, then in the liver, and next in the spleen, kidneys and brain. They are situated in the periphery of the organs, /. c, in the situation of the smallest cap- illaries. Where, however, pyaemia follows a lesion of the rectum, the abscesses are generally found in the liver, since most of the blood from the rectum passes first through that organ. The pus is sweet, rarely foetid, and may resemble ordinary pus, or it may be thin and watery. It always contains pyogenic micrococci. When there is a wound it is usually found unhealthy or putrescent, and surrounded by an inflammatory area ; micrococci are present in it. The veins leading from the wound are usually filled with thrombi, which are generally, though not invariably, undergoing purulent softening, and then contain micrococci. Where the pyaemia has originated in infective osteomyelitis, infective periostitis, or in a wound involving bone, the veins in the medulla of the bone, and those leading from the bone are usually also found filled with purulent thrombi. If the affected veins are followed towards the heart, the end of the thrombus will often be seen projecting into the blocd-current in the larger vein at the spot where the smaller joins it (Fig. 42). Lastly, coccus colonies, i. e., collec- tions of micrococci, are found in the various tis- sues and organs. A consideration of the above morbid appear- ances makes it appear probable that the metasta- tic abscesses may be produced in several ways : I. Thrombosis of the veins leading from the wound is set up by one or more of the conditions that commonly produce thrombosis, such as suppuration around a vein, an abscess breaking into a vein, death of the part i'rom which the vein runs, etc. The thrombus becomes impregnated with the septic pro- ducts forming in the wound, and with the pyogenic micrococci introduced from without. The septic and infective changes ex- tend up the thrombus ; portions of the thrombus where it projects into a larger vein are detached by the force of the blood-stream in the larger vein (see P'ig. 42),and are carried away in the blood, Thrombosed vein. The thrombus is seen projecting from the smaller into the larger vein. 158 GENERAL PATHOLOGY OF INJURIES. and become lodged in the capillaries of the lungs or, possibly, escaping through them, in the capillaries of other parts of the body. These emboli, being of a septic and infective nature, in- stead of leading to the changes which follow ordinary embolism, give rise to septic and infective inflammation terminating in sup- puration and abscess {primary embolic abscesses). 2. Masses of micrococci which have gained entrance, either directly through a wound or indirectly through a mucous membrane, as in the case of infective periostitis, osteomyelitis, etc., are carried from the primary seat of disease by the lymphatics or blood-stream, and become lodged in the capillaries of the various tissues and organs. There blood-corpuscles aggregate around them, thus forming a thrombus, which softens and sets up infective inflammation and suppuration. 3. Portions of the softened thrombus in the lung- capillaries become detached, and are carried by the blood-stream to other parts of the body, where they in turn form emboli, which also set up similar infective inflammation and suppuration {^sec- ondary embolic abscesses). 4. The diff'use punUent collections in the serous and synovial cavities are thought as a rule to depend upon the poisoned condition of the blood and the presence of micrococci, not upon emboli. The syvipfoms usually set in with a rigor, generally a severe one, during which the temperature rises to 103°, 104°, or even higher. Profuse sweating follows. The rigors are repeated from time to time. The temperature chart rei)resents the same series of long up and down strokes characteristic of hectic fever, only differing in that the morning temperature in pyaemia seldom reaches nor- mal. The pulse is quick ; the tongue is red 01 glazed, and later, dry and brown ; wasting rapidly sets in ; the skin often assumes an earthy or jaundiced hue ; the face is anxious, perhaps flushed, or pale ; extravasations from the capillaries of the skin occur, pro- ducing petechiae ; and other eruptions, though less common, as patches of erythema, may appear from time to time, with aphthae or ulceration of the fauces. The breath and the exhalations of the body have a peculiar sweet odor, and albumen may be found in the urine. At about the end of a week metastatic abcesses form in various parts, as the lung, liver and joints ; or diffuse suppura- tion may be set up in the serous cavities, and signs of pericarditis, pleurisy, or peritonitis ensue. Diarrhoea sets in, then delirium, and the patient dies exhausted usually during the second week. In the meanwhile, the wound, if one exists, is generally foul and suppurating, though later it may become dry and cease to form pus; in some chronic cases, which are rare, however, the wound may heal. 'J'he prognosis is extremely unfavorable ; acute cases are always fatal, each rigor making the chance of recovery more GLANDERS. 1 59 hopeless. At times, however, the disease may run a chronic course {chronic pyceinia), differing from the acute in degree rather than in kind. Thus the rigors are less frequent or none may occur. The viscera, as a rule, are not affected, and the ab- scesses show a special predilection for the joints. The patient may die after some weeks, or may linger for some months, or very slowly recover after one or more relapses, with probably stiffness of one or more joints. Or he may subsequently die of phthisis, albuminuria, or lardaceous disease. Treatment. — Little or nothing can be done in the way of treat- ment in acute cases, when once the pyjemic process is established, beyond supporting the strength by fluid nourishment and stimu- lants, opening abscesses as they are formed, and placing the patient under the most favorable hygienic conditions possible. Measures should, of course, be taken to drain the wound and render it aseptic if this has been neglected. Quinine in large doses is generally advised, but little must be expected from it. In infective osteomyelitis and periostitis, amputation through the joint above the affected bone should be done if pysemia appears imminent but has not fully declared itself. In chronic cases, when convalescence has ensued, a sea-voyage or residence at Aix- la-Chapelle or other suitable spa may be of benefit. Glanders is a specific infective disease common amongst horses, and occasionally comm.unicated to man by inoculation through a wound or the unbroken mucous membrane. The poison is believed to be a specific form of micro-organism, the bacillus mallei, since this bacillus after several cultivations retains the power of reproducing the disease in the horse. The disease may run an acute or chronic course. It is nearly always acute in man and chronic in the horse. The acute form is characterized : ( I ) by a thin serous discharge, rapidly becoming foul, purulent, and sanious, from the nasal mucous membrane, with enlargement of the submaxillary glands; (2) by a pustular eruption, resemb- ling that of small-pox, on the skin and mucous membrane of the respiratory and digestive tract; and (3) by the formation of circumscribed nodules in the lymphatics of the subcutaneous and muscular tissue, which usually soon break down into abscesses and foul ulcers. These signs are ushered in and accompanied by fever, which rapidly assumes a typhoid type, and is sometimes preceded by a rigor. Symptoms of pneumonia or pleurisy, or vomiting and diarrhoea ensue, according as the respiratory or alimentary tract is chiefly affected, and death usually takes place within a week from saprsemia, septicaemia, or pysemia. In the chi'onic form the constitutional symptoms are less sev'ere, and the patient may linger for months, or even recover. l6o GENERAL PATHOLOGY OF INJURIES. In the horse the disease is spoken of by veterinary surgeons as "/cTny" when the lymphatic vessels and glands are principally affected, the swellings opposite the valves in the Ivmphatics form- ing the so-called '■\farcy-buds ;'' and 2,% glanders, when the disease falls chiefly upon the nasal mucous membrane. In man ihe two processes generally occur together, as above described. Treatment. — Beyond supporting the patient's strength with concentrated fluid nourishment, opening abscesses as they occur, dressing the ulcers antiseptically, and syringing out the nasal chambers with antiseptic lotions, little or nothing can be done, as no treatment appears to have been hitherto of any avail. It has been recently shown that a chemical substance {ina/kin) present in the artificial cultures of the glanders bacilli produces no re- action when injected into the tissues of healthy animals : but when injected into the tissues of animals affected with glanders a decided rise of temperature takes place. A means of making an early diagnosis is thus afforded, and by its use the disease might probably be stamped out of infected stables. Hydrophobia is a specific infective disease, always propagated by inoculation, and probably due to a specific micro-organism. It has received its name from the prominent symptoms which the pharyngeal spasms produce. It is called rabies in dogs because no fear of water is shown, and because in them there may be great excitement. The disease is generally received by man from the dog, occasionally from the wolf, and more rarely from the cat or fox, and by these animals it may be given to horses, deer, etc. The moculation is generally through a bite by which the saliva containing the virus reaches the lymphatics. At times it has occurred through a scratch which has been only licked by the affected animal, and once through making a post mortem exami- nation on a subject who had died of the disease. Of all persons bitten by rabid animals, about 15 per cent, only suffer from the disease, a fact which probably in chief part depends upon the saliva being wiped off the teeth as they pass through the clothes. The most dangerous wounds are those on the face and hands, and on the bare legs of children, the average mortality of bites on the face being as high as 60 to 80 per cent. Multiple and lacerated wounds are naturally most to be feared, as inoculation in them is more likely to take place. Also the nearer the bite is to the central nervous system, the more easily and rapidly does the poison reach the brain and begin to take effect. Indeed the only certain method of jjroducing the disease in animals is by inocula- ti:m under the dura mater. It was the discovery of this fact which enabled M. Pasteur to make his investigations. 'i'he average period of incubation varies from two weeks to six HYDROPHOBIA. l6l months. Although it is said that the incubation period has been as short as two days, and as long as twenty years, two weeks to two years may practically be given as its limits. There are no symptoms during this period. The vesicles or lyssae said to occur under the tongue from the third to th€ ninth day after the bite do not appear to be a constant phenomenon. The virus has no influence on the healing of the wound, the bite of a mad dog healing like other wounds, either by first intention, or if the tissues are badly lacerated, slowly and painfully. Seeing therefore that there are no symptoms during the incu- bation period, and that in the early stages of rabies there are no xvAktA-t.^t post-mortem signs, the only way of ascertaining if the bite is that of a mad dog is to watch the animal. If the dog is killed at once the patient will suffer much mental anxiety. He must wait for three weeks before the point can be determined by inoculation experiments on rabbits, or he may undergo Pasteui's treatment unnecessarily. Moreover, to wait three weeks may be too late for wounds of the face. Every suspected dog, therefore, should be confined in a strong cage. If mad he will show ad- vancing symptoms, and die in three or four days. It is import- tant, therefore, to recognize the symptoms of rabies in the dog. Symptoms of rabies. — The earhest symptoms are restlessness, dulness, and a tendency to shun the light. The dog often roves far and wide, and has a morbid appetite for pieces of stick, hay, stones-, etc. In the next stage he may rush wildly about, biting other dogs, inanimate objects, or men, frequently those to whom he has been previously attached. The appetite is lost ; there is a desire to drink, and the muzzle is put into the water, but none is taken. Finally he becomes paralyzed, the lower jaw begins to drop, the bark changes to a characteristic hoarse howl from pharyngeal paralysis ; next the limbs fail, and finally the muscles of respiration. Sometimes, however, advancing paralysis is the only symptom, the power of barking being then lost. This form of the disease is called dumb rabies. Fost-mortem signs of rabies. — The stomach contains hay, sticks, stones, etc., and its mucous membrane is congested and scattered over with small hceraorrhages. The trachea is congested and may also be dotted over with small haemorrhages. The nervous sys- tem, especially the cord and medulla, show signs of acute myelitis. This begins with an exudation of leucocytes into the sheaths of dilated vessels, then haemorrhage and finally softening. If a portion of the medulla or cord is required for inoculating pur- poses a piece should be placed at once in a 20 p. c. solution of glycerine and ^pt there for three or four days to kill sepiir micro-organisms ; an emulsion is then made and a drop or two 7* 1 52 GENERAL PATHOLOGY OF INJURIES. injected under the dura mater of a rabbit, which will die in from eighteen to twenty-one days, showing first excitement, and then paralysis of the hinder limbs, extending later to the fore-limbs and head. Pathology of hydrophobia. — The ^x\Vi(:v^?\ post-mortetn changes have been found in the medulla, especially about the region of the glosso-pharyngeal, pneumo-gastric and hypo-glossal nuclei, and in the cerebral cortex. They consist in the infiltration of the peri vascular sheaths with leucocytes, thrombosis of the medium-sized vessels, small haemorrhages, and degeneration of the neive cells ; in short, as in animals, of an acute myelitis. The theory now generally held with regard to the pathology of the disease is that the poison, after remaining for a variable time dormant in the wound, multiphes or matures ; and then that either it or its products slowly enter the blood and set up a specific inflammation in the medulla and cerebral cortex, whereby their power of resistance to reflex irritation is diminished or lost. Hence the occurrence of the spasms on the slightest provocation. Finally, that should the patient not succumb to spasm of the glottis or muscles of respiration, the affected nerve-centres be- come exhausted and no longer respond at all to the reflexes necessary to carry on life, and the heart's action in consequence ceases. The nature of the poison is not known, though the be- lief is gaining ground that the disease depends in some way upon a micro-organism, since rod-like bodies have been diseoveled in connection with the haemorrhage lesions in the cerebral cortex, and a micro- organism has been isolated by inoculating fowls with the virus taken from rabid animals. Symptoms of hydropho/>ia. — At first there may be pricking pain, perhaps some redness and tumidity, at the site of the wound, which has generally long since healed. The patient, if an adult, has often much mental anxiety, and with the onset of the symp- toms may become melancholic. As the disease becomes fully developed the symptoms ])oint to disturbance in the medulla, es])ecial]y about the centres for deglutition and respiration. Thus there is increasing dififirulty in sw^illowing in consequence of pharyngeal spasm, and a peculiar click in respiration in conse- quence of spasm of the diaphragm. The pharyngeal spasms are at first only excited by attempts to swallow, but subsequently the sight ot water and the sound of its trickling from one vessel to another, a blast of cold air, or a sudden light, is sufficient to set them up. Swallowing is now quite impossible, and viscid saliva is forcibly hawked up and expectorated about. The spasms which begin in the pharynx extend to the muscles of respiration and then become general ; the pain is agonizing, and the patient TREATMENT OF HYDROPHOBIA. 1 63 may have hallucinations or violent delirium, but often remains sensible of his dreadful condition to the end. Paralysis finally ensues, and death usually occurs from involvement of the respira- tory muscles. The spasms sometimes diminish as the paralysis advances, and the patient may sink into a delusive calm, during which the power of swallowing may be regained. Sometimes the chief symptom throughout is advancing paralysis. Such cases resemble dumb rabies of dogs. Death may be due in the earlier stages to spasm of the glottis or muscles of respiration ; later to paralysis of the muscles of respiration or to exhaustion. Diagnosis. — The into'mittent character of the spasms {clonic spasms), the hallucinations, and the escape of viscid saliva from the mouth, will generally serve to distinguish hydrophobia from tetanus following the bite of a dog, and from false or hysterical hydrophobia. In the latter case, too, the convulsions will cease if the patient is put under chloroform. The prognosis when the disease has once developed is hopeless. There is no authentic case of recovery from hydrophobia. The treatment may be divided into the preventive and paUia- tive. Preventive treatment. — If the patient is seen immediately after the bite, we should endeavor to remove the poison from the wound, or else destroy it. This may be attempted by suction, a procedure which appears to be quite safe provided there is no crack or abrasion about the lips or tongue ; or if at hand, a cup- ping-glass may be applied. The parts should afterwards be ex- cised or thoroughly cauterized, the best caustics being nitric acid, nitrate of silver, caustic potash, and pure carbolic acid. It has been advised that if the wound has already healed when the patient is seen the cicatrix should be cut out ; but it is more than questionable if this procedure is of any value, especially as it ap- pears that if inoculation by M. Pasteur's method is resorted to before symptoms come on, the disease may be effectually pre- vented from developing. Pasteur's treatment. — This consists in obtaining a virus of fixed strength and then attenuating it so that it can be safely inoculated. To obtain the fixed virus the disease is transmitted through a series of rabbits, the period of incubation becoming less and less as the virus increases in intensity, till, after passing through up- wards of eighty rabbits, the period of inoculation is found to be constant and the virus of maximum intensity. A rabbit inoculated with this fixed virus always develops symptoms on the yth day and dies on the loth. To attenuate the virus a portion of spinal cord of a rabbit inoculated with the fixed virus is suspended in a sterilized bottle over caustic potash. As the cord dries the virus 1 64 GENERAL PATHOLOGY OF INJURIES. becomes less virulent, so that after two days' drying a rabbit in- oculated with it dies in from 1 1 to 17 days ; after 7 days' drying from 23 to 29 days; after 11 days' drying from 30 to 35 days; until after 12, 13, or 14 days' drying, its virulence is completely lost. An emulsion is made of 0.5 centigrams of spinal cord in 2 cubic centimeters of sterilized beef-tea, and a drop or two is sub- cutaneously injected under the skin of the abdomen or flank. The cords are used in an ascending series from the 14th or 15th day of drying upwards, until on the 9th day of treatment a cord which has been dried for only 3 days is used. The treatment is continued for 16 days. The above is known as the Simple method. For face-bites a more rapid method has been found necessary to prevent the disease. In this, which is called the Intensive method, a cord of only three days' drying is used on the 6th day, and the treatment is continued with two days' intermission until the 20th day. This method, however, appears to be som.ewhat dangerous, a few patients so treated having died with symptoms of the para- lytic form of the disease similar to that induced in animals by inoculation. Palliative treatment. — When hydrophobia has supervened, all that can be done is to relieve symptoms. Thus the patient should be placed in a darkened room, and every source of irrita- tion that may cause spasm avoided. Opium and morphia should also be given for the same purpose. Chloral, chloroform, eserine, pilocarpine, curare, and many other drugs have been given ; but all are useless, and some, as chloroform and curare, are not unat- tended with danger. Tetanus is a disease in which the voluntary muscles are thrown from time to time into a state of intense spasm, whilst they re- main in the intervals in a condition of constant contraction {tonie spasm). Cause. — Tetanus was formerly attributed to a lesion of the peripheral nerves ; but recent researches have shown that it is an infective disease depending upon a specific virus generated by the growth of a micro-organism {.bacillus ietani). It is especially prevalent in hot climates, and amongst the negro races ; it occurs more often in men than in women, and in military than in civil practice. It is seldom met wdth in this country except in con- nection with a wound, and is especially common after lacerated and punctured wounds and burns ; but it has been known to oc- cur after every kind of wound, from a mere scratch, or the liga- ture of a pile or the umbilical cord, to amj)utation of the thigh or other capital operation. 'J'etanus, however, has been more often observed to occur when the wound, whatever its cause and char- acter, is in a septic condition. Exposure to cold, damp, and TETANUS. ^65 Fig. 43. sudden changes of temperature were believed to influence its production, and where tetanus occurs, as it sometimes does, in- dependently of a wound, were regarded by some as the essential cause. It is more probable, however, that such conditions merely act as depressing agents, and that the micro-organism in these cases gains admission through a scratch or abrasion which has been overlooked, or by absorption through the unbroken mucous or cutaneous surface. Tetanus is inoculable from animal to animal, and probably from animals to man, since a veterinary surgeon has lately died of tetanus after making a post-moriein examination on a horse dead of the disease. Pathology. — But little is discoverable on post-mortevi examina- tion. At times the nerves leading from the wound have been found congested, at other times un- altered in appearance. Hyperaemia of the medulla and cord, exudation in, and degeneration of the grey matter, and haemorrhages in the white columns, have been noted in some cases \ whilst in others noth- ing abnormal in the nerve-centres has been discovered. The older view of the pathology of tetanus was that the disease depended upon a primary lesion of the peripheral nerves, and that the irritation thus produced was conveyed by the in- jured nerve to the nerve-centres, where it became persistent, and continuing after the real cause had been removed, gave rise to muscular spasm in various parts of the body. The modern view is that the disease is due to a specific virus which affects the me- dulla and cord in a way similar to strychnine. The virus {tetanin tetano-toxin) is a chemical compound, but according to the re- searches of Vaillard and Vincent, is neither an alkaloid nor an albumose, but is allied to snake poison. It is generated in a wound by the growth of the tetanus bacillus. When no wound exists it is believed that the virus may gain admission by absorp- tion through the unbroken mucous or cutaneous surface. It is only quite recently that an absolutely pure culture of the bacillus has been obtained (Fig. 43). The bacillus occurs as long deli- cate threads with slightly rounded ends. When sporing, these threads break up into short rods which usually develop a spore at one end, giving them a drum-stick shape. It is anaerobic, and hence rapidly loses its virulence on exposure to air. Its special The tetanus bacillus. X i,ooo. (After Sternberg.) 1 66 GENERAL PATHOLOGY OF INJURIES. habitat would appear to be ordinary earth, thus serving to explain the frequency of tetanus in the wounded who have been allowed to lie on the ground after battles. It has been found in the sur- roundings of horses, the floor of stables, and in soil taken from beneath the floor of hospital wards in which cases of tetanus have occurred. The bacillus only exists in the soil or the wound ; not in the blood or nervous system. The symptoms usually begin by a feeling of stiffness in the mus- cles of the neck ; the patient complains that he is unable to open his mouth widely {trismus), and that his throat feels sore on swallowing. On examination, the muscles of the neck, the mas- seters, and perhaps the abdominal muscles, are found hard and rigid, and the face presents a characteristic expression from the angles of the mouth being drawn slightly upwards by the contrac- tion of the facial muscles. Later, other of the voluntary muscles, e^jecially those of respiration, become affected, and distinct spasms attended with severe pain and varying in duration, occur from time to time. The spasms are induced by the slightest irritation, a breath of air, the least noise, the merest touch ; and the remis- sions become shorter, or only partial, as the disease is fully estab- lished. During the spasms the face assumes an expression of in- tense anguish {?isus sardoiiici/s), the respirations and pulse are quickened, and the body is variously contorted. Thus, when the spinal muscles are chiefly affected the back becomes arched, so that in severe cases the patient rests only on his head and heals {opisthotonos) ; more rarely the body is bent forward, being rolled upas it were like a ball {onprosthotonos) ; whilst still more rarely it may be drawn to one or other side {plcurosthotouos). The skin is bathed in perspiration, the urine concentrated and high colored, and the bowels obstinately confined. The temper- ature may remain normal, or be but slightly raised ; though some- times shortly before death it runs very high, and has been known to register 112° Fahr. 'Jlie patient is unable to sleep, but the intellect continues clear to the end. Death may occur from spasm of the glottis, spasm of the respiratory muscles, or from exhaustion or syncope. Recovery hardly ever takes place when the symptoms are acute, but if the ])atient survive till the twelfth day the prognosis is more favorable, and becomes more and more so every day. Diagnosis. — From strychnine jjoisoning and hydrophobia, tetanus is distinguished by the spasms being of a tonic instead of a clonic character, and further from hydrophobia by the absence of hallucinations and the discharge of viscid saliva, signs which are characteristic of that affection. Treatment. — Hitherto the treatment has consisted in attempt- ing to tide the patient over the first few days, in the hope that the TREATMENT OF TETANUS. 167 affection might become less acute and gradually wear itself out. Thus little or nothing could be done beyond supporting the strength with fluid nourishment, administered by the rectum, if the patient is unable to swallow, and preventing the spasms as much as possible by the most absolute quiet, the avoidance of all sources of irritation, the employment of such sedatives as chloral or opium, and relieving the constipation by purgatives and ene- mata. Curara, Indian hemp. Calabar bean, eserine, and numerous other drugs internally, and subcutaneous injections of carbolic acid (}■ of a grain), paraldehyde, pilocarpin and urethane, have all had their advocates, and cases have been reported in which suc- cess was attributed to their use. The treatment of tetanus, how- ever, has through the recent researches of Behring, Kitasato, Tizzoni, Cantani, Roux, Vaillard, and others, been placed on a different footing, and the injection of the tetanus antitoxin, with the excision of the wound, although success has not yet been met with in any case that might not possibly have otherwise re- covered, may be looked upon as the only rational treatment. It has been found by these observers that the blood serum of ani- mals rendered immune to tetanus by previous injections of the tetanus-poison i^tetano-toxin) taken from a wound or from artificial cultures of the bacilli, possesses the power when injected into another animal of destroying the toxic properties of the tetano- toxin, or of conferring immunity on the animal even though twenty or thirty times the amount sufficient to kill be injected. In an ordinary case of tetanus, however, the injection of the an- titoxin is not sufficient, in that fresh doses of the poison are con- tinually being generated by the bacilli in the wound, and absorbed into the system. On the earliest signs of tetanus, therefore, the wound should be freely excised or amputation performed before the antitoxin treatment is begun. The antitoxin which is ob- tained by evaporating the serum to dryness in vacuo, in which state it can be kept indefinitely, should be dissolved in ten times its weight of pure distilled water, and injected subcutaneously into any part of the body, preferably the abdominal walls or the inner part of the thigh. The dose will depend upon the severity of the case and the period of the disease at which the treatment is be- gun. For a case of moderate severity, it is recommended to use 23^ grammes as a first injection and half a gramme daily for the next four days. In a severe case, and in one in which treatment has not been begun until some days after the symptoms have come on, 4^4 grammes may be injected at once, and \-2, gramme to i gramme used subsequently, according to the effect of a first dose. In preparing and injecting the antitoxin, care must be taken that it does not come into contact with chemical antiseptics or heat, since both impair its action. 1 68 INJURIES OF SPECIAL TISSUES. SECTION III. INJURIES OF SPECIAL TISSUES. INJURIES OF BONES. Fraciures. — A fracture may be defined as a sudden and forcible solution of continuity of a bone. The Causes of fracture are predisposing and exciting, i. The predisposing causes may be enumerated as senile atrojjhy, fatty degeneration, rickets, mollities ossium, locomotor ataxy, tubercle, syphilitic gummata, caries and necrosis, and malignant growths ; in brief, any condition rendering the bone unusually fragile, to which may be added the male sex as more frequently exposing to \iolence. 2. The exciting causes are either external violence or muscular action, {a) External violence may be direct or indirect. In fracture from di?-ect violence, the bone is broken at' the spot where the violence is applied. Such fractures are;jsually attended with more serious consequences than fractures from indirect violence, since the soft parts are, as a rule, much injured, and the fragments comminuted or fissured, and, perhaps, driven into im- portant organs, as the lung in fracture of the ribs, or the brain in fracture of the cranium, etc. In indirect violence, the fracture occurs at a distance from the spot where the violence is applied, as, for instance, a fracture of the clavicle from a fall on the arm. The bone usually breaks at its weakest spot, and the fracture may be rendered compound, from the fragments, which are often sharp and irregular, being driven through the soft parts. Fracture from indirect violence is most common in the bones of the extremities and the base of the skull. (/^) Muscular action, except in the case of the patella, is not a common cause of fracture. When the long bones are broken in this way, they are usually the seat of some of the affections mentioned above as predisposing causes. When a bone infiltrated with a malignant growth, or softened by mollities ossium, breaks from very slight violence, the fracture is said to occur spontaneously. Varieties of fracture. — A fracture is said to be simple when the skin covering it is not broken ; compound when a woimd through the skin and soft parts leads down to the seat of the fracture. Whether simple or compound, fractures are further spoken of: — I. According to their extent, as: — complete, when the bone is FRACTURES. 1 69 broken quite across ; incomplete or greemtick, when partially- broken and partially bent ; coinmimited, when broken into several pieces ; and multiple, when two or more distinct fractures occur in the same bone, or in different bones. 2. According to the condition of the fragments, as : — impacted, when one fragment is driven into another ; fissured, when there is a mere crack through the bone without displacement ; depressed, when one fragment is pressed in below the surface, as in some fractures of the cranium ; punctured, when there is a small perforation with driving inwards of the fragments ; and splintered, when only a fragment of bone is chipped off. 3. According to the line of fracture, as : — trans- verse, oblique, spiral, longitudinal, or stellate, terms which suffi- ciently explain themselves. A fracture, moreover, is said to be complicated, when associated with other injuries, as rupture of the main artery of the limb, imphcation of a large joint, etc. Displacement of the fragments, especially in the bones of the limbs, commonly occurs, except the fracture is transverse, when, as in the case of the tibia, there may be little or none. The causes of the displacement may be enumerated as : i. The weight of the limb acting on the lower fragment ; 2. Muscular contraction ; and 3. The violence producing the fracture. The amount of displacement will depend in part on the direction of the line of fracture, and in part on whether the periosteum is or is not torn. Thus the displacement is usually considerable when the fracture is obhque, insignificant when transverse, especially if the periosteum is intact. The displacement is spoken of as angular, lateral, longitudinal, and rotatory, according to the direction which the fragments bear to each other. Signs. — Before examining for fracture, the clothes should be carefully removed, and the parts handled tenderly, lest a simple fracture be converted into a compound by a sharp fragment being driven through the skin. Thus, in the case of the leg, the boot should be cut off, the trousers ripped up the seam, and the stock- ing split with scissors. The injured side should always be com- pared with the sound side. The general signs of fracture are : — I. Alteration in the shape of the part; 2. Swelling; 3. Loss of function; 4. Preternatural mobility ; 5. Shortening; 6. Pain; 7. Crepitus ; 8. The sensation of a sudden snap or giving way of the bone experienced by the patient. No one of the above signs alone, except crepitus, is absolutely diagnostic of fracture ; and crepitus itself, when the fragments are impacted, may be absent, or may be stimulated by joint-crepitus, effusion into the sheaths of tendons, emphysema, and by the grating of osteophytes in chronic osteo-arthritis. True crepitus, however, having been once felt, can hardly afterwards be mistaken ; it is readily dis- lyo INJURIES OF SPECIAL TISSUES. tingiiished from false crepitus by its harsher and more grating character. The shortening may be natural or due to some pre- vious injury or disease, as a former fracture, osteo-arthritis, etc. : shortening also occurs in dislocation. Increased mohinty may not be present, as when a fracture is firmly impacted. Fain may, of course, occur from causes other than fracture ; it may often be elicited in fracture when crepitus cannot be obtained. Swellivig, loss of function, and alteration in the shape of the part may be present in other injuries, but are useful signs in some forms of fracture. Too much weight, it need hardly be said, should not be given to the patient's sensations, as a snap or feeling of the bone giving way may occur in rupture of a tendon, ligament, etc. The Diagnosis is often difficult, especially : — i. When the frac- ture is near, or extends into, a joint, owing to effusion of blood or synovial fluid into the joint-cavity. 2. When there is great ex- travasation of blood, or later, effusion of inflammatory products about the fragments. 3. When the fracture is transverse, and there is no displacement, especially if the fragments are held in position by a companion bone, as the fibula in fracture of the tibia. 4. When the fracture is subperiosteal. In the cranium, a simple uncomplicated fissured fracture cannot be diagnosed. How to obtain crepitus. — Grasp the limb firmly above and below the suspected fracture, and when there is shortening, make extension to bring the rough surfaces into contact. Then gently attempt to move the lower on the upper fragment. Having once assured yourself that crepitus is present, desist from your manipu- lations, as they not only give the patient pain, but injure the soft parts. In some cases, as in fracture of the neck of the femur, where the nature of the injury from the presence of other signs is quite obvious, crepitus should not be sought lest an impacted fracture be rendered non-impacted and afterwards remain un- united, or the periosteum uniting the fragments be torn, and a like result ensue. The Method of Union is similar to that which occurs in the healing of a wound of the soft parts by the first intention. P>lood is at first extravasated between and around the fragments (Fig. 44). Then quickly follows a simple traumatic inflammation; the periosteum and adjacent soft tissues, together with the medulla, become infiltrated with leucocytes, which have escaped from the vessels of the inflamed periosteum, medulla, and bone, and by proliferating tissue cells derived from these parts. The inflammation subsides in a few days, leaving the fragments em- bedded in a mass of soft, red, gelatinous material {granulation- tissue), derived chiefly from the leucocytes and proliferated tissue cells, but according to some observers in part from the FRACTURES. 171 remains of the extravasated blood that has not been absorbed. This granulation-tissue, which is called callus, consists here, as in the union of soft parts, of small round cells with a small amount of firm intercellular substance, and delicate loops of capillaries, which are derived in part from the vessels in the Haversian canals, and in part from the vessels in the periosteum, and ad- P"lG. 44. Fig. 45. Diagram of the fragments a few hours after simple fracture. The periosteum is torn and ragged, and separated from the bone for a slight distance above and below the fracture. Blood is extravasated between the fragments, in the medullary canal, and in the periosteum and other soft tissues surrounding the fracture. Diagram of the process of repair in simple fracture. A. Ensheathing callus; B. In- ternal callu.s; c. Permanent callus. Com- mencing ossification of the ensheathing callus is indicated by the darker shading at the angle between the periosteum and the bone. jacent soft tissues. It is found (i) replacing the periosteum, and extending for some distance around the bone, above and below the hne of fracture, forming a spindle-shaped tumor, by which the ends of the fragments are surrounded, as it were, with a fer- rule {ensheaihing callus, Fig. 45, a) ; (2) replacing the medulla for some little distance up and down the medullary canal {internal callus, Fig. 45, b) ; and later (3) between the ends of the frag- ments {pertnanent inlermediate o?- definite callus. Fig. 45, c). The ensheathing callus and internal callus are gradually organized into fibrous tissue, becoming harder and firmer, and in animals, and, in some instances, in children, are converted into cartilage, or fibro- cartilage. The outermost layers of the fibrous tissue into which the ensheathing callus is thus converted form a new periosteum. Ossification of the ensheathing callus now begins — generally in the angle between the periosteum and the bone, and proceeds along the surface of the bone, where it is preceded by the forma- tion of cells like osteoblasts, and also along the surface of the en- sheathing callus beneath the new periosteum, till the upper and lower layers of ossifying callus meet opposite the line of fracture. 172 INJURIES OF SPECIAL TISSUES. Ossification of the internal callus goes on at the same time. Per- manent callus, as soon as the ends of the bone are thus fixed by the ensheathing and internal callus, is formed between the ends of the fragments, and later also undergoes ossification. It is probably derived (i) from leucocytes which have escaped from the vessels in the enlarged Haversian canals of the inflamed and softened ends of the fragments, and (2) from a proliferation of the cells of the connective tissue lining these parts. The ensheathing callus and internal callus having discharged their functions, are gradually absorbed. Where the ends of the fragments overlap, the ensheathing callus fills up the angles (Fig. 46) : and while the open end of the medullary canal in each fragment is thus closed, its continuity through the bone is re- stored by the absorption of the intervening walls of the contiguous and overlapping frag- ments (Fig. 46). When the fragments are in good apposition, and are kept at rest, little or no ensheathing callus is formed; but when there is much displacement, or rest is im- possible, as in a fractured rib, or difficult to obtain, as in a fractured clavicle, a consider- able amount is produced. In children, even when the parts are kept at rest and in good apposition, the formation of much ensheath- ing callus is the rule. Treatment. — Here only the indications for treatment will be pointed out. The particular methods will be given under Special Fractures. A. Treatment of simple fracture. — The in- dications are — (i) to reduce the fracture, that is, to place the fragments in apposition, so as to restore as far as possible the bone to its normal shape; (2) to keep it in this position by properly applied apparatus till firm union has occurred ; (3) to promote the restoration of the normal functions of the part; and (4) to attend in the meanwhile to the general health and comfort of the patient. I. 'Ihe reduction, or as it is popularly called the setting of the fracture, should not l)e undertaken until the apparatus into which the limb is to be permanently jjlaced is ready ; but the fragments should be temporarily fixed, so as to jirevent further injury, such as a sharp fragment being forced tiirough the skin. Thus, in the case of the lower extremity, the injured limb may be bound to the Fracture of the femur with overlapping frag- ments to show round- ing off of angles, and restoration of medullary canal by absorption of intervening bone (St. Bartholemew's Hospi- tal Museum). - TREATMENT OF FRACTURES. 1 73 sound one, or secured by a handkerchief to an impromptu splint, such as an umbrella or walking-stick : or if the patient is not seen till he is already in bed, the limb may be placed between sand- bags or wrapped in a pillow. As a general rule the fracture should be reduced as soon as possible ; but where there is much swelling the part may remain wrapped in a pillow or secured by sand-bags till the swelling has subsided. When the fracture is transverse, the fragments will, as a rule, be but slightly displaced, and little as regards reduction will be required. In other instances, as when the line of fracture is obhque, considerable trouble in bring- ing the fragments into apposition may be experienced. The chief obstacles to be overcome are (i) the contraction of the muscles, which are thrown into action by the irritation of the fragments ; and (2) the impaction of the fragments, or the inter- position of muscle or tendon between them. The splint or other apparatus being in readiness, extension in the case of fracture of a limb should be made on the lower fragment, preferably, as a rule, through the intervention of the joint below. Thus, in fracture of the fore-arm or leg, extension should be made from the hand or foot respectively, whilst counter-extension is applied at the same time to the upper fragment, also preferably through the joint above. Whilst steady traction is thus being made, the Surgeon should gently manipulate the fragments, and he should not rest satisfied till the symmetry of the part has been as far as possible restored, and the limb is found, both on inspection and measurement, to correspond as near as may be with the opposite side. In this position the parts should be held till the apparatus for permanently fixing them has been applied. Where great diffi- culty is experienced in reducing the fracture owing to muscular spasm, the limb should be flexed or placed in such a position as will tend to relax the opposing muscles, or if this does not suffice an anaesthetic may be administered. At times the subcutaneous division of a tendon may become necessary before the fracture can be reduced. In some impacted fractures, as of the neck of the humerus or femur, it may be advisable not to disturb the frag- ments, as by so doing non-union, a worse condition than impac- tion, may result. The special methods of reduction which may be required for certain fractures will be given under Varieties of Fracture. 2. To keep the fragments in apposition till union has taken place, numerous contrivances have been invented. They may be said to consist of splints, cradles, fracture-boxes, bandages hard- ened by plaster of Paris, silica, paraffin, glue, or gum and chalk, and such material as gutta-percha, poroplastic felt, and leather, moulded to the individual case. In oblique fractures, where the T74 INJURIES OF SPECIAL TISSUES. ends of the bone cannot be retained completely in apposition, Lane advises that an incision should be made down to the bone and the fragments secured by wiring. The method of applxing splints will be better learnt by three months' dressing in the wards than by any verbal description. The points that should be chiefly attended to are : i. The splints should be well paddeii. 2. Pressure should not be made over points of bone. 3. Strappmg or bandages should not be put on too tightly. 4. Circular constriction of the limb should be avoided. 5. The splints where possible should reach beyond both the joint above and the joint below the fracture. 6. The fracture should not, as a rule, be covered with the bandage. 7. The patient should be seen within twenty-four hours after the splints have been applied, as swelling of the part is apt to occur, and the bandages thus become too tight. 8. The part having once been properly secured in splints, should not needlessly be disturbed. 9. Should the fragments become displaced from spasm of the muscles, steady extension as by a stirrup, weight, and pulley, will usually overcome the difficulty. 10. The part below the fracture may sometimes be bandaged with advantage to prevent oedema. The time the splints should be kept on varies greatly, and will be stated under each individual fracture. On their removal the limb should be kept at rest for some time longer in a plaster of Paris, gum and chalk, or other form of stiff bandage, till complete consolidation has taken place. At some hospitals the fracture, if not severe, is placed at once in a plaster of Paris bandage or plaster of Paris splints {Bavarian splints^. If this or other similar material is used, the limb should be well padded with cotton-wool, the toes or fingers left exposed, the joints above and below included in the bandage, and the limb subsequently raised. The patient should be visited a few hours after the plaster of Paris has been applied, so that should the circulation have become impeded from swelling of the limb, the plaster bandage may be removed before any serious damage has had time to ensue. The indications for at once removing, or for loosening the band- age by cutting it in places are : i, much pain; 2, swelling; 3, numbness ; and 4, signs of obstructed circulation in the fingers or toes. A tight bandage, it should be remembered, is more dan- gerous in the upper than in the lower limb, because in the former most of the venous return is by the superficial veins. Should the bandage become loose, it must of course be removed and re- applied. 3. To promote the restoration of the normal functions of the part physiological after-treatment is required. Thus it will often UNUNITED FRACTURE. 175 Fig. 47. be found after the apparatus is finally removed, especially if the fracture is near a joint, that the joint is stiff, the tendons are more or less glued together, and the muscles wasted and atrophied. Under these circumstances shampooing, massage, electricity, friction with stimulating liniments, and passive movements of the joint, should be sedulously employed. 4. The general health and comfort of the patient 'iYi.ovXdi not be neglected. Thus if he is confined to bed, boards should be sub- stituted for the ordinary webbing or steel laths of the bedstead ; the sheets should be kept smooth ; and bed-sores guarded against by the use of water-cushions and by hardening the skin over prominent points of bone with spirit lotions. Old people should not be kept too long in bed, lest ])assive congestions of the lungs occur. The general health should be promoted by attention to the secretions, regulation of the diet, and administration of seda- tives to relieve pain and promote sleep. Ununited fracture and false joint. — An ununited fracture is one in which the fragments are either totally ununited, or merely bound together by fibrous tissue. Some fractures, such as transverse fractures of the patella, and fractures extending into joints in general, sel- dom or never unite by bone, but remain merely bound together by fibrous tissue ; but as fibrous union here appears to be the normal method of repair, they are not, as a rale, spoken of as ununited fractures. The condition of the fragments in an ununited fracture varies. The fragments may be completely sepa- rated, with the ends rounded off and the medullary canal closed ; or they may be bound together by long pliable bands of fibrous tissue per- mitting of considerable movement, or by tough fibrous bands allowing of but very little, or by a fibro-cartila- ginous material — a kind of ensheath- ing callus. The last condition, how- ever, is thought by some to be merely an example of delayed union, and not one of permanent ununited fracture. h. false Joint or pseudarthrosis is merely a variety of ununited fracture in which the ends of the fragments are rounded off and False joint followins fracture of the humerus. St. Bartholomew's Hospital Museum.) 176 INJURIES OF SPECIAL TISSUES. eburnated, or covered with a layer of fibrous tissue or fibro-car- tilage, and enclosed in a strong fibrous capsule formed by the condensation of the surrounding soft tissues (Fig. 47). A fluid resembling synovia has occasionally been found within the capsule. A false joint may resemble a hinge or a ball-and-socket joint. The latter condition is more common in fractures near the articu- lar ends of bones where rotatory as well as angular movement may occur ; the former in fractures through the shafts of bones where angular movement only is permitted. The Causes are local and constitutional. The local dat: i. The fragments not having been kept thoroughly at rest ; 2. The fragments not having been placed in apposition in consequence of {a) muscular contraction; {b) the loss of a large piece of bone, as in compound fracture ; (r) the intervention of a piece of muscle, tendon, or periosteum, or a foreign body, as a portion of clothes, between the fragments ; and {d) the effusion of synovial fluid in the case of a fracture into a joint ; 3. The necrosis at the end of one of the fragments ; 4. The interference with the arterial supply of one of the fragments, as from injury of the medullary artery: and 5, The poor supply of blood to one of the fragments, as in fracture of the anatomical neck of the hu- merus. Constitutional causes. — Syphilis, tubercle, gout, Bright's dis- ease, fevers, scurvy, the cancerous cachexia, pregnancy, locomotor ataxy, old age, alteration of the patient's habits, the sudden depri- vation of stimulants, are all said to be causes of ununited fracture. No doubt any condition that lowers the vitality and consequent power of repair of the tissues has a tendency to delay union, but it seems doubtful if any of the above conditions except scurvy is, in itself, apart from the local causes, sufficient to prevent the bone uniting. In paralysis agitans the difficulty of keeping the patient quiet, and hence the almost complete impossibility of immobiliz- ing the fragments by splints, etc., may be regarded as a cause of non-union. Sometimes the callus, after having been formed, appears to be re-absorbed, the fracture being then spoken of as disunited. 'J'his appears to be not uncommon in scurvy. Treatment. — Constitutional as well as local treatment may be required. In recent casee — /. e., where the fracture is found un- united after having been kept in splints for the usual time, a con- dition sometimes called delayed union in contradistinction to ununited fracture, the sjjlints should be re-applied, and in such a manner as to insure perfect immobility of the fragments ; whilst the general health should be improved by every means in our power ; and any constitutional taint, as syphilis, gout, etc., that may UNUNITED FRACTURE. 1 77 be detected, combated by appropriate remedies. If tlie patient has been accustomed to stimulants, and has been deprived of them, he should be allowed a moderate quantity. In some cases it may be expedient to put the fracture in an immovable appa- ratus, and let the patient get about on crutches. Should union still not occur, the ends of the fragments should be rubbed together to excite some amount of inflammation, and sphnts or other apparatus be again applied. This failing, and in long- standing cases, two courses are open ; either to try to unite the fragments by some operative procedure, or to apply some form of permanent apparatus to fix them in position. The choice of these methods will depend upon the situation of the fracture, whether it is of the nature of an ununited fracture or a false joint ; and upon the patient's age, constitutional con- dition, occupation, and rank of life. Thus in the case of an ununited fracture of the upper third of the femur in a patient of advanced age or of broken constitution, an operation is attended with great risk to life, and for such, some form of apparatus is better suited. But when the patient is young or of good consti- tution, or his occupation is such that he cannot afford an appara- tus and the continual expense of keeping it in good order, and especially where the fracture is in the shaft of the hu- merus, an operation should be undertaken. Such operations may be divided into three classes, according as they have for their object i, the setting up of inflammation about the ends of the fragments, or in the fibrous tissue uniting them, and so in- ducing ossification ; 2, the fixation of the fragments by wire or other forms of suture, by ivory cylinders, bone ferrules, etc., and 3, the cutting out of the false joint, and bringing the refreshed surfaces of the bone into apposition, and keeping them there till union has occurred. Among the first, which are applicable to an ununited fracture rather than to a false joint, may be mentioned — {a) the subcutaneous scraping of the ends of the fragments; {b) passing a seton between them ; and (c) cutting dow^n upon and inserting ivory pegs into the fragments in order to induce ossification. Of these the subcutaneous method is, perhaps, at- tended with the least risk, but cases to which it is applicable are the exception. The passage of a seton is highly dangerous, and should never be employed. The insertion of ivory pegs for the purpose of inducing ossification is not reliable. Under the second method — namely, that of direct fixation of the fragments, are in- cluded {a) suturing the fragments; {b) the introduction of ivory cyhnders into the medullary canal ; and (r) fixation by bone ferrules, {a) Suturing, as formerly done, allowed of lateral and longitudinal displacement if the fracture was oblique'. 178 INJURIES OF SPECIAL TISSUES. Wille, therefore, advises that in oblique fractures, two grooves (Fig. 48) be cut with a saw in the fragments, the direction of the grooves being at a right Fic;- 4S. angle to the fractured surfaces, and the frag- ments tied together with wire. Further, where both the fragments can be drilled vertically, he draws with a book, in- Method of wiring the fragments in oblique fractures. Veilted lOr thC purpOSC (Fig. 49), the wire through the drill holes, divides it, and twists each half together (Fig. 50). ((5) The insertion of ivory cylinders, or, better, of hol- FlG. 49. Fig. 50. Wille's method of wiling the fragments in oblique fractures. low cylinders of bone, into the medullary cavity, is successful in fixing the fracture and preventing lateral and longitudinal dis- placement where the fracture is not oblique, (c) Fixation with bone ferrules (Fig. 51) is '■'"'■• SI- advised by Senn. For the femur and humerus he em- ploys the femur of the ox (Fig. 51A) ; for the tibia, the tibia of the ox (Fig. 51K) The ferrule should be a quarter-of-an inch to an inch in breadth, the medullary canal being en- larged by a round file till the ferrule does not exceed one-sixth of an inch in thickness. When an inch broad it should be perforated as shown in Fig. 51c, so as to facilitate its absorption after the fracture has united. If desired it may be partially or completely decalcified. If the ferrule is too large the space between it and the fragments may be packed with small splinters- Scnn's bone ferrules for fixing the fragments in un- united fractures. (After Senn.) UNUNITED FRACTURE. 179 Senn's bone ferrules for fixing the fragments in ununited fractures in situ. (After Senn.) Fig. 53. Fig. 54. of bone. The position of the ferrules when m situ is shown in Fig. ^2. The thb-d • Fig c:2 method, or operation for cutting out a false joint, consists in mak- ing an incision down to the bone, chiseling or sawing away ob- liquely the ends of the fragments, and then fixing them in one of the ways above-men- tioned. Recently in unu- nited fractures with loss of substance from necrosis, the gap has been filled by grafting a piece of iDone be- tween the fragments. The grafts may be ob- tained from a young animal, or from a limb immediately after am- putation. In one suc- cessful case, wedge- shaped pieces of bone removed in osteotomy of the tibia were used. Whilst being trans- ferred the grafts should be kept at a temperature of 100° in a capsule of boiled salt solution (3j to Oj). Malunited frac- ture OR VICIOUS UNION. — I. Fractures incon- sequence of having been improperly set or not kept at rest in good position, may unit^at an angle (Fig. 53), or in some othtr faulty direction. 2. If splints have been removed too early, or Malunited fracture. (St. Bar- tholomew's Hospital Mu- seum.) Vicious union after frac- ture. (St. Bartholo- mew's Hospital Mu- seum.) l8o INJURIES OF SPECIAL TISSUES. if in the case of the lower extremity the patient has been allowed to walk too soon, the callus may yield, and deformity result. 3. Two adjacent bones, as the radius and ulna in the fore-arm, may become united to each other by callus (Fig. 54). 4. A greenstick fracture from neglect to straighten the partially bent bone before applying splints may consolidate in its distorted condition. Treatment. — If the fracture is recent, and the fragments are not firmly united, the patient should be placed under an anaesthetic, the faulty position rectified, and splints properly applied. If firm union has already occurred, an attempt should be made to re- fracture the bone, under an anaesthetic, with the hands ; if this fails, and in long-standing cases, osteoclasia by means of Grattan's or Thomas's instrument should be undertaken, or subcutaneous osteotomy may be performed, or in some instances a wedge- shaped piece of bone removed. A sharp fragment projecting beneath the skin may sometimes be sawn off with advantage, though it should be remembered that such projections often be- come rounded off with time. Separation of epiphyses. — This injury may be regarded as a variety of fracture. It consists in the forcible wrenching of the epiphysis from the shaft at their cartilaginous line of union, and consequently can only occur in subjects under twenty-one years of age, the period at which nearly all of the epiphyses have united with the diaphyses. The injury is most common in the upper and lower ends of the humerus, and, from the proximity of the epiphyseal lines to the shoulder and elbow-joints respectively, is liable to be mistaken for a dislocation Repair usually takes place by osseous tissue ; hence the bone ceases to grow at the in- jured end, and permanent shortening of the limb if the patient has not completed his growth will then result. For treatment, see Special Fractures a?ui Dislocations. A COMPOUND FRACTURE is ouc in which there is a wound through the skin and other soft tissues leading to the fracture. Cause. — The wound may be produced, i. At the same time as the fracture, either by the violence directly tearing open the soft tissues, or, as is more usually the case, by one of the fragments being forced through the skin either by the original violence or by muscular contraction. 2. Subsequently to the fracture, by the patient trying to rise or to use the injured limb; or by want of care in removing the clothes, in handling the fracture, or trying for crepitus. 3. Still later, by ulceration or sloughing of the soft parts, due to inflammation set up through failure to render and keep the injury aseptic, and the laceration of the tissues or the pressure of a projecting fragment. State of the parts, — 'Ihere may be a mere puncture, with but COMPOUND FRACTURE. Fig. 55. lus; B. Internal callus; c. Necrosed fragments ; D. Granulations lining wound leading to fracture. (After Billroth.) little if any more injury to the soft tissues than may be met with in simple fracture ; or with or without a large external wound of the skin there may be extensive laceration of the soft tissues, protrusion of one or other fragment, extensive comminution of the bone, implication of a large joint, rupture of the main artery, vein or nerve, and in ex treme cases crushing and laceration of the whole of the injured part of the limb. Union of compound fractin-e. — When the wound is small, and has been closed at once, and the soft parts are but little injured, the process of repair is as a rule similar to that of a simple fracture. When the wound is large, or there is much laceration of the soft tissues or comminution of the bone, suppura- Diagram showing process tion is very likely to ensue, and union is then ?<" separation of necrosed . , , ^ -^ , . . . - , bone m compound Irac- erfected by granulations springing from the ture. a. Ensheathing cai ends of the fragments and periosteum, the process being analogous to union of the soft parts by the second intention. The granu- lations either undergo direct ossification, or first pass through a fibrous, or in some instances a cartilaginous stage. The loose fragments and injured tissues, where the bone is comminuted and the soft parts are much bruised or lacerated, are cast off by the process of ulceration (Fig. 55) before healing ensues. Where, however, a fragment retains its connection with the periosteum, it may not lose its vitality, but may help in the restoration of the bone. Where a large portion of bone is de- nuded of periosteum it generally dies, and is usually separated as in the ordinary process of necrosis (Fig. 55). It may, however, become embedded in the new bone, and remain a source of irri- tation for years. Dangers of compound fracture. — i. Immediate dangers : shock and collapse from loss of blood, which may prove fatal in a few hours ; more rarely fat-embolism. 2. Intermediate dangers ; septic inflammation, erysipelas, saprcemia, septicaemia, pyaemia and tetanus. 3. Late dangers : hectic, lardaceous disease, and ex- haustion from long-continued suppuration. The treatment varies according to the state of the parts, the age and heaUh of the patient, and the situation of the fracture. Our aim, when possible, should be to convert a compound into a simple fracture. Thus, when the wound is small, a mere puncture, it should, after being well cleansed by antiseptics, be closed by a piece of antiseptic gauze, and the case treated as a simple frac- l82 INJURIES OF SPECIAL TISSUES. tore. When the wound is large and lacerated, or other serious injury of the bone, soft parts, or neighboring joint has been sus- tained, the question of amputation will arise. (See below, Ain- piitaiion in Compound Fracture.^ Having, however, deter- mined to save the hmb, the indications are — (i) to reduce the fracture, and maintain the fragments at perfect rest, and (2) to promote the healthy heahng of the wound. The fracture should be set as described under simple fracture ; if the fragments pro- trude they should be reduced where practicable, sawn off where not, enlarging the wound in the skin if necessary, but taking care not to remove more bone than is sufficient to accomplish the object. Splinters when attached by periosteum should not be removed, but simply placed in position and then secured, under some cir- cumstances, by sutures. If it is found difficult to keep the frag- ments in place, they may be fixed in position by wiring or by Senn's bone-ferrules (page 177). The wound should be rendered aseptic by washing out all corners with some antiseptic fluid. When this can be thoroughly done, the soft tissues-muscles, tendons and fascise — should be united by catgut sutures and the wound closed ; but when there is much laceration, and thorough cleansing cannot be effectually carried out, the wound should be kept freely drained to prevent the decomposition of any extra- vasated blood and discharges. The limb should then be secured in some form of apparatus, so arranged that the wound is not covered by it, but is freely accessible for dressing without dis- turbing the fragments. If the patient's general condition remains good, and he has no pain or discomfort, the dressings may be left undisturbed till the wound has healed ; but should suppuration occur, a careful inspection ought to be made daily to see that the drainage is efficient ; and if any collection of pus, which is apt to form in the intermuscular planes, be discovered, it should be let out with antiseptic precautions and the wound drained. Any portions of bone that may necrose should be removed as soon as loose. When the wound has healed, the fracture should be treated in the same way as a simple one. Any complications, as erysipelas, saprsemia, etc., that may occur must be treated as de- scribed in other parts of the book. The constitutional treatment is the same as that indicated in other severe injuries. (See also Simple Fracture.) Question 0/ amputation in compound fracture. — In slight and un- complicated cases, and in those severe injuries in which the hmb is completely shattered, the course to be pursued is quite clear ; in the one case to spare the limb, and in the other to amputate im- mediately, liut in other instances the question of attempting to save versus amputate becomes one of the most serious and anxious COMPLICATIONS OF FRACIXTRE. 1 83 that the surgeon has to decide. It was formerly taught that we should amputate — i. If there is great laceration of the soft parts and extensive loss of skin. 2. If there is much comminution of the bone. 3. If the main artery or nerves of the limb are torn. 4. If a large joint is implicated. 5. If the limb is likely to be of little subsequent service from the severity of the injury ; and 6. If the patient is old or his constitution broken down. No one of these signs is in itself in every case a sufficient reason for ampu- tating ; and when we can succeed in rendering the wound com- pletely aseptic some of them, as comminution of the bone, implication of a large joint, and the advanced age of the patient, can hardly be now ever considered as a justification for so severe a measure. The main considerations are : Can the wound be rendered aseptic, and, if so, is the arterial supply sufficient to prevent gangrene ; is the condition of the nerves such that the hnib will not be hopelessly paralyzed ; and is the laceration of the muscles and tendons within such liinits as will allow of a useful limb ? If these questions can be answered in the affirmative an attempt should be made to save the limb ; if in the negative amputa- tion should be done. The indications for amputation are of course more imperative if the fracture involves the lower extremity, especially the femur ; but each case must be judged on its own merits, and some surgeons will attempt to save what others con- demn. Every legitimate effort should of course be made to save a limb, but we must remember that in attempting to do so we may place the patient's life in danger, and that too often it is a question of a hmb versus the life. If amputation is not performed at once or within the first twenty-four hours, and it then becomes evident that the limb m_ust be sacrificed, the amputation should not as a rule be undertaken till the traumatic fever has subsided, the surgeon watching care- fully for the most favorable opportunity that presents itself. The signs calling for amputation during the suppurating stage are : — Extensive suppuration, great sloughing of the soft tissues, inflam- mation and suppuration of a neighboring joint, necrosis of large portions of bone, exhaustion, hectic and lardaceous disease. Complications of fracture. — A simple fracture may be com- plicated by any of the geiieral affections attending other injuries, as shock, traumatic delirium, tetanus, retention of urine; and by such local conditions as, i, concomitant dislocation; 2, extravasa- tion of blood ; 3, rupture of the main artery, vein, or nerve ; 4, im- plication of a joint ; 5, gangrene from tight bandaging ; 6, paralysis from the use of a crutch, or the implication of a nerve in the callus ; 7, venous thrombosis ; 8, embolism ; 9, formation of ulcers or bed-sores over prominences of bone; 10, erysipelas; 11, fat- 184 INJURIES OF SPECIAL TISSUES. embolism ; and 12, suppuration where there is much laceration of the tissues with giving way of the skin, the fracture then becoming compound. A cotnpound fracture may in consequence of the open wound be complicated, in addition to the above-mentioned affections, by septicinflammation'AVL^siippuratioJi, nccrosis,saprcemia,septicccmia, pycemia, hectic and tetanus. Of these complications of fracture, whether simple or compound, the only ones that need be further mentioned here are the follow- ing :— Fracture combiiied tvith dislocation. — In simple fracture the treatment consists in placing where possible the fracture in splints, and then attempting the reduction of the dislocation. Where the dislocated end cannot be replaced the fragments must be allowed to consolidate, and another attempt then made to reduce the dis- location ; or the surgeon may try to manipulate the dislocated portion into its socket, and then apply splints to the fracture. In compound fracture this complication is a much more serious one, especially when it occurs in the lower extremity, and involves one of the larger joints. In the knee, ankle, and wrist, amputation, and in the elbow and shoulder, excision, is usually indicated. In the smaller joints the dislocation may be reduced, and the case treated as a wounded joint complicated by fracture. Fracture implicatiiii^ a Joint. — A simple fracture extending into a joint is not an uncommon accident ; indeed the elbow- and knee-joints are always involved in fracture of the olecranon and patella respectively, and the shoulder and hip-joint in the intra- capsular fracture of the neck of the humerus and femur. The in- jured joint may become stiff or ankylosed, though usually no serious mischief ensues. Suppuration is very rare. The limb in putting up the fracture should be placed, except in the case of fracture of the olecranon, in a position in which it will be of most service should bony ankylosis ensue. Inflammation and stiffness of the joint from fibrous adhesions should be treated in the way described under Diseases of Joints. A compound fracture extending into a joint, though more serious, does not necessarily call for amputation or excision, and may be treated in the way de- scribed under Wounds of Joints, liut should such be required, excision in the upper extremity and amputation in the lower may be said with certain reservations to be the rule of practice. If an operation is considered unnecessary the case should be treated as a wounded joint, and splints according to the variety of fracture applied. Fat-embolism is a rare complication of fracture, but is more frequent in the comijound than in the simple variety, and in bones COMPLICATIONS OF FRACTURE. 1 85 that have undergone atrophy. It appears that in consequence of the crushing of the medulla, fat-globules gain admission into the veins, and become lodged in the capillaries of the lungs, brain, kidneys, and other organs. It is attended by dyspnoea, either cyanosis or pallor, collapse, irregular action of the heart, and at times by coma and death. Venesection, injection of ether into the veins, and artificial respiration, have been suggested in way of treatment. Crutch palsy is due to the pressure of a crutch on the musculo- spiral nerve. It is best avoided by well padding the crutches, or by having handles to the crutches so that part of the weight falls on the hands. An ingenious crutch with handles has lately been introduced. The paralysis, which chiefly affects the extensor muscles of the fore-arm, giving rise to dropped wrist, usually passes off when the crutch is no longer used. Should it not do so, electricity and massage may be employed. Paralysis or neuralgia sometimes occurs in consequence of the implication of a nerve in the callus. An operation is then at times necessary to liberate the nerve. Gangrene from tight bandaging is occasionally met with, and is of the moist variety. All bandages should of course be at once removed, in the hope that the limb may recover. When the gan- grene is thoroughly established, amputation above the seat of fracture, and of course well beyond the gangrene, must be per- formed. Short of gangrene, the partial cutting-off of the blood- supply may cause inflammation and degeneration of the muscles, followed by stubborn contracture {ischcemic rigidity). Extravasatio7i of blood into the tissues is not uncommon in simple fracture, owing to the tearing of some of the smaller blood- vessels by one of the rough fragments. The extravasated blood causes in some instances considerable swelling, and on making its way to the surface gives the part a bruised and black appear- ance, and frequently causes the cuticle over it to be raised into blebs. These blebs differ from those formed in gangrene in that they are fixed and firm, whilst the latter are movable over the moist and slippery skin beneath. No special treatment is re- quired, the blebs should not be opened, and the blood will grad- ually be absorbed. In rare instances, however, suppuration ensues. Rupture of the main artery or vein occasionally occurs, causing when the skin is unbroken a tense swelling at the seat of fracture, attended in the case of the artery by coldness of the limb, and cessation of the pulse in the arteries below. In compound frac- ture, rupture of the artery is, as a rule, easily diagnosed, in that pressure on the artery above the fracture stops the bleeding. Treatment. — Should the swelling in simple fracture increase in l86 INJURIES OF SPECIAL TISSUES. spite of elevation of the limb, cold, and pressure on the main artery above, and gangrene threaten, three courses are open : i, ligature of the artery above ; 2, tying the artery at the seat of frac- ture ; or 3, amputation. In the lower limb amputation is probably, as a rule, the safest course ; in the upper limb ligature of the ves- sel at the seat of fracture may be attempted. But the conditions that call for the adoption of one or other of these methods are too various to discuss here. In compound fracture the vessel should be tied in the wound if possible. If not, amputation will probably, though not invariably, be the right course. INJURIES OF JOINTS. Contusions of joints may be produced by any mechanical vio- lence. They are generally attended with pain and stiffness on movement, and, in severe cases, with swelling from effusion of blood {h(^marthf'osis), and later, of serous fluid (sy?ioviiis) into the synovial cavity. If the contusion is neglected, especially in tuberculous children, acute or chronic inflammatory changes may ensue, leading to destruction of the joint. The treatment consists in placing the part at rest on a splint, or in a plaster-of-Paris bandage, and applying cold by means of an ice-bag or Leiter's tubes. Where there is much effusion into the synovial cavity, and consequently considerable tension and pain, aspiration of the joint may be advantageously practiced, and pressure afterwards applied. Sprains. — A sprain is a stretching or partial rupture of the liga- ments of a joint without separation of the articular surfaces. Sprains are generally due to a violent wrench or twist of the joint, and are often accompanied by laceration of the tendons and other soft tissues around. They are of most frequent occurrence in the ankle, shoulder, wrist, and knee. Sig7is and dia^^nosis. — Severe pain, often localized to certain points, and increased on movement, inability to bear weight on the limb, swelling and ecchymosis from effusion of blood in and around the joint, and later inflammatory effusion into the synovial cavity. The absence of signs of fracture or of discoloration will usually suffice to distinguish a sprain from one or other of these injuries ; but where there is much swelling it may be difficult or impossible to make a diagnosis till the swelling has subsided. If there is any doubt, the injury should be treated as a fracture. The consequences of a neglected sprain may be very serious, especially in rheumatic and gouty subjects. Thus, as the result of the incomplete absorption of the inflammatory products, the .imperfect repair of the torn ligaments, the formation of .fibrous DISLOCATIONS. 187 adhesions in and around the joint, and the gluing of the surround- ing tendons to their sheaths, a sprain may be followed by long- continued pain, stiffness, weakness and even fibrous ankylosis of the joint. At times in tuberculous subjects a sprain may be the starting-point of destructive joint-disease. Treatme7it. — The indications are to place the joint at perfect rest till the torn ligaments have had time to heal ; to prevent or subdue inflammation ; and, should stiffness or ankylosis have en- sued, to restore the mobility of the joint by breaking down any adhesions that may have formed. Thus, if seen at once, a plaster- of- Paris or a Martin's bandage should be put on ; or if much sweUing has already occurred, the parts should be placed on a splint or in a sling, and either cold in the form of lead-lotion or ice, or heat in the form of hot fomentations, apphed. For very slight cases, however, a few days' rest with the part supported by a wet bandage, followed by the use of a stimulating linament, is all that is usually necessary. The joint in any case should not be kept too long at rest lest stiffness ensue ; but as soon as all signs of inflammation have disappeared, passive movements should at once be begun. If stiffness or fibrous ankylosis has already oc- curred, friction, shampooing, and massage may be tried ; or the joint may be forcibly wrenched under an ansesthetic, provided all signs of active inflammation have ceased. Dislocations. — A dislocation is the forcible separation of the articular end of a bone from the part with which it is naturally in contact. Varieties. — Dislocations may be divided into the Congenital and the Acquired ; the latter again into the Spontaneous and the Traumatic. The Spontaneous are those that occur as the result of disease of the joints, and are treated of elsewhere (see Diseases of yoints). The Traumatic, or accidental disclocations, with which we are here specially concerned, are spoken of as com- pound or simple according as they are, or are not, complicated with an external wound leading into the joint ; and in either case as complete ox partial according as the articular surfaces are, or are not, completely separated from each other. The causes of dislocation are predisposing and exciting. The predisposing causes may be enumerated as : i, weakness of the ligaments surrounding the joint from previous dislocation or disease ; 2, the shape of the joint — ball-and-socket joints from their extensive range of movement being more easily dislocated than hinge joints ; 3, middle-life — the bones being then strong and capable of resisting fracture and the muscles powerful ; 4, the male sex — men being more continually exposed to violence than women. 77ie exciting causes are usually, i, external violence,. 1 88 INJURIES OF SPECIAL TISSUES. either direct or indirect, and sometimes, 2, muscular action. Examples of each will be met with in the section on special dis- locations. The Signs common to all dislocations are : i. Alteration in the shape of the joint. 2. Inability to move the limb on the part of the patient, and more or less fixidity to the efforts of the Surgeon. 3. An alteration in the relations of points of bone about the joint, 4. An abnormal position of the end of the displaced bone ; and 5. Shortening or lengthening of the limb, or an alteration in its axis. The signs are frequently obscured by swelling in and about the joint, due to extravasation of blood or effusion of synovial fluid. Hence the importance of accurately ascertaining the nature of the injury immediately after the accident, as when swelling has supervened it may not be possible to make a diag- nosis till it has subsided. The state of the parts will be more especially referred to under each special dislocation. Here it may be briefly stated that the head of the bone is generally forced through the capsular liga- ment ; whilst other of the ligaments, surrounding tendons, and muscles, may be ruptured or tightly stretched, and the arteries and nerves displaced, pressed upon, or torn. In the ball-and- socket joints the end of the bone will be found either opposite the rent in the capsule, or drawn to some distance from it by muscu- lar contraction. If reduction is effected early, the damaged ligaments and muscles are soon repaired ; but they remain for some time weakened and stretched, and thus predispose to re- dislocation. Hence the importance of keeping the parts at rest until firm union of the ruptured capsular and other ligaments has occurred. After reduction a moderate amount of inflammation and serous effusion in and about the joint generally ensues, but usually subsides in a few days if the parts are kept at rest, the joint becoming gradually restored to its normal condition. If rest is neglected, however, the rent in the capsule may not heal, but remain as a permanent hole with smooth edges, allowing the head of the bone to slip in and out of its socket. In some in- stances, moreover, the inflammation may run into suppuration, which may be followed by ankylosis of the joint. The impediments to reduction are : — In recent cases : — i. The spasmodic contraction of the muscles surrounding the joint. 2. The small size of the rent in the capsule. 3. The hitching of points of bone on each other ; and 4. The interposition of liga- ments, tendons or muscles. In old-standing cases : i . The forma- tion of adhesions around the displaced bone. 2. The closure of the rent in the capsule. 3. The permanent shortening of the ligaments and muscles ; and 4. The altefatioft in the shape of the DISLOCATIONS. l8g articular surfaces, in part from absorption and in part from the formation of new bone. The contraction of the muscles generally increases from the time of the accident ; hence every hour the dislocation remains unreduced the more difficult the reduction becomes. T/ie conseqiiences of ?ion-reductioji are either the formation of a new joint, or ankylosis, the former being more common in ball- and-socket joints, the latter in hinge joints. V/hen any move- ment between the dislocated bones exists, the osseous surface on which the displaced bone rests is converted into a new articular cavity by a process of absorption of the old bone, and the forma- tion of new bone around ; the end of the displaced bone becomes adapted by a similar process of absorption to its new socket ; and the soft tissues around become condensed so as to form a kind of new capsule. The old socket in the meantime becomes more or less obliterated, its articular cartilage absorbed, and its cavity filled up with fibrous tissue or new bone. The range of move- ment in the newly-formed joint will at first be limited, but in the course of time under appropriate treatment will become much more free, and a very fairly useful limb may be obtained. When on the other hand the dislocated bone is immovably fixed upon another, the articular cartilage is absorbed, the contiguous osseous surfaces unite, and bony ankylosis is said to ensue. The muscles, moreover, from want of use, undergo shortening or partial atrophy and fatty degeneration, leaving the limb in a more or less shrunken and wasted condition. Treatment. — The indications are : i . To replace the articular surfaces in contact ; and 2. To keep them there until the rent in the capsule has united and the torn ligaments and muscles have had time to heal. Unless the case is seen immediately after the accident, whilst the patient is faint, and the muscles are in con- sequence relaxed, an anaesthetic had better be given to overcome the resistance of the muscles. The reduction may then be ef- fected either by, i, manipulation, or 2, extension. I. Manipulation consists in putting the limb through certain movements of flexion, extension, rotation, and circumduction, varying according to the situation and variety of the dislocation. By means of these movements we endeavor : — («) To overcome the obstacles to reduction by relaxing the stretched ligaments and tendons, and disengaging any hitching points of bone ; and (/5) To make the displaced head retrace as it were its steps, and re- enter its socket. In order to employ manipulation successfully it is essential that the Surgeon should know the anatomy of the part, the direction in which the bone has traveled to reach its abnormal situation, and the probable position of the rent in the capsule. . 190 INJURIES OF SPECIAL TISSUES. 2. Extension is a much less scientific method of reducing a dis- location, and should never be resorted to, except in certain forms of dislocation which will be mentioned hereafter, till manipulation has been tried. It was the method almost always employed bv the older Surgeons, and has for its object the forcible dragging of the displaced end of the bone into its socket, or opposite its socket, into which it is then drawn by muscular contraction. In many forms of dislocation the method is as harmful in practice as it IS wrong in principle, since the displaced head, as in some forms of dislocation of the hip, can only be drawn into its socket in this forcible manner by rupturing the resisting ligaments and tendons. In employing extension, traction is made in the long axis of the limb by the Surgeon, either with his hands or by means of a jack-towel secured by a clove hitch to the limb, or if more force is required, by multiplying pulleys. Counter-extension is in the meanwhile made in the opposite direction to the extend- ing force, but in the same straight line, either by the surgeon pressing with his heel or knee on the part above the dislocation, or by fixing the part with a jack-towel or suitable strap to a hook in the floor or wall. When sufficient extension has been employed to draw the head of the bone opposite its socket, the Surgeon should endeavor to guide it into its place. Before the introduc- tion of chloroform this was usually effected by the contraction of the muscles themselves, after the head had been drawn down by the extending force. In old-standing cases, before either manipulation or extension is employed, the adhesions, which offer the chief obstacle to re- duction, should be first broken down by cautiously rotating or circumducting the limb. When the rent in the capsule has united, the old socket been filled up, and a new joint formed, re- duction is of course physically impossible; but even then the breaking down of the adhesions may greatly improve the range of motion and consequent usefulness of the limb. In attempting the reduction of a long-standing dislocation, however, great care must be exercised, or irreparable damage may be done. Rather than use any great violence, it is in some cases better at once to cut down upon the dislocation and divide any bands which may be found preventing reduction. Not only may the accidents be- low enumerated be thus avoided, but reduction may be safely accomplished at later periods than was formerly possible, and with antiseptic treatment of the wound there is but little risk, and good movement of the joint may be expected. Among the accidents that hane attended violent efforts at reduc- tion may be mentioned : — i. Rupture of the main artery, vein or nerves. 2. Laceration of muscles and tendons. 3. Tearing open CONGENITAL DISLOCATIONS. I9I the skin and soft tissues, thus rendering the dislocation compound. 4. Fracture of the bone. 5. Inflammation and suppuration of the joint and surrounding parts ; and 6. The evulsion of the limb. How long after a dislocation may an attempt he made at rediic- tion ? — Sir Astley Cooper gave the time at between three and four months ; but since the introduction of chloroform successful cases have been reported after much longer periods. In an old- standing case the circumstances which should influence us in de- ciding whether an attempt at reduction should be made are : — the age of the patient, the situation of the dislocation, the presence or absence of pain, and the amount of usefulness of the limb. By the new method of open division of the adhesions about the joint, the time at which a dislocation can be reduced is consider- ably extended. This method, however, should not be employed unless the movements of the joint are much restricted, and the usefulness of the limb in consequence is impaired. The afte7' treatment consists in maintaining the part at rest by suitably-applied strapping and bandages, and in preventing or subduing inflammation by cold, evaporating lotions, etc. The part, however, should not be kept at absolute rest longer than is sufficient for the torn hgaments and other soft tissues to heal, lest adhesions form and stiffness of the joint ensue. Passive move- ments, therefore, should be cautiously begun after a few weeks ; and friction, shampooing, or galvanism subsequently employed to restore the tone of the wasted muscles. Where stiffness has oc- curred the adhesions should be broken down under an anaesthetic, provided there are no signs of active inflammation in the joint. Treatment of compound dislocations. — The dislocation should be reduced, the parts placed at perfect rest, and the case treated as a wound of the joint (see Wonnds of Joints). In consequence of the extensive laceration of the ligaments and other soft tissues, reduction is usually quite easy. When a compound dislocation is combined with a fracture of the bone, and there is much lacer- ation of the soft parts, amputation of the limb in the lower ex- tremity, and resection of the joint in the upper, will probably be required. Congenital dislocations are those that occur during intra- uterine life, and generally depend upon some malformation of the articular surfaces, rather than upon actual displacement of an originally normal articulation. They are all very rare, the so- called "congenital dislocation" of the hip, however, being the least so. Little or nothing, as a rule, can be done in the way of treatment. But continuous extension in the horizontal position with pressure over the trochanter has in the case of the hip been attended with considerable success. During the last few years 192 INJURIES OF SPECIAL TISSUES. several operations have been practised for congenital dislocation of the hip by Lorenz, Hoffa, Ogston, and others. Briefly, these operations consist in the division of contracted muscles and liga- ments, the gouging out of a new acetabulum in the ilium, and in the replacement of the remains of the head of the femur in the new socket thus formed. Wounds of joints. A joint may be merely punctured, or it may be laid freely upon. The wound may be of an incised, lacerated or contused character, and complicated by extensive injury of the surrounding soft tissues, or by dislocation or frac- ture of the articular ends of the bones. In the latter case the wound may be further complicated by the protrusion of the dis- located bones or the ends of the fragments. A wound of a large joint should always be regarded as serious, as owing to the difficulty of securing an efficient drain, and of preventing decomposition of the extravasated blood and serous secretion in the synovial pouches, septic or infective inflamma- tion is very liable to be set up, and rapidly run on to suppuration and disorganization of the joint. The peculiar absorptive power of the synovial membrane, moreover, favours the entrance of the chemical products of decomposition into the system, and conse- quently enhances the risk of Septic poisoning, to which, or to such infective processes as septicsemia or pysemia, the patient may succumb. Further, should he survive these earlier dangers of blood-poisoning, he is still liable to fall a victim to hectic, or to exhaustion or lardaceous disease consequent upon the pro- longed drain on the system attending the suppuration in the synovial membrane, the articular ends of the bones, and the sur- rounding soft parts. Medium-sized wounds are the most dangerous, as such cannot always be rendered aseptic nor drainage be effectually secured. Punctured wounds, when made with a clean instrament and in an oblique direction, may heal under appropriate treatment with- out any inflammatory or other trouble. Should septic, or infec- tive poisons, however, gain admission at the time of puncture, or subsequently through neglect of the wound, or should the joint not be kept properly at rest, a punctured wound may be followed by the most intense inflammation of the synovial membrane, and' total disorganization of the joint, with its attendant dangers of blood-poisoning. Extensive and lacerated wounds of joints, when not sufficiently severe to call for amputation or excision, axe not necessarily a source of extreme anxiety, as they usually per- mit of effectual cleansing and drainage, and under the use of an- tiseptics may heal up by granulations without giving rise to any serious constitutional disturbance. In such cases, however, bony CONGENITAL DISLOCATIONS. 1 93 ankylosis will generally ensue, though in some instances the car- tilages may escape destruction, and a fairly movable and useful joint may be obtained. S(^ns. — When the joint is laid freely open the nature of the in- jury is obvious, and any displacement or splintering of the bones can be seen or ascertained by the examination with the finger. When the wound is of a punctured character and the incision in the skin is some distance from the joint, the signs are not always so apparent. In such cases an account of the depth to which the instrument penetrated, and the direction in which it appeared to run, will help us to determine whether the synovial membrane has been entered. The escape of a glairy fluid like white of egg — the synovial secretion — will make the diagnosis certain. If in doubt, the case should be treated as if the joint had been opened, but on no account should the wound be probed for the purpose of setthng the point. Should inflammation ensue, the signs will be the same as those of acute arthritis (see Diseases of Joints). The treatment will depend on the size and character of the wound, the joint affected, the nature of the complications, and the age and constitution of the patient. The chief indications are to prevent inflammation and its attendant consequences, or if the injury is of a very severe character, to endeavor to save the patient's life by the sacrifice of his limb. Thus, if the wound is small and uncompUcated, an attempt should be made to convert it into a subcutaneous wound by sealing it with iodoformized col- lodion, or better by placing over it an antiseptic dressing, after having first thoroughly cleansed the skin and rendered it aseptic. One or more silver or chromicized gut sutures may first be inserted if the wound is tou large to be closed in this way. The hmb should be then placed on a splint at perfect rest, and cold applied by means of an ice-bag or by Leiter's tubes. Should inflammation follow, half a dozen leeches should be placed over the joint, and warm applications be substituted for the cold ; whilst should the local and constitutional disturbance increase and the joint become distended, aspiration should be practiced to reheve tension, opium given to soothe the pain, and the treatment persevered in. If, however, ///J is withdrawn by the aspirator, the joint should be laid freely open, drained, dressed antiseptically, and placed in the position in which, should ankylosis ensue, it will subsequently be of most use. If, notwithstanding free incisions, the suppura- tion goes on, continuous irrigation with some weak antiseptic fluid may be tried, or the whole limb kept continuously in a hot bath, the patient, if necessary, as in the case of the knee, being himself immersed. Should signs of saprsemia or exhaustion from hectic set in, amputation must be performed. 9 194 INJURIES OF SPECIAL TISSUES. Larger wounds of joints, especially when lacerated, should be thoroughly cleansed with antiseptic lotions, well drained, and dressed antiseptically. A counter-opening at a dependent' spot may in some cases be advantageously made, as for instance in the popliteal space in wounds of the knee, and a tube passed through the joint. Where there is extensive laceration of the soft parts, much comminution of the bones, or other complications of such a nature as to render it doubtful whether a useful limb can be ob- tained, the question of amputation or excision must be raised. In deciding on the propriety of an operation, the surgeon will be in- fluenced by the situation of the joint, and the probable power of the patient, either on account of his age or the general state of his constitution, to stand the acute inflammation and prolonged suppuration which must almost necessarily ensue if the limb is not removed. Briefly it may be said, that an injury in which the elbow might be treated in the ordinary way or by excision of the joint, would in the knee probably call for amputation ; that a wound in the wrist is generally more serious than one of the ankle ; and that the sacrifice of the limb is required for a much less severe wound of the knee than the ankle. INJURIES OF MUSCLES AND TENDONS. Contusions of muscles are very common as the result of falls, blows, kicks, or other violence. They may vary from a slight bruising with or without tearing of the muscle-fibres and blood- extravasation to complete pulping of the muscles. Signs. — In the slighter cases there is dull aching pain increased on movement, ill-defined and deep seated swelling, and later, ecchymosis as the blood makes .its way to the surface. Some stiffness or loss of power from partial atrophy frequently follows, and occasionally inflam- mation and abscess. Severe cases are frequently associated with other injuries of the part, as fracture of a bone, laceration of a large blood-vessel, etc. The //r(2/W(?/?/consists in keeping the part at rest with the muscle as much as possible relaxed, and in pre- venting inflammation by cold, lead and opium lotions and the like. Shampooing, massage, and galvanism may subsequently be neces- sary to restore any loss of power that may ensue. Wounds of xMUScles may be incised, lacerated, jjunctured, or contused. When the wound is made transversely, the divided ends, which gape widely, must be approximated by placing the limb in such a position as will' relax the muscle, and then united by aseptic sutures. When the wound is deep or parallel to the fibres, a drainage tube may be inserted to prevent the retention of the discharge by the bulging of the muscle. Union takes place by fibrous tissue. DISLOCATION OF TENDON. I95 Rupture of muscle may occur from a sudden and violent spasmodic action, or during vomiting, tetanus, or delirium. As examples may be mentioned rupture of the sterno-mastoid of the child in a difficult labor, the rectus abdominis in parturition, the biceps in raising weights, the supinator longus and gastrocnemius in lawn-tennis, the quadriceps extensor at foot-ball, and the adduc- tors of the thigh in riding. A sensation of tearing is often felt at the moment of rupture, followed by pain, and, if the rupture is complete, by loss of function. The rupture is indicated by a gap, above and below which is felt a swelling formed by the ends of the retracted muscle ; or blood is extravasated betv/een the rup- tured ends, occasioning a hsematoma. Rupture of the sterno- mastoid in infancy is said to be followed by contraction of the muscle and consequent wry-neck. The treatment consists in ap- proximating the divided ends as much as possible by position and by suitable bandages and splints, and in applying ice and evapo- rating lotions to control the blood extravasation, and to prevent inflammation. If a blood-tumor forms it should not be opened, unless suppuration occurs. 'Wounds of tendons may be divided into the subcutaneous and the open. The former are discussed under Tenotomy. When a tendon is divided in an open wound, its cut ends should be approximated by placing the parts on a splint in such a position that the muscle is as much as possible relaxed, and the divided ends then united by aseptic sutures. In long-standing cases an attempt may also be made to unite the cut tendon if the patient's general state of health is favorable, and there is no evidence of extensive destruction of the tendon or of its adhesion to the neighboring structures. When the ends of the divided tendon are found to have retracted and to be so far apart that they can- not be made to meet, one end may be split longitudinally, but not quite to the divided end, turned down and united to the other end by suture. In some cases where the divided ends will not meet they may be united by a leash of catgut. In other cases, as in the tendons of the fingers, the distal end may be united laterally to a neighboring tendon. Dislocation of a tendon from its sheath or groove without fracture or other injury occasionally occurs from a sudden twist or strain. It is indicated by pain and partial or complete loss of function of the affected muscle, swelhng and ecchymosis ; whilst on examination, the displaced tendon may sometimes be felt in its abnormal situation. The injury is most common about the ankle, and in the fore-arm, back and neck. The treatment con- sists in replacing the tendon by manipulation, breaking down any adhesions that may have formed, and retaining it in place (which 196 INJURIES OF SPECIAL TISSUES. is often difficult) bv a suitably-applied pad and bandage, or in the case of the ankle or wrist by a plaster-of-Paris bandage, and subsequently by a leather support. Rupture of a tendon may occur as the result of external violence or during some sudden and involuntary muscular action, and is very common in the plantaris and tendo Achillis, and somewhat less so in the biceps (see Injuries of the Upper and Lower Extremity). The tendon, except when the ends become widely separated, as generally happens in the case of rupture of the long tendon of the biceps, usually unites readily on the ends being approximated and kept at rest in that position. Evulsion or tearing out of a tendon with part of its muscle occasionally occurs as the result of catching the finger or thumb in a machine, on a hook, etc. Part or the whole of a digit is usually torn off, bringing away with it the fiexor tendon, this being more firmly attached to the bone than the extensor. In conse- quence of the tendon-sheath being thus left open, suppuration is liable to extend up it into the forearm. Free drainage of the wound and antiseptic dressings are then imperative. INJURIES of arteries. Contusion or bruising of an artery without laceration or other injury of its coats is of occasional occurrence, and is said to be followed by contraction and permanent diminution in the size of the vessel, and even by gangrene of the limb. Little that is defi- nite, however, is known of this injury. Rupture or subcutaneous laceration of an artery may occur as the result of any severe violence, but is perhaps most often due to the passage of a wheel over a limb, incautious attempts to re- duce an old dislocation of the shoulder, and excessive violence in breaking down adhesions in stiff joints. 1. The rupture may be partial, i. e., the internal and middle coats only may be torn. In such a case the external coat may subsequently yield to the pressure of the blood, thus laying the foundation of an aneurysm ; or the internal and middle coats may be folded inwards into the interior of the vessel, obliterating its calibre, and in this way may cause, esiDecially if the vein is also injured, gangrene of the limb (Fig. 56). 2. i'he rupture /nay be complete, i. e., all the coats may be torn across. Here in a similar manner the artery may become oc- cluded without any haemorrhage ; or blood, often in enormous quantities, may be poured out into the tissues of the limb. In either case gangrene may ensue, especially if the vein is also ruptured, and the injury occurs in the lower extremity. Some- RUPTURE OF SUBCUTANEOUS LACERATION. 197 Fig. 56. times the extravasated blood, particularly in the upper extremity, may become encysted, a sac being formed for it by the inflamma- tion and condensation of the surrounding tissues. This condition IS called a circumscribed traumatic aneurysm in contradistinction to diffused traumatic aneurysm, the term sometimes applied to the injury when the blood is simply extravasated into the tissues, though in this latter case the name ruptured artery is more appropriatte. The symptoms vary according to the nature of the injury. When the main artery becomes occluded there will be pain at the seat of rupture and cessation of the pulse below, while later gangrene will probably, though not invariably, ensue. Should the artery not be occluded, blood in large quan- tities will escape into the tissues, giving rise to a rapidly-increasing swelling, in which on pulsation can be detected, although a bruit may sometimes be heard ; the limb becomes cold, livid, and swollen, and the pulse, as a rule, can no longer be felt in the arteries below. When the extravasation is very large, constitutional symptoms of haemorrhage will also be present, and signs of gangrene, if the ruptured artery is in the lower limb, will probably soon supervene, since not only is the main arterial supply cut off, but the col- lateral flow and venous return are also im- peded by the pressure of the extravasated blood on the collateral arteries and veins. On the other hand, should the blood, as oc- casionally happens in the upper limb, become encysted, the swelhng will slowly assume the characters of an ordinary aneurysm. Treatment. — (a) When the artery is occluded all that can be done is to endeavor to prevent gangrene occurring by maintaining the warmth of the limb till the collateral circulation has had time to become established. Should gangrene occur, amputation must be performed as soon as a line of demarcation has formed, (b) When blood in large quantities is extravasated into the tissues the treatment will depend on the situation of the ruptured artery. Thus, in the case of the popliteal, amputation is usually called for, especially if the vein is also ruptured, as gangrene, for the reasons stated above, will almost invariably ensue if the main artery is tied either above or at the seat of rupture. In the case of the axillary, however, where the collateral circulation is much more Obliteration of the sub- clavian artery by the infolding of the internal and middle coats with- out injury of the ex- ternal coat. 198 IN7URIES OF SPECIAL TISSUES. free, the ruptured artery may be cut down upon and secured above and below the bleeding spot. Wounds of arteries may be divided into the penetrating and the non-penetrating. T. The non penetratiiiiy^ are those in which either the outer only, or the outer and middle coats, are notched or torn. Here the wound may heal, or the uninjured coat or coats may ulcerate, give way^ and haemorrhage ensue, or may gradually yield, as may also the cicatrice left on the healing of the wound, to the pressure of the blood, and lead to the formation of an aneurysm. 2. The peneiraiiuo are those in which the interior of the artery is laid open. In this case much will depend upon the size of the artery, and whether it is completely or only partially cut across, and upon the direction and size of the wound. (a) Wou7ids of large arteries, as the aorta or puhnonary artery, whatever their nature, are usually immediately fatal. (b) Wounds of arteries of the second and thij-d degree, as the femoral and brachial. If the artery is completely divided, and the edges of the wound are cleanly cut, repeated haemorrhages rapidly terminating in death will generally ensue ; but if the edges are uneven and ragged, as in the avulsion of a limb by machinery or by a cannon-ball, the external coat becomes twisted up, and the middle and internal coats retract and contract, a clot forms within the vessel, and no haemorrhage occurs. If the artery \% partially divided and the wound is made transversely to the long axis of the vessel, the longitudinal tension of the elastic coat causes the wound to assume a diamond shape, and severe haemorrhage will ensue ; but if the wound is made parallel to the long axis of the vessel, and is small (a mere puncture) it may heal by adhesive inflam- mation. In the latter instance the cicatrix may remain per- manent, or it may subsequently yield, iiroducing a traumatic aneurysm. (c) Wounds of medium-sized arteries, as the radial and tibials, are attended when the vessel is completely and evenly divided by sharp haemorrhage, followed by syncope, and temporary arrest from the formation of a clot. The artery may then become per- manently occluded ; usually, however, as the heart's power is restored the clot is washed away and haemorrhage recurs. In this way haemorrhages, alternating with temporary arrests, continue until death ensues from exhaustion. When the edges of the wound are uneven, or the artery is only partially divided, the effects are similar in each case to those described above in arte- ries of larger size. (d) Wounds of small arteries. — If the artery is completely divided it will usually become occluded in the way described TREATMENT OF WOUNDED ARTERIES. 1 99 under nature's method of arresting haemorrhage (p. 126) ; but if only partially divided such occlusion does not as a rule take place, and repeated heemorrhages follow. Complete division will then often suffice to cause its occlusion, a plan which was frequently resorted to when bleeding from the temporal was practised. When the wound through the soft tissues leading to a wounded artery is small or of a punctured character, the superficial part of the wound may close, whilst the blood continues to be extrava- sated from the wounded vessel into the deeper part, where it may become encysted from the condensation of the soft tissues around {^circumscribed traumatic aneurysm). Treatment OF wounded arteries. — i. When an artery is seen spouting in an open wound, a ligature should at once be applied to the bleeding end. Other methods of securing the vessel, as torsion or acupressure, may of course be used if preferred ; but as the ligature is almost invariably used at my own school, I shall, to prevent repetition of what has been already said under arrest of haemorrhage (p. 126), speak of ligature only in the context. 2. When the end of a large artery is seen pulsating, but not bleeding in consequence of it having been torn across, I should, myself, apply a ligature to it as a precaution, though by some this would not be considered necessary. 3. When an artery is exposed for some distance in its continuity, two ligatures had better as a rule be applied and the artery divided between them, especially if it be notched or bruised. 4. When an artery has ceased to bleed, even though the haem- orrhage may have been sharp, the wound should on no account be enlarged for the purpose of tying the bleeding vessel, unless it can be seen or felt ; since not only may it not bleed again, but as the bleeding has ceased it may also be difficult or impossible to find it. In such a case, however, especially if the patient is much collapsed, he should be watched for the first sign of any return of the haemorrhage, firm pressure in the meantime being applied over the wound, and where practicable over the course of the main artery above and below. The whole limb, moreover, should be carefully bandaged from below upwards. 5. When the hjemorrhage is moderate and clearly arterial, the external wound small, and the artery not seen, pressure should be applied in the way mentioned above, and will probably suffice. 6. When the bleeding is severe and evidently arterial, and the external wound is still open, whether the wound be deep, recent, inflamed, or sloughing, the well-established rule, to which, how- ever, there are of course exceptions, is to cut dotcn upon the bleed- ing point and apply a ligature to each end of the artery if divided, or above and below the wound if the artery is punctured or only 200 INJURIES OF SPECIAL TISSUES. Fig. 57. partially cut across. To do this it is generally sufficient to en- large the wound in the soft tissues ; but where the wound is on one side of the limb and the bleeding apparently comes from an artery on the other, a probe should be passed through the wound, its projecting point cut down upon, and the bleeding artery sought through this incision and tied as above. The object of this procedure is to prevent the necessity of making a very large wound. The reasons for t\iiig an artery at the place where it is wounded are : — i. It is often impos- sible to determine, without cutting down upon it, what artery is bleeding, and should the al- ternative plan of securing the main artery higher up be adopted, the wrong artery after all may be tied and the bleeding continue. Thus, for example, in a supposed wound of the femoral VA 11 it might be the profunda, or even a small mus- ^'\ ^V/ cular branch that was bleeding. 2. Even sup- posing the main trunk were the one wounded, the blood might still be carried by the collateral vessels into the artery beyond the ligature, either above or below the wound in the vessel, and bleeding recur from either the proximal or distal end (Fig. 57). 3. Should, moreover, ligature of the main artery higher up thus fail to arrest the haemorrhage, not only will the patient be further reduced by loss of blood, but the subsequent ligature, which will then probably in the end have to be applied to the bleeding artery in the wound, may through the extra interference with the collateral vessels induce gangrene of the limb. 4. Tying the main artery above is in itself in some cases a more dangerous and difficult procedure than enlarging the wound. The reason for applyini^ a ligature to both ends of the vessel if it is divided, or above and beloiv the wound if it is 7nerely punctured or only partially cut across, \^ that ligature of the proximal end only may be insufficient to arrest the h?emorrhnge, since_ the blood, as seen in Fig. 57, may be carried round by the collateral channels into the artery below the wound, and may thence escape by the open distal end. In some instances the above rule of cutting down upon and tying the artery at the wounded spot cannot be carried out. Thus, where the artery is inaccessible, as in punctured wounds of Diagram to illustrate the manner in which, after a lig- ature has been ap- plied at a distance from a wound in an arlerv, the blood may te carried back again into the artery above and below the wounded spot by collateral vessels. The arrows indicate the direction of the blood current. " TRAUMATIC ANEURYSM. 20r the tonsil, or about the angle of the jaw ,•* or where important structures would be damaged by enlarging the wound, as the tendons in the palm of the hand in wounds of the palmar arch, it may be necessary to tie in the former case one of the carotids, in the latter the brachial. Moreover, it may at times be safer to re- move a limb than to search for the bleeding vessel, as for instance in wounds of the posterior tibial artery in the upper third of the leg, especially if the injury is complicated by fracture. Again, it may not only be found impracticable to ligature the artery at the wounded spot, but also impossible to tie or even compress the main vessel nearer the heart, as for instance in wounds of the sub- clavian above the clavicle. Here all that can probably be done is to trust to pressure firmly appHed to the wound. Whilst cutting down upon a bleeding artery hgemorrhage should be restrained by the use of an Esmarch's bandage, or by the tourniquet or the fingers applied to the main artery above the wound ; and in the case of a wound of the external iliac or gluteal, by Davy's lever passed up the rectum and made to com- press the common iliac. Where it is impracticable to control the bleeding in any of these ways, the wound, if necessary, should be sufficiently enlarged to admit one or two fingers, and the bleeding vessel having been recognized by the escape of warm blood, should then be compressed by the finger, the wound farther enlarged, and the artery secured with the aid of an assistant be- fore the finger is removed from the bleeding spot. Should gangrene ensue after ligature, and spread rapidly, ampu- tation must be performed at the seat of ligature ; but if it involves only one or two fingers or toes, or spreads slowly, a line of de- marcation should be waited for before amputating. Traumatic aneurysm. — Two forms are described, the diffuse and the circumscribed. The diffuse is practically a ruptured or wounded artery with extravasation of blood into the tissues. There is no attempt at the formation of a sac, and the term aneurysm applied to it is misleading. (See Ruptured Artery, p. 196.) The circumscribed may be formed in several ways, as already stated under Rupture and Wounds of Arteries. Thus, i. An ar- tery may be wounded, pressure be applied, the external wound heal, and blood slowly escape into the tissues. 2. An artery may be wounded, heal, and the cicatrix subsequently yield. 3. An artery may without external wound be punctured by a fragment of fractured bone, or torn in reducing a dislocation, and blood in either case be extravasated into the tissues. 4. An artery may be wounded but not penetrated, and the uninjured coat or coats may yield to the pressure of the blood. In all of these cases the 202 INJURIES OF SPECIAL TISSUES. soft tissues around become condensed and form the sac of the aneutysm. Where the aneurysm is produced by the yielding of any portion of the arterial coat, this at first will form the sac, but sooner or later it will give way, and the sac will then be formed by the condensation of the soft tissues around, as when the blood escapes directly into the tissues. The course, termination, and signs of a circumscribed traumatic aneurysm are similar to those of a spontaneous aneurysm. The treatment, however, inasmuch as the artery in the neighborhood of the sac will probably be healthy, differs from the treatment of a spontaneous aneurysm, in that the artery may be tied immediately above the sac, or the sac may be laid open and the vessel tied above and below. Thus, if the injured artery is small, it may be tied above and below ; if large, immediately above, un- FiG. s8. less the aneurysm threatens to —^ i«s^ ii?*^ ^^ burst, under which circum- 5^ ^ gf -^ Stances the aneurysm should be laid open and the artery tied where it enters and leaves the sac. A RTERIO VENOUS ANEURYSM is a pulsating tumor depending f upon an abnormal communica- tion of an artery with a vein. There are two kinds : in one *^-2 A \j^ "i'>-i f*^ tii tci lai blood is forced into the vein at each beat of the heart, causing its walls to be dilated into a fusi- form or sac-like swelling {aneurysmal x^arix) ; in the other (Fig. 5815), the blood first passes into a small aneurysm formed by con- densation of the tissues between the artery and vein and thence into the vein, the dilatation of the vein being consequently less than in the preceding variety {luiricosc aneurysm) . Both forms may occur spontaneously, but are usually the result of some in- jury, as a stab, wounding the walls of both vessels. The lesion was of common occurrence at the bend of the elbow when vene- section was in vogue, the lancet passing through the median basilic vein and bicipital fascia into the subjacent brachial artery. Si\^ns. — An aneurysmal varix gives rise to a pulsating tumor in which a peculiar bru't, compared to the buzzing of a fly in a l)Tper box, is heard. The artery is dilated and thinned above owing to the impediment to the circulation, and is smaller below ; whilst the vein is dilated, especially above, and j^ulsates. In WOUNDS. 203 varicose aneurysm, in addition to the above signs, wliich are com- mon to both forms, an ordinary aneurysmal bruit can be heard. Treatment. — In aneurysmal varix some form of elastic support should be applied, or if the swelling is increasing, the artery tied above and below its point of communication with the vein. In varicose aneurysm pressure may first be applied to the artery above the sac, combined with direct pressure on the sac. If this fails the artery must be tied above and below the sac, since if left to nature there is grave danger of rupture and haemorrhage. When the carotid or the femoral artery and the adjoining veins are the subject of the lesion, no operative treatment as a rule should be undertaken unless the lesion is recent, and the blood as well as passing into the vein is being likewise extravasated into the tissues, and threatening to break through the external wound. In such a case, should pressure applied to the main artery and over the site of the wound fail, the artery must be cut down upon and tied above and below the wound. Unless pressure controls the hsemorrhage from the vein, a lateral ligature must be placed on the wound in its wall, or if the wound is too large to admit of this being done, the whole vein may be tied above and below the wound, and then divided between the ligatures. INJURIES OF VEINS. • Rupture or subcutaneous laceration of a vein occasionally oc- curs from causes similar to those producing rupture of an artery, an accident moreover with which it is frequently associated. When the vein is of large size, much blood may be extravasated into the tissues and may produce gangrene by pressure on the vessels carrying on the collateral circulation, though such a result is much less common than after rupture of an artery. The blood, except when the extravasation is large, is usually absorbed, but may break down and suppuration ensue. Wounds. — Punctured and incised wounds, when small and parallel to the long axis of even large veins, readily heal by adhe- sive inflammation without obliteration of the lumen of the vessel. At times, however, a clot may form in the wound, and successive layers be deposited upon it until ultimately the vein is occluded. When a vein is completely cut across, as in amputation, it usually collapses as far as the next pair of valves, a clot forms as high as the first collateral branch, and the vein becomes permanently oc- cluded in a way similar to that described under Healing of Wounded Arteries. In consequence, however, of the vein-wall containing less elastic and muscular tissue than an artery, bleed- ing sometimes continues unless stopped artificially. 204: INJURIES OF SPECIAL TISSUES. Treatment. — When the wound is a mere puncture in the con- tinuity of the vein, unless it is found that pressure will control the haemorrhage, the coats should be nipped up by forceps and a lateral ligature applied. If a vein continues to bleed during an amputation, it should be tied like an artery. A large wound, or one made in the longitudinal axis of a large vein, necessitates ligature of the vein in two place, and the division of the vessel between the two hgatures. T.\\t dangers of wounds of veins ACC.). Their response, however, to the continuous current becomes less and less till they finally cease to contract at all. As a consequence of the degeneration of the affected mus- cles their opponents undergo adaptive shortening, thus producing various deformities, as for example the hammer fingers {main en griffe) seen after division of the ulnar nerve. The treatment varies according as the wound of the nerve is recent or of long standing. In the former case the nerve should be sought in the wound, the divided end sutured, the limb placed at rest on a splint in such a position that the united ends are not subjected to tension, and every effort subsequently made to ob- tain healing of the wound of the soft parts by the first intention. If the divided ends of the nerve are lacerated or contused, the injured portions should be cleanly cut away before applying the sutures. If the nerve is only partially divided the divided parts should be sutured. The sutures, consisting of fine China twist, should be passed v.'ith a small curved needle through the sheath of the nerve in four or five places. At St. Bartholomew's one of the sutures is generally passed completely through the nerve, a quarter of an inch from the divided ends, to ensure a better hold. In every recent wound it should be as much a matter of routine to suture large nerves if divided, as to tie wounded arter- ies. If the nerve does not unite, an attempt may be made to procure union after the wound is healed, as may also be done in long-standing cases of non-union, though many months or even a year or two may have elapsed. An incision over the ununited ends should be made parallel to the nerve, the bulbous upper end of which can generally be felt through the soft tissues. The ends, which may have retracted so as to be as much as an inch or more apart, should be sought, the bulbous ends shaved away little COMPRESSION OF A NERVE. 20'J ■ by little with a sharp scalpel till plenty of nerve-fibres are seen on the surface of the section, the lower end also refreshed and the two united in the manner described above. Where the ends are embedded in much cicatricial tissue they should be freed by careful dissection, and when much separated stretched so as to bring them into apposition. If the nerve is only partially di- vided, and the divided portions are bound down by cicatricial tissue, the injured segment of nerve, in its entire thickness, should be cut away before applying the sutures. In some in- stances sensation may return within twenty-four hours of suture ; but it may be more than a year in long-standing cases before the function of the nerve is restored. In the meanwhile the nutrition of the parts supplied by it should be promoted by warmth, and the muscles prevented as much as possible from degenerating by galvanism, massage, friction, and passive movements. Transplantation of nerves or nerve-grafting. — since the publi- cation of Mr. Mayo Robson's successful case of transplantation of a portion of the posterior tibial nerve taken from an amputated limb in the gap left in the median nerve on the removal of a tumor, the operation of nerve-grafting has become a recognized surgical procedure. In some cases, also, a piece of nerve has been taken from an animal for the same purpose. An attempt to restore the function of the nerve in this way may be made where the proximal and the" distal ends of a divided nerve cannot be brought into apposition, as, for instance, after a portion of nerve has been destroyed in a compound fracture, or after a portion of nerve, damaged by the contraction of cicatricial tissue, by the formation of callus or by the growth of a tumor in its substance, has been removed. The conditions for success are : — Great care in dissecting out and handling the nerve, its immediate transfer- ence, the employment of a single suture at each end, the avoid- ance of all tension, strict asepsis, and immediate union of the wound of the soft parts. Subcutaneous rufi'ure of a nerve is rare, but is occasionally met with as the result of a severe twist or wrench. I have seen it twice in the peroneal nerve where it winds round the head of the fibula. It is attended with severe pain at the time of injury, perhaps also referred to the periphery of the nerve, and the gradual foimation of a bulbous sweUing on the nerve immediately above the rupture. The same effects follow as in division of a nerve in an open wound. The treatment is also similar. In the evulsion of a hmb the nerves may be torn away from their roots, as in the instance of a boy recently in St. Bartholo- mew's Hospital, whose leg was torn off above the knee, bringing with it the whole sciatic nerve as far as its origin from the spinal ■ cord. 208 INJURIES OF SPECIAL TISSUES. Compression of a nerve occasions numbness and tingling, and, if severe and prolonged, partial or complete paralysis of the parts supplied by it, and the series of changes described in the last section. As examples may be mentioned crutch palsy, due to the pressure of a crutch upon the large nerves in the axilla ; the dropped wrist, from the involvement of the musculo-spiral nerve in the callus in fracture of the humerus ; the tingling, numbness and partial paralysis sometimes following dislocations of the shoulder from the pressure of the head of the displaced bone on the brachial plexus ; the pain c?.used by the pressure of a tumor on a nerve ; the " pins and needle'^. " felt in the feet after sitting on the edge of a chair from compression of the sciatic nerve, etc. The treatment consists in releasing, if practicable, the nerve from the compressing agent. If a wound of the soft tissues is necessary to accomplish this object, healing without suppuration should be obtained, if possible, as otherwise the nerve may become again compressed by the resulting scar-tissue. Contusions of nerves. — A familiar example of this injury is a blow on the ulnar nerve, as it lies behind the internal condyle. There is intense pain at the spot struck, and shooting pains and "pins and needles" in the parts supplied by the nerve. These symptoms pass off shortly, but occasionally they may be more severe and last for several weeks, in which case there is probably some effusion of blood in the nerve. In rare instances ascending neuritis, persistent neuralgia, or even paralysis, and changes similar to those observed after complete division of a nerve, may follow. Foreign bodies in nerves. — A portion of a needle broken off in a nerve, the lodgment of small shot from a gun accident, etc., may give rise to inflammation of the nerve, persistent irritation and pain at the injured spot, spasm in the muscles, and pain or tingling in the parts supplied by the nerve. Such accidents have occasionally been followed by epileptiform convulsions. The treatment is to cut down upon and remove the foreign body. DISEASES OF BONE. 2O9 SECTION IV. Diseases of Special Tissues. diseases of bone. Diseases or Bone may be classified into those depending upon — I. Inflammation and its results. 2. Simple defect or increase in nutrition. 3. Constitutional dyscrasia ; and 4. New growths. I. Inflammation and its Results. Inflammation of bone. — In studying inflammation of bone it should be borne in mind that it is in the soft parts of bone, — the periosteum, the medullary membrane, and the delicate vascular connective tissue which pervades the Haversian canals and cancelli, that the inflammation occurs, and that the pathological process, though somewhat modified by the hard and resisting nature of the osseous framework, is essentially similar to that which occurs in the soft tissues. The same vascular and exuda- tive changes ensue, and are accompanied by the like phenomena of redness, heat, pain and swelling. The inflammation, moreover, may be of a simple and local, or of a diffuse and septic or in- fective character, and variously influenced by such constitutional states as syphihs, struma, gout, and rheumatism, or by the pres- ence of miliary tubercle. Further, it may terminate in resolution, or, in sclerosis, caries, necrosis, or suppuration, conditions com- parable to fibroid thickening, ulceration, gangrene and suppura- tion of soft parts. On account of the intimate connection of the bone with the periosteum and medullary membrane, inflammation is seldom limited to any of these structures, and when one is affected the others generally soon become also involved. Ac- cording, however, as the inflammation begins in, or is chiefly confined to the periosteum, medulla or bone, the disease for con- venience is spoken of as periostitis, osteomyelitis, and osteitis. Periostiiis, or inflammation beginning in or chiefly affecting the periosteum, may be acute or chronic. Acute Periostitis may occur (i) as a simple local, or (2) as a diffuse and infective inflammation, the former being generally the result of some local injury, the latter of some severe constitutional dyscrasia. Q* 2IO DISEASES OF SPECIAL TISSUES. Acute simple periostitis is generally the result of a local injury, and occurs most frequently in the tibia, that bone being most ex- posed to injuries, as kicks, blows, etc. Pathology. — The inflam- mation is of the ordinary, simple kind, and usually terminates in resolution ; occasionally, however, suppuration occurs, attended by some superficial necrosis, or the inflammation may become chronic. Symptoms. — There is acute throbbing pain, increased on pressure, and worse at night. If the bone is superficial, as in the case of the tibia, there may be also local redness of the skin, oedema, heat and evident swelling over the bone, followed, should suppuration occur, by fluctuation. Treatmeut. — Rest, elevation of the part, and the application of cold, with perhaps a few leeches, will usually suffice; but should suppuration threaten, hot boracic poultices should be put on, and a free incision made as soon as pus has formed. Opium may be required to relieve pain. Diffuse infective periostitis, sometimes known as " acute ne- crosis," is always of a grave nature, as not only may it lead to the death of large portions of bone, but it may also terminate fatally from septicaemia or pyaemia. Cause. — It generally occurs in debilitated children, following upon some slight injury, as a blow or fall upon the part. It is, however, probable that it depends upon some constitutional mis- chief, and that such local influences as injury, cold, etc., although they may act as slight exciting causes, have little or nothing to do with it. It also occurs as a sequela of the continued fevers. From the constancy with which micro-organisms {staphylococci, streptococci) have been found in the pus, it is now generally be- lieved to depend, chiefly or in part, in some way, on their pres- ence in the system. Pathology. — The disease appears to begin generally, as here described, as an acute infective inflammation of the periosteum which rapidly spreads through the bone to the medulla ; but some believe that it begins in the medulla, and thence spreads to the periosteum. In any case pus is rapidly formed beneath the periosteum, stripping the latter from the bone, which, thus cut off from its nutrient supply, dies. Sometimes the whole diaphysis may thus perish. The epiphyses, however, gen- erally escape, as they are sup|;lied by a separate set of vessels, which, as long as the epiphysial caitilage remains unossified, do not anastomose with those of the diaphysis. For the like reason the joints usually escape, but as the periosteum is continuous with their capsular ligament the inflammation may at times spread to them through this structure. Symptoms and diagnosis. — The disease is attended with severe inflammatory fever, and is often preceded by a rigor, and some- times accompanied by delixium. The shafts of the long bones CHRONIC PERIOSTITIS. 211 are most frequently attacked, especially the lower end of the femur, the tibia, and the humerus. The nature of the local mis- chief may not at first be recognized, and the affection may be mistaken for acute rheumatism, but the deep-seated intense pain, which becomes agonizing on the least attempt at handhng, soon makes it probable that the periosteum is affected. The soft parts covering the bone become swollen and oedematous, the skin white and waxy looking, and later dusky red, clearly indicating the presence of deep-seated suppuration. From abscess, how- ever, it cannot always be diagnosed, except by an exploratory incision which will disclose bare bone. Should one of the neigh- boring joints become involved the symptoms become more urgent and the local signs of acute arthritis supervene. Signs of blood- poisoning now frequently manifest themselves, and the patient may rapidly succumb to septicaemia or pycemia. Should recovery take place it is usually with the loss of considerable portions of bone, and after months of suffering, or it may be with a stiff joint or the loss of a limb. Treatment. — Immediately the nature of the disease is discov- ered a free incision should be made to the bone under the strictest antiseptic precautions, and the wound dressed with sal alembroth gauze or similar antiseptic material. x\bundant fluid nourishment, and probably stimulants, will be required, with large doses of qui- nine if symptoms of blood-poisoning supervene. Should a joint become involved and suppurate it must be laid freely open and dressed antiseptically ; whilst if the wound leading to the dead bone becomes septic, and signs of saprsemia occur, the question of amputation must be raised. The necessity of an early incision cannot be too strongly insisted upon, as by its means extensive denudation of the bone and necrosis may frequently be averted, and the risks of blood-poisoning greatly reduced. Should necro- sis occur, the dead bone will have to be removed when it has be- come loose. Subperiosteal resection of the whole of a diaphysis is recommended by some surgeons as a means of preventing or lessening the danger of blood-poisoning, but the operation does not appear to have met with much favor. During the last year I removed the whole diaphysis of the ulna, with the result that all constitutional symptoms ceased at once and the boy made an ex- cellent recovery, but up to the present there is no sign of the formation of new bone. Chronic periostitis is nearly always associated with some amount of inflammation of the subjacent bone, and is generally limited in extent, constituting what is commonly called a node. Cause. — It is mostly due to syphilis, but may be of rheumatic, tuberculous, or traumatic origin, or caused by the spread of inflammation from an 212 DISEASES OF SPECIAL TISSUES. Fig. 59. ulcer of the soft parts. It sometimes occurs as a sequela of typhoid and other of the continued fevers. Pathology. — The periosteum becomes swollen and thickened from small-cell-infiltration of its deeper layers, whilst a similar infiltration occurs in the Haversian canals of the contiguous bone. The inflammatory material may, under appropriate treatment, be absorbed ; or it may undergo ossification, or more rarely break down into pus leading to caries or sometimes to necrosis of the subjacent bone. The ossifying variety (see Fig. 59), or the hard node as it is called when cir- cumscribed in extent, is more common in the long bones, the suppurating or soft node in the bones of the cranium. A suppurating node in the ex- tremities is probably always of tuberculous origin; a suppurating node on the cranium is generally syphilitic. Symptoms and diagnosis. — The patient com- monly complains of a deep-seated, dull, boring pain, worse by night than by day. On examina- tion a hard, irregular swelling of the bone is felt, not as a rule very painful on handling, and not accompanied by redness of the skin. On the head the swell'ng is soft and fluctuating, and may have to be diagnosed from an abscess, new growth, or sebaceous cyst. Its evident connection with the bone, the history of syphilis, the effect of treatment, and if still in doubt, exploration with a grooved needle, will clear up the point. Treatment. — Iodide of potassium is useful in all forms of chronic periostitis, but it may often be necessary to give it in large doses. In the syphi- litic variety it generally acts like a charm. In the rheumatic an ointment containing iodide of potassium, mercury, and belladonna may also be used locally with benefit. In the tuberculous, cod-liver oil and syrup of the iodide of iron should be given. In all forms opium internally is indicated when there is much pain. The soft node on the cranium should on no ac- count be opened, even where the skin is inflamed and appears about to give way, as iodide of potassium will then often promote complete resolution. OsTEO-MYEi.rris, or inflammation beginning in or chiefly affect- ing the medullary membrane and cancellous tissue of bone, may like periostitis be acute or chronic. Acute osteo-mvelitis may also occur as a simple localized or as a diffuse septic or infective itifiamniation. Simple acute osteo-myelitis is generally the result of an injury Chronic periostitis. (From St. Bar- tholomew's Mu- seum.) DIFFUSE INFECTIVE OR SEPTIC OSTEO-IVIYELITIS. 2T3 Fig. 6o. exposing the medulla as a compound fracture, or the sawing of a bone in amputation. In the latter instance it is usually quite local, though at times it may spread a slight distance up the bone and cause a localized central necrosis. The sequestrum in such a case has commonly a conical form, in consequence of the inflam- mation as it spreads up the medullary cavity affecting less and less of the surrounding bone lamellae. Beyond keeping the wound perfectly aseptic and removing the sequestrum when loose, no special treatment is required. Diffuse infective or septic osteo-myelitis. — Cause. — This variety may be idiopathic (infec- tive) or traumatic (septic) in origin. The idio- pathic variety, like acute infective periostitis, usually occurs in young and either debihtated or strumous subjects without apparent cause, and also like it is generally believed to depend upon the presence of micro-organisms {staphylococci, streptococci^ in the system. Indeed, as already stated, the disease described as infective perios- titis is believed by some pathologists always to begin as an infective osteo-myelitis. The traumatic variety appears only to occur as the result of injury to the interior of bone, especially where the cancellous tissue is exposed, and where the wound is not kept aseptic. Hence it is most often met with after compound fracture, excisions, amputations, and the operation of trephining the skull. Pathology. — Whether iodopathic or traumatic the inflammation rapidly spreads through the bone to the periosteum, and diffuse suppuration ensues, the danger of sapraemia, septicgemia, and pyaemia being even greater than in diff"use perios- titis, in consequence of the large patulous veins of the medulla becoming filled with purulent and either infective or septic thrombi. The iodopathic form would appear to depend upon the presence of infective micro-organisms {staphylococci, streptococci^ in the system ; the traumatic usually on these micrococci introduced from without, and hence is prob- ably preventable if the wound is kept strictly aseptic. Should the patient in either case not be carried off in a few days by saprsemia, septicaemia, or pyaemia, the whole diaphysis may die, or suppuration occur between the diaphysis and epiphyses, and de- struction of the neighboring joints ensue (Fig. 60). In less se- vere cases the medullary membrane may become thickened, and Acute osteo-mye- litis of the tibia, with destruction of the knee and anklejoints (St. B a r t h olomew's Hospital Mu- seum.) 214 DISEASES OF SPECIAL TISSUES. • only the layers of bone immediately surrounding it may die {cen- tral ?iecrosis) . The symptoms of the idiopathic form are similar to those of acute infective periostitis (see p. 210), save that at first there may be less oedema and swelling of the soft parts ; but soon the periosteum becomes involved, and then the one disease can hardly be distin- guished from the other. The septic or traumatic variety is at- tended by high fever, rigors, and swelling and oedema of the limb, and a puffy tumor of the scalp when the diploe is involved. In the case of an amputation the wound looks imhealthy, the flaps separate, and the periosteum recedes, leaving the end of the bone exposed. A fungous mass of granulations generally pro- trudes from the medulla of the divided bone. Treatment. — In the idiopathic variety an early and free in- cision through the periosteum to the bone should be at once made. In traumatic cases every effort should be directed towards rendering the wound aseptic, and ensuring an efficient drain. Of late considerable success appears to have attended the scraping out of the inflamed medulla from the affected bone, and then in- sufflating the cavity with iodoform. The constitutional treatment should be similar to that described under acute periostitis. Should blood-poisoning {saprcemia) threaten, the question of amputation must be raised. If this is decided on it should be done through the knee-, elbow-, or shoulder-joints, if the bones of the leg, fore- arm, or arm are involved, so as to avoid again cutting through cancellous bone. Amputation at the hip-joint is in itself so serious an operation that it is an open question whether it should be undertaken in the case of osteo-myelitis of the femur. The operation, however, is less dangerous than formerly, and as it holds out the only chance, its propriety should cert.iinly be dis- cussed if the case is seen early. When septicaemia or pyaemia is already fully established amputation should not be undertaken. Chronic ostko myelitis can hardly be distinguished from chronic osteitis. Indeed, in chronic inflammation of bone the soft tissues lining the medulla, cancellous spaces, and Haversian canals are generally equally involved in the process, as is also frequently the periosteum. At times, however, the inflammation may be more or less limited to the medullary membrane, and to the layers of bone contiguous to it, and may then terminate either in central necrosis, or in ossification and the consequent oblitera- tion of the medullary cavity {osteo- sclerosis^. OsTEiTLS, or inflammation of the bone itself, is always associated with some amount of inflammation of the periosteum and of the medullary membrane, and hence it is often difficult in any given pathological specimen to determine whether it is one primarily of OSTEITIS. 215 osteitis, periostitis, or osteo-myelitis. It may occur in any bone, or in any part of a bone, but is most frequent in the cancellous ends of the long bones, in the cancellated bones of the tarsus and carpus, and in the bodies of the vertebrae. The term osteitis as here employed refers to a chronic or subacute inflammation of bone, acute inflammation of bone being practically indistinguish- able from acute osteo-myelitis or periostitis, under which it is included. The causes may be predisposing and exciting. Among the former may be mentioned syphilis, tubercle, and rheumatism ; among the latter any local injury, and exposure to cold, damp, or malarial influences. Fig. 61. Pathology. — As in inflammation of soft parts, the first stage of osteitis is one of increased vas- cularity, the bone appearing red and injected from dilatation of the blood-vessels in the Haversian canals. Next, exudation and escape of leucocytes take place into the dehcate con- nective tissue occupying the space between the blood vessels and the bony walls of the Haversian canals and cancelli respectively, and the cells of the connective tissue itself also undergo prolifera- tion. The earthy salts are loosened from their connection with the animal matter, and the bone lam.ellge and trabeculse are softened, eaten into as it were, and absorbed by the pressure of the in- ]^ flammatory material which here, as elsewhere, assumes the form of a small-cell-exudation {granulation-tissue^. The bone is destroyed Rarefvin° irregularly, appearmg crescentically eaten out (St.' Banhqio- into spaces known as Howship's lacunce, in each Kh!Ieuni.)°^^"^ of which, and immediately in contact with the bone, are found large cells {osteoclasts') containing many nuclei. It is believed that these osteoclasts, which are in some way de- rived from the inflammatory exudation, take an important though unknov/n part in the absorption of the bone. The bone- corpuscles themselves are generally thought to be entirely passive, and to take no part in the rarefying process. In this way the Haversian canals and cancelli become dilated, the compact bone being thus converted into cancellous, and the cancellous further widened out (see Fig. 61). The periosteum and medullary membrane generally appear thickened. In inflamixiation of bone, as in inflammation of the soft tissues, several terminations may occur. Thus, resolution may take place, and the bone resume more or less its normal appearance ; or the inflammatory material may undergo ossification, and the bone beome hard and indurated osteitis. 2i6 DISEASES OF SPECIAL TISSUES. {osfeo-sclerosis or osteoplastic osteitis), a change comparable to that which occurs in the fibroid thickening of the soft tissues ; or the rarefying process may continue until the affected portion of bone is completely destroyed by the granulation-tissue {rarefy- ing osteitis or caries), a termination similar to ulceration ; or if the inflammation is more acute, the vessels in the Haversian canals may become strangulated by the pressure of the inflammatory material, and the inflamed portion of bone die {necrosis), a termination of like nature to gangrene of the soft tissues; or finally, the inflammatory material may break down into pus {sup- pu ratio?}), and an abscess be produced in a way similar to that which occurs in the soft parts. Signs and diagnosis. — The signs vary according to the intensity of the inflammation, and are similar to those of simple periostitis, and when, as is frequently the case, the osteitis is associated with inflammation of the periosteum, the two can hardly be distin- guished. There is deep-seated boring pain, worse at night and increased on exercise, perhaps some slight oedema, but seldom any redness unless the periosteum is involved, and then only when the bone is superficial. There is at first no swelling of the bone, though subsequently it may become perceptibly enlarged. The deep-seated character of the pain, its increase and long con tinuance after percussion of the bone, with, possibly, relief by steady pressure, and the absence of much, if of any, perceptible swelling, point to osteitis ; whereas pain of a more superficial character and increased on pressure, together with an earlier ap- pearance of swelling, indicates periostitis. From chronic abscess it is not always possible to diagnose osteitis, though in abscess the pain is generally more localized, and a slight yielding of the bone at one spot may be discovered. Treatment. — Rest, elevation of the part, a few leeches in the more acute forms, the administration of iodide of potassium and in some instances mercury, the application of small blisters from time to time in the more chronic cases, and opiates internally, with opium or belladonna liniments externally to relieve pain. In obstinate cases linear osteotomy, which consists in making an in- cision down to the inflamed bone, and continuing it into the bone substance by means of a Hey's saw or a chisel, will, by removing tension, generally give permanent relief and prevent further changes ensuing. Should the existence of an abscess be sus- pected, the bone may be drilled in several directions or a small trephine applied. Where there is a taint of gout, struma or rheumatism, appropriate remedies for these affections must, of course, be given. Rarefying, osieitis, caries, ok ulceration of bone, is com- RAREFYING, OSTEITIS, CARIES, OR ULCERATION OF BONE. 217 Fig. 62. parable to ulceration of the soft tissues, and is characterized by the rarefaction, molecular death, and loss of substance of the bone-tissue, and the tendency of the inflammatory exudation to caseous degeneration and suppuration. Cause. — Tubercle and syphilis are undoubtedly the most fre- quent causes of caries. Sometimes, however, caries would appear to depend on a debilitated state of the system, in which there is no evidence of tubercle or syphilis, and to which the terra struma may with propriety be applied. Occasionally it is the result of an injury. Pathology. — Caries, as has already been stated, is one of the terminations of osteitis ; indeed, it is often somewhat difficult to say where osteitis ends and caries begins. In caries the thinned and eroded trabeculje of the inflamed bone become still further thinned and eroded by the action of the small-cell- exudation and osteoclasts, until the aff'ected portion of the bone is completely de- stroyed and replaced by granu- lation-tissue. Under appropri- ate treatment ossification of the granulation-tissue may occur ; more often, however, especially in tuberculous cases, the in- flammatory material undergoes caseation, and may break down into pus and an abscess be formed, which may remain as such in the interior of the bone or under the periosteum, or later may open externally, giv- ing rise to a sinus leading to the disease. In other cases the small-cell-exudation undergoes further proliferation, and either makes its way to the surface of the bone (Fig. 62), and thence through the soft tissues and skin, or it perforates the articular cartilage and enters a joint {/ungating caries). At other times the granulation-tissue merely destroys the bone without the pro- duction of pus {dry caries or caries sicca) ; whilst again the in- flamed bone in the centre of the area may die en masse from the cutting- off" of its blood supply, and become separated from the surrounding bone, forming a sequestrum at the centre of the carious spot {caries necrotica). In tuberculous cases giant-cells and the tubercle bacillus have been discovered in the inflamma- tory exudation. The favorite seat of caries is the cancellous tissue, whereas that of necrosis is the compact. Caries is most frequently met with in the bodies of the vertebrae, in the cancel - 10 If^^^^ Diagram of caries. A. Granulation-tissue; B. Small-cell-exudation destroying the bone: c. Small-cell-exudation between vessels and walls of the Haversian canals; D. Normal bone. 2l8 DISEASES OF SPECIAL TISSUES. lous ends of the long bones, and in the short bones of the tarsus and carpus. The tubercuhir variety, to which many restrict the term caries, is distinguished by the more maiked tendency of the inflammatory material to undergo caseous changes; by the soft, greasy, crumbling condition of the bone ; by the more extensive destruction of the bone ; and by the little tendency shown towards the formation of new bone and repair. The swiptoms at first are those of local chronic osteitis and periostitis, namely some pain, with oedema and swelling of the soft parts over the inflamed bone ; but soon the inflammatory products make their vvay to the surface, and a sinus or sinuses leading to the carious bone form. The sinuses have generally a button of oedematous granulations at their entrance, and a thin, purulent, and commonly foul- smelling discharge containing bone salts in solution escapes from them. On probing or on enlarging the sinus and introducing the finger, the bone is felt to be soft and friable, breaking down and readily bleeding. Caries of the verte- brae and of the articular ends of bone will be described under Diseases of the Spine and Joints respectively. The treatment will necessarily vary according to the situation of the disease. When accessible the carious bone may be gouged away. In doing this it will be known when all the carious bone is removed by the part becoming hard to the gouge. The sinuses should be well scraped with a Volkmann's spoon, and the wound dressed with iodoform-glycerine emulsions and iodoform gauze. Unfortunately, however, after the carious part has been removed the disease may recur in the surrounding bone, so that in caries of the tarsus or carpus it may be better to excise the whole of the affected bone or bones, or where the caries is extensive, to am- putate the foot or hand. NecrosIs is the death en masse of the whole or part of a bone, and is analogous to gangrene of soft parts. It is, however, of more frequent occurrence than gangrene, inasmuch as, owing to the hard and resisting nature of bone, the vessels are more liable to become compressed by the inflammatory effusion, and the blood-supply in consequence to be cut off. For the same reason necrosis is more common in compact than in cancellous bone ; whilst the reverse holds good with regard to caries. Hence, moreover, necrosis is more frequent when the inflammation is acute, caries when it is less acute, as in the latter case the bone- trabeculoe slowly yield anil disintegrate before the less quickly- produced inflammatory exudation, and the vessels consequently esca])e compression. '1 he bones most often affected are the tibia, the femur, the lower jaw, the bones of the skull, and the phalanges of the fingers. NECROSIS. 2t9 Fig. 63. Cause. — The immediate cause of necrosis, like gangrene, can in all cases be traced to the cutting off of the blood-supply of the bone, and this again may be due to inflammation, injury, or more rarely, as in the necrosis which sometimes occurs in old people, to some change in the vessels probably analogous to that produc- ing senile gangrene of soft parts. The causes of inflammation of bone inay, therefore, also be looked upon as causes of necrosis ; but syphilis, the specific fevers, especially scarlatina, and mercurial and phosphorous poisoning, may be particularly mentioned. Pathology. — In injury, the death of the bone is due to the stripping off of the periosteum, the destruction of the medullary membrane, or more rarely the plugging of the vessels in the Haversian canals with cloth. In this way necrosis may occur after compound fracture, or in stumps after amputation ; but the inflammation that follows the injury has no doubt also a share in its pro- duction. The way in which necrosis is brought about in inflammation has already been described under periostitis, osteitis, and osteo-myelitis, and according as it results from one or other of these causes will it vary in its situation and extent. Thus, when due to simple periostitis it is generally limited to the external lamellae of the bone {per- iphei-al necrosis) ; when to simple osteo-myelitis, to the layers immediately surrounding the med- ullary canal {central necrosis) ; when to diffuse, septic or infective periostitis or osteo-myelitis, it may affect the whole thickness of the shaft (Fig. 63), and possibly the whole diaphysis {total necrosis) ; whilst when due to osteitis it is usually associated with caries, and only a portion of cancellous tissue perishes {caries necrotica). Characters of dead bone. — The dead bone, which is called a sequestrum or an exfoliation, is bloodless, white, hard, dry and sonorous when struck, but often becomes brown or black w-hen exposed to the air and the action of the discharges. Its free surface is smooth and even, or if previously inflamed, rough and irregular ; its margins are serrated and ragged ; and its previously attached sur- face is rough and uneven. It is heavy when sclerotic changes have occurred, light and porous when associated with caries. Process of separation. — When a portion of bone has become ne- crosed it acts as a foreign body and nature tries to cast it off. In some situations she is successful, in others she f:nls, and if not Necrosis of shaft of tibia. (Druitt's Surgery.) 220 DISEL^SES OF SPECIAL TISSUES. -=rs„,„^:t:^. Diagram of the process of separation of dead bone. c. Dead bone; i. Inflamed living bone with formation of granulation-tisfiie where it is in contact with the dead part; a. Healthy living bone. assisted by art the dead bone may remain as a lifelong source of irritation. The separa- FlG. 64. ce z c tion of dead bone is best studied in superfi- cial situations, as in the cranial bones (Fig. 65), where its process can be watched. Here, say, from the breaking down of a syphilitic node {syphilitic pcriosiilis'), a portion of bone is ex- posed and dies. This, acting as an irritant, causes the bone around to become inflamed (Fig. 64) ; rarefaction {ulceration^ ensues, and around the dead portion is formed a groove, which gradually deepens and extends beneath the dead part until the latter is completely cut off from the living, and if not removed by art simply comes away, or exfoliates, as it is technically termed. The cavity left becomes filled with granulations, which subsequently ossify, and so restore the lost part. In situations, as in the tibia (Fig. 66), where the periosteum has not been destroyed, ossification of this membrane proceeds at the same time as the bone is being separated. The dead bone thus becomes sur- rounded on all sides by new bone, and lies bathed in pus in a cavity lined with granulations (Fig. 67), and though loose, is thus prevented from being cast off. It is then said to be invagina/etl, and is called a seqtiestriim. At certain spots where the periosteum and soft tissues have been perforated by the discharges from the inflamed bone making their way to the surface, ossi- fication does not occur, and these apertures thus left in the casing of new bone are called cloaca; ( P'igs. 66, 67, 68, d). In necrosis of the popliteal surface of the femur, where the peri osteum is very thin, and is merely in contact with the loose fat Fig. 65. Syphililic necrosis of llic skull. (St. Iiartholoniew's Hospital Museum.) NECROSIS. and cellular tissue of the popliteal space, the periosteum is usually destroyed and no osseous sheath is formed, the dead bone then lying in contact with the popliteal artery. In this situation, moreover, the necrosis is usually limited to the triangular popliteal surface of the bone, the firm attachment of the fibrous intermus- FiG. 66. Figs. 66, 67, and 68 illustrate the formation of a sequestrum, its separation from the living bone, and the cavity left alter its removal, n. Dead bone: b. Living bone; c. The sepa- rated periosteum lined by granulations; d. Cloacae lined by granulations, which are indi- cated by shading, and are continuous with those lining the cavity containing the sequestrum; f. New periosteal bone perforated by cloacse; f. Cavity left after removal of the dead bone. (After Billroth.) cular septa to the ridges in the femur on each side of this surface preventing the further separation of the periosteum and conse- quent death of more bone. After th'e removal of the sequestrum the cavity (Fig. 68, /) fills with granulations, though more slowly than after the removal of an exfoliation. Symptoms. — These vary according to the cause, stage and situa- tion of the necrosis. When of inflammatory origin the symptoms at first will be these, already described, of periostitis, osteo- myelitis or osteitis, according as one or the other of these has produced it. When suppuration has occurred and an incision has been made to the dead bone, or the discharges have made their way to the surface, or the wound, in the case of an injury, leading to the dead bone has remained open, a sinus or sinuses will exist. These generally discharge a thick foul-smelling pus, and are accompanied by much thickening of the bone, and red- ness and brawniness in some instances of the surrounding skin. On passing a probe the dead bone will probably be felt. In trau- matic cases there will further be the history of the injury. Having 222 DISEASES OF SPECIAL TISSUES. discovered dead bone, the next point to ascertain is if it be loose. This may be done by observing if it can be moved by a probe, or, if two sinuses exist, by passing a probe down each and pressing alternately first in the one, then in the other. If the sequestrum is loose, a see-saw motion may thus be given to it. In superficial situations such as the cranium, or where a bone protrudes or is exposed, as in a stump or compound fracture, the dead bone will at once be known by the characters already given (page 199). The chief distinctive signs bet'cveen necrosis and caries are : — In necrosis the dead bone is generally hard and smooth, in caries soft, rough, and crumbling ; in necrosis the granulations around the sinus are healthy and the skin is generally normal ; in caries there may be no granulations, or if present they may be oedematous, and the skin around is undermined or inflamed ; in necrosis the discharge is thick and yellow, in caries thin and watery ; in necrosis there may be great thickening of the bone, in caries there is usually but little. It must not be for- gotten, however, that caries may be associated with necrosis. In some cases of necrosis no suppuration occurs {quiet necrosis^, but the bone becomes greatly swelled from the excessive forma- tion of new bone around the dead portion. It then closely resembles a new growth, from which it may be impossible in some instances to distinguish it without an exploratory incision (see Tumors of Bones). Treatment. — The dead bone should be removed as soon as it is loose. When it is superficial this can easily be done by the forceps, after slightly enlarging if necessary the sinus through the soft tissues, or where the end of the sequestrum is exposed in a stump by simply drawing it out. But where the dead bone is in- vaginated and cloacae leading to it are small, a more serious operation is required {scquestrotoniy). The operation is much facilitated by the use of an Ksmarch's bandage. The sinus lead- ing to the most convenient cloaca should be enlarged by a simple incision in the longitudinal axis of the limb, the sequestrum siezed by forceps, and if practicable drawn out. If the cloaca is too small to admit of this it must be enlarged, or two cloacse, if pres- ent, may he laid into one by cutting away with a mallet and chisel, Hoffman's forceps, Hey's saw, gouge, etc., the intervening portion of the sheath of new bone. No more of the ntw bone, however, than is absolutely necessary should be cut away, for fear of weaken- ing the limb. For the same reason cloacae should be enlarged in the longitudinal axis of the bone. The extraction of the sequestrum may often be aided by the use of the elevator, or by cutting it in two pieces with the bone-scissors. The cavity should then be sprinkled with iodo-form, packed with iodoform SUPPURATION AND ABSCESS IN BONE. 223 or sal alembroth gauze to prevent bleeding, and the wound dressed with gauze impregnated with the same or other antiseptic material. Whilst the cavity is healing, which when large it may take many weeks or even months to do, the patient's strength must be sup- ported by tonics and a generous diet. At times the sequestrum is so intimately interlocked between the old and the new bone that it may be impossible to remove it. In popliteal necrosis, where there is no periosteal sheath and the dead bone is in contact with the popHteal artery, great care is required to prevent injury to that vessel. The incision for exposing the dead bone should be made either on the outer side of the popliteal space, or cautiously through the space a little to the outer side of the large vessels. In some cases, where the patient's powers are flagging from long-continued suppuration, or signs of lardaceous or other visceral disease are manifesting themselves, amputatiop may be called for. Suppuration and abscess in bone. — Diffuse suppuration in bone has already been described a? a common termination of dif- fuse osteo-myelitis and periostitis. Circumscribed suppuration or abscess is generally of the chronic variety, and, as already stated, is one of the terminations of chronic osteitis. Chronic abscess in bone is most common in the cancellous ends of the long bones, especially in the upper and lower end of the tibia and lower end of the femur, but is oc- casionally met with in other bones. The causes especially leading to the ter- mination of osteitis in abscess are thought to be the presence of tubercle or of micro- organisms, the strumous diathesis, or a feeble state of health. At times the abscess can be apparently traced to an iniury. Pathology. — In the course of rarefying osteitis the bone-trabeculge are gradually destroyed, and their place is taken by a small-cell-exudation, which now assumes the form of granulation-tissue. This in the focus of the inflamed spot softens and breaks down into pus, whilst that around the centrally-softened spot con- stitutes the abscess wall, and forms to the naked eye a distinct membrane (Fig. 69) lining the bony cavity {pyogenic membrane^. The bone around the absceos generally becomes sclerosed owing to the ossification of the inflammatory products, whilst Xi^'^' bone is formed beneath the periosteum. In this way, as the abscess en- FlG. 69. Abscess in end of tibia. The pyogenic membrane is well seen. (From St. Bartholo- mew's Hospital Museum.) 2 24 DISEASES OF SPECIAL TISSUES. Fig. 70. Necrosed cann-Uous bone in abscess cavity. (From ^t. Bartholomew's Hospital Museum.) larges at the expense of the old bone, new bone is continually formed around, and hence the pus seldom makes its way to the surface as in the soft parts. As the abscess, however, approaches a joint, new bone is not formed beneath the articular cartilage, and so the pus on reaching the car- tilage may perforate it and escape into the joint. When the inflam- mation is more acute, suppuration may occur before the bone-trabe- cul^e have been completely de- stroyed, under which circumstance a sequestrum of cancellous tissue may be found free in the abscess cavity (Fig. 70). I'he symptoms are chronic, and often obscure. Generally there is pain of a dull, boring, and localized character, often intermittent, and worse at night ; tenderness on pres- sure at the spot where the abscess is approaching the surface ; some oedema and pitting of the soft tissues ; occasional enlargement of the end of the bone ; and later some dusky redness of the skin. Intermittent attacks of inflam- mation of a neighboring joint without other apparent cause are very suggestive of ab.scess. These symptoms will usually serve to diagnose abscess from rheumatism, local periostitis, and a new growth in the end of the bone. From chronic osteitis it cannot always be distinguished ; but this is not of so much importance, as the treatment is practically the same. Treatment. — An Ksmarch's bandage having been apjjlied, a crucial or T-shaped incision should be made over the tender spot, and the bone trephined. If the pus does not escape, a perforator should be thrust in various directions into the cancellous tissue in the hope of discovering it. The abscess-cavity, after having been well scraped, should be moj^ped out with caibolic acid or chloride of zinc, and dusted with iodoform, and the .wound dressed with iodoform or other antiseptic gauze, great care being taken to keep it aseptic. Should the abscess break into a joint, amputation will probably be necessary. 2. Diseases depending upon Simple Defect or Increase in Nutri- tion of Bone. Under this head are included two diseases of bone in which neither inflammation nor such constitutional affection as syphilis or struma appear to take a part — Atrophy and Hypertrophy. TUBERCLE. 2 2 S Atrophy of bone is a common accompaniment of old age. It may also be produced by pressure and disuse. Thus it is seen in the bodies of the vertebrse from the pressure of an aneurysm of the aorta or a tumor in the mediastinum ; in the bones of a lim.b from disuse, as in long-continued joint-disease, and in stumps after amputation. An atrophied bone is ahvays decreased in weight, often in size ; and in some situations, as the neck of the femur, is liable to fracture on slight provocation. Atrophy is always attended with more or less fatty degeneration. Hypertrophy of bone is an overgrowth of bone which is due merely to an increase of nutrition, and not to any inflammatory change. It is generally dependent upon excessive functional activity of the part, the bone increasing in size and strength com- mensurately with the hypertrophy of the muscles. It may also occur in association with general hypertrophy of the tissues in the affection known as congenital hypertrophy. It must be distin- guished from inflammatory thickening of bone, a condition to which the term "hypertrophy" is sometimes, though incorrectly, applied. 3. Constihitional Affectio7is of Bone. Under this head are included Syphihtic and Tubercular affec- tions of bone. Rickets, Scurvy-rickets, MoUities Ossium and Acromegaly. Syphilitic affections of bone are common both in acquired and congenital syphilis. In the former they generally occur dur- ing the tertiary stages of the affection, either as gummatous in- flammations of the periosteum (nodes), or as chronic inflamma- tory thickenings or gummatous infiltrations of the bone itself, leading to caries, necrosis, or sclerosis. For a full account of the peculiarities of the above affections when due to syphilis the stu- dent is referred to a work on Pathology. The affections of the bones in congenital syphilis have already been briefly referred to in the section on that subject (see page 73). TuBEKCLE. — We have already seen that many of the inflamma- tory diseases of bone, especially some forms of rarefying osteitis or caries, are attributed to the presence and degeneration of tubercle; and it has been pointed out in what respects the affec- tions of tubercular origin differ from those of a simple or trau- matic nature. Here it need only be added that miliary tubercles may often be found scattered through the medulla and in the cancellous tissue in cases of acute tuberculosis ; but as in these cases the bone-affection plays but a secondary part and cannot be diagnosed during life, nor indeed as a rule gives rise to any symptoms, it need not be further described. 2 26 DISEASES OF SPECIAL TISSUES. Rickets, though generally described under Diseases of Bone, is a constitutional affection occurring in infancy and early childhood. It is characterized by impaired nutrition and arrest of develop- ment of the whole body, and especially by the softening and the resulting deformity of the bones. Causes. — (i) Malnutrition produced by improper food, espec- ially an excess of the starchy elements during infancy ; (2) debil- ity of the mother during gestation and lactation as the result of excessive child-bearing or over-suckling ; and (3) bad hygiene, /. e., want of fresh air and sunshine, residence in damp dwellings, uncleanliness, and lack of attention generally. Struma and syphilis in the parent, but I think without sufficient evidence, are also given by some as causes. Pathology. — The bone-changes consist essentially in the forma- tion of soft, vascular, imperfectly-ossified bone, which replaces the healthy bone as the latter is gradually absorbed in the normal process of development. This ill-formed bone is produced both at the line of the epiphysis and under the periosteum, /. e., in those situations where active growth normally occurs. In the former situation the intermediate semi-transparent bluish zone of ossifying cartilage between the diaphysis and epiphysis is greatly increased in thickness and its line of junction with the bone is no longer straight but broken, in consequence of the irregular advance of ossification. The adjacent bone is soft and spongy, and contains here and there islets of cartilage which have escaped ossification, whilst its medulla is abnormally vascular. It is to the excessive formation of this proliferating layer of cartilage and ill formed bone immediately underlying it that the enlarge- ment of the ends of the long bones and the beading of the ribs so characteristic of rickets is due. Microscopically the cartilage- cells in the bluish zone are seen enlarged, and instead of being arranged in regular columns are grouped irregularly ; whilst the calcification of the matrix between them is also seen proceeding in an irri^gular manner, so that calcified or ossified patches exist here and there vv'here all should be cartilage, and portions of car- tilage where all should be bone. The vascular medullary spaces which are continuous with these channels in the shaft likewise project in an irregular manner into the cartilage, and the laminae of bone formed from the osteoblasts lining these spaces are defi- cient in eaithy salts. Under the periosteum, the superficial layers of which are unaffected, similar soft bone is laid down in conse- quence of the osteoblastic layer, though increased in thickness, producing osteogenetic fibres deficient in earthy salts. Hence, whilst all the bones are more or less softened, the long bones become swollen at their ends, and the flat bones thickened, espec- RICKETS. 227 ially along their line of suture. The liver, spleen and lymphatic glands are often enlarged from irregular increase of their fibrous elements, and the muscles are generally soft, flabby and wasted. Symptoms. — Rickets is most frequently met with between the ages of eighteen months and two and a half years. Among the early symptoms may be noticed sweating of the forehead and perhaps of the upper part of the body, throwing off the bedclothes from a desire of the child to be cool, a general restlessness, and often an excessive tenderness on handling and aversion to move- ment. Sometimes large quantities of phosphate of lime are found in the urine. The abdomen is generally enlarged, and there is frequently some gastric catarrh and flatulence. The swelling of the ends of the long bones, especially of the lower end of the radius and tibia, the beading of the ribs where they join the carti- lages, and the thickening of the cranial bones along their line of suture are characteristic of the disease. Later, bending of the bones occurs. Thus, the long bones generally give in the direc- tion of their normal curves and near the epiphyses, leading to knock-knee, bow-legs, and other deformities. The yielding of the ribs to atmospheric pressure produces the deformity known as pigeon-breast. The spine presents a general curvature with the convexity backwards in infants and young children, and in older children a lateral or a lordotic curve. The pelvis is ill de- veloped, flattened and usually of a reniform or hour-glass shape, in consequence of the depression of the promontory of the sacrum. The head is square, the forehead prominent, and the fontanelles are late in closing. The occip- ital bone is sometimes thinned so that it yields on pressure or it may be in places absorbed, a condition known as cranio- iabes. By some pathologists, however, this condition is believed to be due to con- genital syphilis. Dentition is generally delayed, or the teeth, if cut, often soon decay and fall out. Bronchitis, diarrhoea, convulsions, laryngismus stridulus and chronic hydrocephalus are not infrequent complications ; and to any of these, but especially to the first two, the child may succumb. Under appropriate treatment the disease is nearly always arrested, and perfect recovery results. The bones, how- ever, if much bent are liable to become consolidated in the de- formed condition, and premature synostosis of the diaphysis and Fig. A longitudinal section of a rickety femur. (St. Bar- tholomew's Hospital Mu- seum.) 22S DISEASES OF SPECIAL TISSUES. epiphysis is apt to occur, inducing a stunted growth. Tlie bones are also harder and denser than natural, especially on the side of their concavity, where a thick buttress-like layer of dense hard bone is formed. (See Fig. 71.) The treattnejit resolves itself into proper feeding and correct- ing bad hygienic conditions. The child should have plenty of new milk and cream ; and the juice of raw or underdone meat, or underdone meat that has been pounded up, should be given in quantities suited to the age and powers of assimilation. Farina- ceous food should be restricted in amount, and in the case of infants forbidden. Abundance of fresh air and sunlight and at- tention to cleanliness are especially indicated. In the way of medicine cod-liver oil is the most important, and may almost be looked upon as a specific. It should be combined with syrup of the phosphate or lacto-phosphate of iron and lime in half-drachm to drachm doses. The deformity of the legs may be corrected in the earlier stages by insisting upon the child not being allowed to stand or walk. To ensure its being kept off its legs, splints reach- ing from the waist to below the feet may be applied. Confirmed deformities can only be dealt with by instruments or operation, which will be described under bow-legs, knock-knee, osteoclasia, osteotomy, etc. Scurvy- RiCKE'i s is an acute affection of young children. It is also known as aciile rickets and as infantile scurvy. The disease is characterized by a sudden swelling in connection with the bones, and especially with the femur. The swelling is due to ex- travasation of blood beneath the periosteum. The ohxti si^ns are acute tenderness, oedema, and generally a spongy condition of the gums. 'J'he ireaUneni consists in rest and in the use of such con- stitutional remedies as are appropriate for scurvy. MoLLiTiES ossiuM or OsTEO-MALACiA is a rare disease, character- ized by softening of the bones through the re-absorption of their earthy salts and destruction of their osseous lamellse. Cause. — It is a di.sease of adult life, and most often occurs in females during the child-bearing period. Sometimes it appears to be hereditary ; but its causation is practically unknown. rath»/oi,'y. — The disease appears to begin in the medullary tissue of bone, which is replaced by a soft, dark-red gelatinous material somewhat resembling spleen-pulp, whilst later the whole bone, with the exce])tion of a thin layer immediately beneath the periosteum, becomes replaced by this material and reduced to little more than a mere shell, 'i'he bone appears first to become decalcified and then destroyed. The exact pathology of the pro- cess is not known, but it has been suggested that the decalcifica tion of the bone is due to the action of lactic acid, which has MOLLITIES OSSIUM. 229 IMicroscopical appearance of a fragment of bone in mollifies ossium. (From Rind- fleisch.l been found both in the bone and the urine, or to excess of car- bonic acid in the veins of the medulla, which are said in the early stages to be enlarged. The microscopical appearances lend some support to this view, as in a bone-trabecula (see Fig. 72) the P'°- 7^- decalcification is seen to begin around the Haversian canals and medullary spaces, the bone- corpuscles in these parts having entirely disappeared, while in the centre of the trabecula they are still present. At times the gela- tinous material is in places yellow and fatty-looking. In some of the specimens in St. Bartholo- mew's Hospital the medulla appears entirely filled with fatty material ; but it is a question whether these specimens, though called mollities ossium, are not of a different nature from the dis- ease to which the term is generally applied, and do not rather depend upon a senile change. Symptoms. — In the early stages the disease may be mistaken for rheumatism or neuralgia, as, beyond some general feeling of weakness with obscure pains in the bones, it is attended with no definite symptoms. Suddenly, however, fracture of some bone occurs, whilst others become bent and variously distorted without any or with but the slightest provocation. Thus the pelvis, thorax, spine, and extremities become misshapen and sometimes extraordinarily deformed. The pelvis is flattened from side to side, the symphysis pubis projects in the form of a beak, giving a rostrated appearance to the pelvic inlet, whilst the tuberosities are approximated and the pubic arch is diminished in width. Thus, parturition is rendered difficult if not impossible. The condition of the urine is an important element in the diagnosis, a peculiar form of albumen and abnormal quantities of phosphates and lactic acid being found in it. The disease progresses and the patient generally dies of exhaustion, or during parturition, or of dyspnoea consequent upon respiratory trouble induced by the weakened ribs. In a few cases recovery has taken place Treatment. — No remedy is at present known for the disease. The strength must be supported by tonics and abundance of nourishing food, pain must be relieved by opium, and rest en- joined in order to prevent fracture. The patient should be warned of the danger of child-bearing. Should she be already pregnant, the question of inducing premature labor must be 230 DISEASES OF SPECIAL TISSUES. raised ; whilst, should she be at her full time, craniotomy, or in advanced deformity of the pelvis, Ceesarean section may be necessary. In a large number of cases of late, especially in the districts on the Continent where the disease is prevalent, oopho- rectomy has apparently arrested the disease and the bones are said to have again become firm. Acromegaly. — This disease is characterized by a symmetrical enlargement of the bones of the hands and feet as well as of those of the head and face, the nasal and inferior maxilla being chiefly affected. The disease is supposed to be associated with changes in the pituitary body, but at the best is at present little under- stood. 4. New Groiuths in Bone. New GROWTHS. — Nearly all the varieties of tumor described in the section on that subject (p. 77) occur in bone, vSome, indeed, as the exostoses, are altogether confined to the bony tissue ; others occur in it so frequently that it may be said to be their favorite seat ; others, again, are in this situation so rare that they may be dismissed as pathological curiosities. Some, moreover, the carci- nomata, only occur in bone as secondary growths, the primary malignant tumors of bone, formerly described as carcinomata, being now classed as sarcomata. Tum.ors of bone may spring from the periosteum, the medulla, or the bone itself, and exhibit a remarkable tendency to undergo calcification or ossification, and when of slow growth to assume the character of true bone. OsTEOJMATA OR ossLous TUJMORS havc the structure of true bone, and are only met with in connection with bone. They must be distinguished from other forms of tumor that have undergone cal- cification or ossification. They may be divided into the circum- scribed and the diffuse. Circumscribed osseous Untiors or exostoses occur in two chief forms, the cancellous and the compact. {a) The cancellous or spongy exostoses consist of cancellous bone containing marrow in its cancellous spaces, and surrounded by a delicate layer of compact bone, which itself is covered with a capping of cartilage, or sometimes merely with periosteum. They are most frequently met with in the young, and are con- sidered by some to be ossifying enchondromata and to spring from portions of the epiphysial cartilage that has escaped ossifica- tion. Their common situation is at the junction of the diaphysis and epiphysis of long bones, or at the origin or insertion of muscles — as for example, the inseition of the adductor magnus into the tubercle just above the internal condyle of the femur, NEW GROWTHS. 23 1 and the pectoralis major into the external bicipital ridge of the humerus. They are also very com.mon on the last phalanx of the great toe. {!?) The compact or ivory exostoses consist of dense, hard bone, which usually contains no Haversian canals. They nearly always spripg from the bones of the skull and face, and are generally sessile or broadly pedunculated, and of a lenticular shape. Symptoms. — The cancellous variety are met with as hard, smooth or irregular, and frequently pedunculated tumors of slow growth, and are commonly of small or moderate dimensions. Sometimes they are quite painless, but at other times they cause pain on movement or pressure, as is the case with the small exostosis which so frequently grows from the distal end of the dorsal surface of the last phalanx of the great toe. This, which is usually harder than the more common form of cancellous exostosis, but less hard than the ivory, occurs as a tumor project- ing under the nail, and raising it up as it grows. In some cases exostoses affect simultaneously many bones, and at times nearly all the bones of the body. They are then generally hereditary, and often symmetrical, and are spoken of as multiple exostoses. They have the structure of the cancellous form. The evident firm attachment of the ivory exostoses of the skull to the bone, their slow growth, small size, great hardness, the freedom with which the scalp moves over them and the absence of pain and history of fracture or other injury, sufficiently serve to distinguish them. Treatment. — A spongy exostosis, unless occasioning pain, de- formity, or other inconvenience, or growing rapidly, may be left alone ; otherwise, it should be removed by a chisel, bone-nippers, saw, etc., taking care it is completely extirpated, as what is left will have a tendency to grow again. In removing an exostosis from near the knee-joint, the synovial membrane may be avoided by flexing the knee, and so drawing the membrane away. Ivory exostoses should not as a rule be interfered with, as they are so hard that no ordinary saw will cut through them, and the skull has been fractured in attempts to remove them with the chisel. If causing great inconvenience, however, it is probable that they might be safely removed by the rapidly-revolving saw of the sur- gical engine. Diffuse osseous tumors occur in connection with the bones of the face, often filling up the antrum, occluding the nasal cham- bers, and producing much deformity. They are composed of finely-cancellated bone, and are more compact than the can- cellous exostoses, but less compact than the ivory. Their slow growth, extreme and uniform hardness, and irregular nodulated 232 DISEASES OF SPECIAL TISSUES. Fig. 73. surface will serve to distinguish them from sarcomata undergoing ossification. There is usually little or nothing that can be done in the way of treatment. The superior maxillary bone, however, has at times been confined to it alone. Enchondromata or CARTILAGINOUS TUMORS. — The general and microscopical characters of these growths have already been de- scribed under Tumors (p. 82). In the bones they are most frequently met with in the fingers (Fig. 73) and the ends of the long bones. In the fingers, where they are generally multiple and often con- genital, they usually begin in the interior of the ends of the phalanges or meta- carpal bones, and as they increase in size, expand the bone around them into a thin shell, which may finally give way, allow- ing them to protrude. When growing from the articular ends of long bones, they generally spring from the periosteum, and thence grow both outwards and in- wards, but seldom involve the articular surface. They are thought by some to possibly arise from the epiphysial cartilage, especially as they are most often met with in the young. They should not be con- founded with sarcomata, in which con- siderable masses of cartilage are frequently developed, or with the exostoses, which are often capped with cartilage, and are regarded by some as ossifying enchondromata. The enchondromata rarely ossify, but may undergo calcification or mucoid softening, and when unmixed with sarcomatous ele- ments are quite innocent. Symptoms. — Their slow growth, great hardness, evident attach- ment to the bone, the absence of glandular enlargement, and non-implication of the surrounding tissues and skin will serve for their diagnosis. When of large size ulceration of the integuments covering them may be produced by their pressure. Treatment. — If small, and involving, say, only one finger, they may be enucleated, taking care not to injure the neighboring joint. But when several fingers are implicated, and the hand is rendered useless, aini)utation of the affected fingers, or of the whole hand, may be necessary. 'I'he removal of the limb is usually called for when they grow about the articular end of a long bone, especially if they have attained a large size. FiiJROMA'JA OR FIBROUS 'iUMORS Hcldom occur in bone except in the jaws or in connection with the base of the skull. They then Cartilaginous tumors of the bones of the hand. (From iJruitt's Surgery.) SARCOMATA. 233 Fig. 74. constitute the common form of epulis and naso-pharyngeal poly- pus respectively, and are described under Diseases of the Jaws and Nose. LiPOMAiA OR FATTY lUMORs too rarely occur in bone to require special mention. I have seen one or two growing from the outer surface of the periosteum {parosteal lipoma). They were not diagnosed before operation. Sarcomata in bone may be divided into the periosteal and the endosteal, the former being commonly of the round-celled, spindle-celled, or mixed variety, the latter of the myeloid variety. The periosteal (Fig. 74) spring from the deep layers of the periosteum, and as they increase in size invade the bones beneath on the one hand, and the soft tissues surrounding them on the other, till finally the skin is involved, and they protrude as a fungous mass if the patient has not been already carried off by the dissemination of the growth through internal organs. They are very prone to calcification and ossifi- cation, and are then sometimes spoken of as osteoid sarcomata ; but the simple ex- pression ossifying sarcomata, as less inis- leading, and as more indicative of what really happens, had better be employed. Their favorite situations are the neighbor- hood of the large joints, which, however, they seldom involve. Though not usually implicating the lymphatic glands, they often rapidly infect the system through the blood-stream and quickly return after removal. The endosteal or central spring from the medulla in the interior of the bone, and are of slower growth and generally less mahgnant than the periosteal. As they increase in size they expand the bone around them into a thin shell (Fig. 75), which finally gives way, when they grow with greater rapidity, behaving as the periostea] variety. The myeloid form of the endosteal sarcoma is the least mahgnant, and may not return after enuclea- tion or complete removal for several or many years, and possibly not at all. A variety called parosteal, in which the sarcoma in- volves the outer layers only of periosteum, has been described. Symptoms. — In a typical case oi periosteal sarcoma thtxe will be a rapidly growing tumor, evidently connected with the bone, not as a rule painfdl, nor usually attended with heat, oedema, redness, Or 10* Periosteal sarcoma of femur. (St. Bartholomew's Hos- pital Museum.) 234 DISEASES OF SPECIAL TISSUES. increase of body temperature. The swelling is soft and semi- fluctuating or boggy, sometimes indistinguishable by touch from an abscess ; or hard in some parts, soft in others, or, if ossifying, uniformly hard all over. The superficial veins may be tortuous and dilated, and the neighboring lymphatic glands enlarged. The patient, who is usually young, frequently complains of having lost both weight and strength, al- ^'°- 75- though till later there may be ^ ^ "^ no cachexia. Often there is a '^. %!» -^_ , - -,, distinct history of the growth having appeared some time after an injury of the part, and IJ;; it is probable in some cases , :^; such may be the cause of the • ;5 growth. The endosteal axe. oi !;' much slower growth, and are .; generally accompanied by bor- ' ^^^,: ing pain whilst the bone is ■ /# being expanded. Sooner or ■^J?£teJ^e^ l^ter they give rise to a more ^' or less uniform swelling, gener- ■'' ally of the articular end of Endosteal sarcoma in. head of libia. ^St. Q^g Qf ^j^g ]q,-,„ ^oneS, and aS Bartholomew s Hospital Museum.; , ,i r i i the shell of bone becomes thinned a peculiar sensation, known as egg-shell crackling, may sometimes be felt on palpation. After they have protruded from the bone they present similar signs to the periosteal, and at times distinctly pulsate, especially when connected with the pelvic bones. They may then be mistaken for an aneurysm. Diagnosis. — ^The above signs will commonly serve to distinguish a sarcoma from an innocent tumor of bone. From an inflamma- tory affection, such as subacute periostitis or osteitis, quiet necrosis, or an abscess in the interior of the bone, it is sometimes very difficult to diagnose a sarcoma. The absence of signs of inflammation, or increased body temperature, of oedema, and of pain on pressure, point strongly to the swelling being of a sar- comatous nature. But these signs may be present in rapidly- growing sarcomata, and may be but faintly marked, or not apparent, in inflammatory affections. A steady increase of the growth whilst under observation, notwithstanding rest and appro- priate remedies for inflammation, the gradual loss of weight and strength, and the unequal consistency and irregular surface of the swelling are more certain indications of its malignancy ; but puncture with a grooved needle, or even an exi)loratory incision, may be required before the nature of the tumor can be cleared CARCINOMA. 235 up. From an aneur3'sm, a pulsating sarcoma may be very diffi- cult to distinguish, especially when growing from the pelvic bones. In the tumor the pulsation is not equally expansile over all parts, and although it may be stopped by pressure on the artery above, the tumor does not become smaller ; nor is it felt to refill when the pressure is removed during two or three beats of the heart, as in aneurysm ; and a bruit, if present, is not so distinct. Portions of expanded bone, moreover, may be felt in parts of the tumor, and there may be glandular enlargement and other general signs of malignancy. From an inflammatory condition of a neighbor- ing joint a tumor of the end of the bone may generally be dis- tinguished by the absence of signs of inflammation ; by the swelling being less regular in contour than in a joint-affection, and apparently being connected more intimately with one of the bones entering into the articulation than with the other ; and by a care- ful review of the history of the case. Treatment. — Periosteal growths, unless the glands are much enlarged and there is evidence of dissemination having occurred, call for amputation of the limb, or removal, if practicable, when growing from the bones of the head or trunk. Small growths, however, may at times be dis- sected ofl" the shafts of the long bones, and the surface of the bone scraped, gouged away, or destroyed by the actual cautery. Endosteal growths, if small, may in some cases be enu- cleated, but usually, like the periosteal variety, call for amputation. In some situations, as in the head of the radius, the affected portion of bone may be excised. The treatment of sar- comata of the jaws and of other special regions is described under Tumors of the Jaws, etc. Carcinoma never occurs as a primary growth in bone. It may spread to the bone, however, from the skin or mucous membrane, as seen, for example, in some cases of squamous carcinoma of the leg or lip, or be deposited there in the course of the general dissemination following on primary carcinoma of other tissues or organs, as the breast or liver. In the latter case it is seldom discovered till after death, unless it gives rise to spontaneous fracture (Fig. 76). Treatment. — Where epithelioma has spread to the bone, free and early removal with the knife -before the glands have become affected is the only treat- ment that holds out a prospect of success. In the case of a limb, Secondary carcinoma of the shaft of the humerus causing spontaneous frac- ture of the bone. (St. Bartholomew's Hospital M u se - um.) 236 DISEASES OF SPECIAL TISSUES. amputation well above the disease is generally called for, although where the bone is but little involved a free sweep of the growth and the gouging away of the underlying bone may under some circumstances be justifiable. Glands that have become affected should be removed if practicable. CvsTS IN BONE are rare, except in the jaws. Hydatid cysts are occasionally met with, but require no special description (See p. loi). The sanguineous or blood cysts formerly described were probably sarcomatous tumors in which hemorrhage had taken place. Aneurysms in bone are occasionally met with, and vascular ERECTILE TUMORS Consisting of anastomosing vessels, and some- what resembling nsevi of the soft tissues, at times occur in the bones of the skull. The majority of pulsating tumors in bone, however, are of the nature of soft sarcomata. DISEASES OF JOINTS. Synovitis, or inflammation of the synovial membrane, may be acute, subacute, or chronic. Acute synovitis. — Cause. — Generally a slight injury, as a sprain or over-exertion of a joint, or exposure to cold and wet in a gouty or rheumatic subject. Synovitis, moreover, especially in the knee, often occurs during an attack of gonorrhoea, and is sometimes seen in the earlier stages of syphilis. It is well known as a symptom of acute rheumatism and pyaemia, in which latter affection rapid suppuration and implication of the other tissues . of the joint occur. Pathology. — The synovial membrane becomes red and con- gested and loses its lustre, the synovial fringes turgid, and the synovial fluid increased in quantity and slightly turbid from admixture with inflammatory products. Resolution may now occur, or the inflammation may become chronic, or it may spread to the cartilages, bones, etc., and terminate in suppuration and the probable disorganization of the joint (see Acute Arthritis). Signs. — The joint is hot, excessively painful, especially on movement and pressure, and if the inflammation is very intense, the skin may be slightly reddened, and the tissues around ocdem- atous. The joint is usually held flexed, that is, with the capsule and ligaments relaxed — the position of greatest ease. Where the joint is superficial the swelling is well marked, the outline of the synovial membrane being distinctly maj^ped out. Thus in the knee, the joint perhaps most commonly affected, the synovial membrane can l)e seen extending u])wards under the crureus and jvasti, and bulging on either side of the ligamentum patellar. The patella itself is raised from the condyles of the femur, and on CHRONIC SYNOVITIS. 237 making pressure on it the fluid is displaced, and the patella can be felt to strike against the condyles {riding of the patella). In the elbow, the synovial membrane can be seen extending under the triceps and on either side of the olecranon ; in the ankle, bulging beneath the extensor tendons and behind the malleoli. Feverish symptoms varying in intensity according to the severity of the inflammation are generally present. The inflammation may now gradually subside or assume the chronic form. Should, however, suppuration occur, and the other tissues of the joint become involved, the pain, swelling, and oedema increase, and the skin becomes of a dusky red, whilst a chill or distinct rigor ushers in a more severe type of inflammatory fever. Treatjiient. — The joint should be placed at absolute rest on a splint, and the patient, in the case of the hip, knee, or ankle, con- fined to bed. In applying the spHnt, care should be taken that the limb is in the position best suited for future use should anky- losis ensue ; thus the knee should be straight, and the elbow bent at a right angle. Where the joint has already been drawn into a faulty position, this must be rectified, the patient being placed under an anaesthetic, as the manipulation is attended with intense pain. Cold, by means of evaporating lotions or Leiter's tubes, may in shghter cases be applied to the joint. When, however, the inflammation is very acute, half-a-dozen leeches followed by hot applications should be substituted for the cold, with liniments of belladonna and opium to assuage pain. Where there is much distension and the synovial membrane threatens to give way, the joint should be aspirated and elastic pressure applied, or if sup- puration occurs, laid freely open and drained antiseptically. Amputation may be called for should the patient's powers fail under the long-continued suppuration that at times ensues. Subacute synovitis. — The term subacute is applied to less severe cases of acute synovitis. But as one form of the disease differs from the other in degree rather than in kind, and as the causes, symptoms, and treatment are similar, no special descrip- tion is required. Chronic synovitis. — Causes. — Similar to those of the acute form, of which it is often a sequel. When occurring in strumous subjects, it probably nearly always depends on the presence of the tubercle bacillus, and will be described under tubercular disease of the joints. Fathologv. — The synovial membrane is slightly thickened, and the synovial fluid increased in quantity ; but there is little or no change in the cartilages or the other tissues, though, if the disease is neglected, it may run on to total disorganizatioji of the joint. At times,- the synovial membxane becomes greatly distended with 238 DISEASES OF SPECIAL TISSUES. clear serous fluid, a condition known as hydrops arliciili, and in this state it may remain for years without any further change en- suing ; or, after long periods, the synovial membrane may become thickened, and little masses of cartilage form in its hypertrophied fringes. In other instances pouch-like protrusions of the synovial membrane may extend along the muscles and other tissues, often to some distance from the joint, where they give rise to bursa- like-swellings {Mo rraiii Baker's cysts). Signs. — The joint, as in the acute affection, is swollen, and the synovial membrane slightly thickened ; but there is little or no heat, there may be no pain, and the skin is unaltered in appear- FlG. 77. Fig. 78. Fig. Thomas's hip-joint splint (front view) with pattern. Thomas's hip-joint splint ap- plied. Fatten on sound limb. (Heath's Minor Surgery.) Thomas's knee-joint splint with foot-piece for extension. (Heath's Minor Surgery.) ance. The patient, however, complains that the joint feels weak and stiff on movement, but he does not suffer from starting-pains at nights. In hydrops articidi the synovial membrane is greatly distended but not thickened, and save a sensation of weakness and want of security in the joint on walking, the affection gives no trouble. In what may be termed the /^//;-.vfl!/^'^?;7>/r of chronic synovitis, in addition to the joint-affection, more or less tense, fluctuating and translucent swellings occur in the neighborhood of the joint. On pressure, these swellings become less tense TREATMENT OF CHRONIC SYNOVITIS. 239 Fig. 80. and some of the fluid contained in them can at times be forced back into the joint. Treatment. — The indications are ( i ) to prevent further irrita- tion by placing the joint at perfect rest, (2) to promote the ab- sorption of the inflammatory products by pressure and counter- irritation, and (3) to remove any stiffness that may remain on the subsidence of the inflammation by passive movements, massage, or the breaking down of fibrous adhesions. Thus, the joint should be fixed in an accurately-fitting poroplastic or a moulded leather splint, or a plaster-of-Paris bandage ; and the limb, if a joint of the upper extremity is affected, should be carried in a sling. In the case of the lower extremity, the patient, if unable to lie up, may wear a Thomas's hip or knee splint, according to the joint affected, and be allowed to get about on crutches with a pat- ten fixed to the boot of the sound limb (Figs. 77, 78, 79 and 80). Pressure may be applied by strapping the joint with ammoniacum and mercury plaster, or with Scott's dressing, or by means of a Martin's bandage. Counter-irrita- tion may be affected either with the liniment of iodine, small flying blisters, or the actual cau- tery. Rest, however, though most essential in the treatment, should not be continued too long, lest the joint become stiff. Should this happen, friction, massage, and passive movements must be sedulously used, or if all signs of inflamma- tion have ceased, the adhesions may be broken down under an anaesthetic. In the meantime, the patient's general health must not be ne- glected, and any constitutional tendency to gout, rheumatism, etc., should be corrected by appropriate remedies. During convalescence a stay at Buxton, Harrogate, Wiesbaden, or some other suitable spa may be of benefit. In hydrops artiaiU the treatment recommended above may first be perseveringly tried. After prolonged rest has failed, massage of the limb with exercise of the joint may sometimes affect the absorption of the fluid ; this failing, the joint may be aspirated and pressure re-applied. Should it refill, it may be injected with iodine, or in very severe cases laid open, well washed out, and drained. Where cysts have formed in the neighborhood of the joint, they should, if pressure fails to cure them, be left alone or dissected out and neck tied. It is not safe to puncture them, for fear of setting up suppuration in the joint, Thomas's knee-joint splint applied. Pat- ten on sound limb. (Heath's Minor Surgery.) 240 DISEASES OF SPECIAL TISSUES. and even a free incision, with antiseptic precautions, is not devoid of risk. Acute arthritis is the term appHed to a general inflammation of all the tissues of a joint. It may begin in the synovial mem- brane, in the articular ends of the bones, or in the tissues around, but in whatever way it begins, the whole joint rapidly becomes involved in the inflammatory process. The cai/ses are very various, and include those given under acute synovitis. Among the most frequent causes, however, may be mentioned penetrating wounds, infective periostitis or osteo- myelitis, epiphysitis, the bursting of an abscess in the soft parts or in the end of the bone into the joint, pyaemia, and the continued and the exanthematous fevers. Pathology. — The course of the disease differs somewhat accord- ing to its cause and mode of ori- FiG. 81. gin. In a typical case beginning in the synovial membrane and running on to complete disor- ganization of the joint and sub- sequent ankylosis the following changes occur : — The inflamma- tion rapidly spreads from the synovial membrane to the bones and surrounding soft tisi;ues ; the cartilages are destroyed ; the lig- aments are softened ; the articu- lar surfaces are displaced by the action of the muscles ; and the joint is converted into the cavity of an abscess (Fig. 81). The capsule of the joint now gives way, allowing the inflammatory product to escape. The soft tis- sues break down into pus, and the abscesses open externally, forming sinuses leading down to the joint. Should the inflammation now subside, granulations spring up from the denuded ends of the bones, the two layers of granu- lations unite, and after passing through a fibrous stage undergo ossification {l^ony ankylosis), leaving the patient with a stiff joint. The pathological process by which these changes are brought about is as follows : The synovial membrane, which at first ap- pears red and injected, rapidly becomes infillratcd with inflam- matory products, and is converted, together with the adjacent capsules, into a tliick layer of granulation-tissue. I'he inflamed articular ends of the bones also become infiltrated witli inflamma- Acute arthritis of the knee-joint beginning in the synovial membrane. The lig.'i- ments arc ahnost destroyed and the tibia is displaced backwards and outwards. The joint was filled with pus. (.St. Bar- tholomew's Hospital Museum. J ACUTE ARTHRITIS. 24 1 tory products and pass through the changes described under rare- fying osteitis. The cartilages thus cut off from their nutrient supply lose their lustre, and while portions die and are cast off into the interior of the joint, the rest is invaded both on its free and deep surface by the granulations derived from the synovial membrane on the one hand, and from the articular end of the bone on the other. As the result of this invasion, the cartilagin- ous matrix liquefies, and the cartilage cells proliferate, while the brood of young cells thus formed in part coalesce with the cells of the invading granulation-tissue, and in part escape into the joint in the form of pus. The soft tissues around the joint are now invaded by the granulation-tissue, abscesses form, the skin gives way, and sinuses are left leading to the interior of the joint. After the inflammatory products have escaped, should the inflam- mation subside, the layers of granulation-tissue, which spring up from the surface of the bones that have been denuded of their cartilage, come into contact, and unite in the way described under union of the soft parts by the third intention. Ossification sub- sequently ensues. Under less favorable circumstances the inflam- mation may assume a septic character, and the abscesses around the joint burrow widely amongst the muscles and other soft tis- sues. Or the periosteum or the medulla of the bones may be- come involved in the septic inflammation, and extensive caries or necrosis ensues. The septic products may become absorbed, and the patient die of saprsemia or pyaemia, or suppuration may con- tinue and death result from hectic or lardaceous disease. Signs. — The disease may begin like an ordinary attack of synovitis, but the pain soon becomes intense and agonizing on the least movement, the heat more marked, and the skin often covered by a blush of redness. The swelling at first takes the form of the synovial membrane, but soon becomes general, and the joint assumes a flexed position. In the meantime the con- stitutional disturbance is severe, the temperature high, the pulse rapid, the tongue furred, and a chill or rigor may perhaps occur. Painful startings of the joint now set in, in consequence of the reflex irritation of the muscles ; abscesses form and make their way to the surface, and burrow in the tissues around j and the joint-surfaces become displaced from each other (Fig. 8i). After the abscesses have opened, the inflammation may subside, probably leaving the joint stiff; or the patient may die of septic poisoning or of exhaustion. The treatment at first should be similar to that of acute synovitis ; but should suppuration set in, the joint must be freely opened and antisepticahy drained, and all abscesses that have formed around treated in the same manner. When effectual II 242 DISEASES OF SPECIAL TISSUES. drainage cannot be secured continuous irrigation or immersion in a hot bath may be tried. If septic poisoning or exhaustion threaten Ufe, amputation must be performed. Epiphysitis is an inflammation of the soft growing tissue be- tween the shaft and the epiphysis. It is therefore necessarily confined to the young, and is of most frequent occurrence under the age of ten. It may be acute, sub-acute, or chronic, and may or may not involve the neighboring joint. The epiphyses most- often affected are those of the hip, knee, and shoulder, but several may be imphcated at the same time, or one after the other in rapid succession. Cause. — Slight injuries, tubercle, infective micro-organisms, and sepsis as from the absorption of a septic poison after hgature of the umbilical cord. Pathology. — The inflammation as a rule terminates rapidly in suppuration, in which case either the articular cartilage may be perforated and the pus escape into the joint setting up acute arthritis, or the epiphysis may become completely cut off from the diaphysis and form, as in the case of epiphysitis of the upper end of the femur, a loose sequestrum in the interior of the joint. In less acute cases the inflammation may subside v/ithout suppu- ration ensuing, under which circumstances premature synostosis may take place between the diaphysis and epiphysis, and the growth of the bone at the affected end be thus arrested. The chronic cases may also terminate in suppuration and destruction of the joint ; but if this does not occur, the prolonged vascularity may lead to increased nutritive changes, and instead of growth being arrested by premature synostosis, the bone may be in- creased in length. Symptoms. — Severe constitutional disturbance ; swelling of the end of the bone ; tenderness, heat, and sometimes redness of the skin ; stiffness and fixidity of the joint ; pain increased on move- ment ; and jjrobably, later, signs of acute arthritis ; grating of the epiphysis on the dia])hysis ; and if the ca])sule of the joint bursts, the formation of a large abscess in the limb. In the chronic form the signs are those of the early stage of tubercular joint disease. The treatment consists in placing the limb in a corrected posi- tion on a splint, the application of a few leeches, and free in- cisions down to the epiphysis with antiseptic precautions as soon as there are signs of suppuration. Should it appear probable that pus is contained in the e])ii)hysis the latter should be cau- tiously perforated. If the joint, notwithstanding this treatment, becomes affected, it must be laid freely open and drained anti- septically, and any secjuestrum that may be present removed. CHRONIC TUBERCULAR ARTHRITIS. 243 Chronic tubercular arthritis, also called tumor albus or white swelling, pulpy degeneration of the synovial membrane, and fungous or strumous inflammation, is characterized by a gradual enlargement of the joint, unaccompanied by redness or much in- crease of synovial secretion. It begins very insidiously, is chronic in its course, and is prone to end in the total disorganization of the joint. Though most frequent in the young, it may occur at any age. Causes. — It is generally attributed to some slight injury to the joint, occurring in a strumous or unhealthy subject ; but fre- quently no history of any such injury is forthcoming. The im- mediate cause is the presence of the tubercle bacillus which has gained admission to the system in the way described under Tubercle. Pathology. — The disease may begin either as a chronic inflam- mation of the synovial membrane, or as a fungating caries of the articular ends of the bones; in the former case, the synovial membrane, which first appears red and injected, gradually be- comes thickened and oedematous, and ultimately pulpy and gelatinous and in places fatty looking. The synovial fluid in the meantime becomes turbid or muco-purulent, but is rarely much increased in quantity ; the synovial tufts, at first soft and floc- culent, gradually assume the form of spongy granulation-tissue, and grow over the cartilage from the sides till they completely cover it, " lying over it like a veil." Prolongations from this veil of granulations, compared by Billroth to the roots of ivy pene- trating a wall, insinuate themselves into and spread in all direc- tions through the cartilage, which they ultimately destroy, and then in like manner invade the bone. The granulation-tissue may also make its way between the bone and the cartilage, and unite with that derived from the synovial membrane, thus leaving portions of cartilage loose between the two layers of granulations. At the same time, fungous granulations derived from the synovial membrane may invade the tissues around the joint, and under- going caseous or fatty degeneration in places, break down into abscesses which may open both externally and into the joint, leading to the production of sinuses and fistulge. The ligaments being thus softened and destroyed, allow the articular surfaces to be dislocated by the contraction of the muscles ; whilst the muscles and bones themselves, partly from want of use and partly from the debilitating nature of the disease, undergo atrophy and fatty degeneration. When the disease begins in the bone it takes the form of a rarefying osteitis, the fungating granulations invade the deeper surface of the cartilages, perforate them, and then set up the changes in the synovial membrane and other tissues d'e- 244 DISEASES OP SPECIAL TISSUES. scribed above. The ininute changes which occur during the above-mentioned phenomena are those already described under inflammation. All that need be repeated here is, that the synovial membrane, ligaments, and in places the surrounding tissues, become infiltrated with small round cells, and ultimately converted into a layer of vascular granulation-tissue ; that the cartilage-cells prohferate whilst the matrix undergoes softening and liquefaction ; and that the articular ends of the bones are eroded and destroyed in the way described under Caries. In places in the granulation-tissue are found non-vascular areas, con- sisting of tubercle nodules, in which the tubercle bacillus is found. In the early stages under appropriate treatment the inflammation may subside, and the joint resume its normal condition. After the cartilages, however, have been destroyed, such a favourable ending is of course impossible, and all that can be hoped for is, that the layers of granulations covering the denuded bones may unite and ankylosis ensue. The dangers to be apprehended are that the tubercle should become disseminated, lighting up phthisis, meningitis, etc. ; or that long-continued suppuration should induce hectic, exhaustion, or lardaceous disease. Signs. — The disease is generally chronic, often lasting for years. It usually begins very insidiously : there may be some slight stiff"- ness of the joint, attributed perhaps to a trivial injury, or in the case of the lower extremity a slight limp in walking. The joint may be held in a slightly-bent position, and the range of flexion and extension may be somewhat restricted. Occasionally the disease is ushered in by an acute attack of synovitis. At first there may be little or no swelling, or the swelling may take the form of the synovial membrane ; but as the disease advances, it becomes general and uniform, so that the points of bone about the joint become obscured. The wasting and atrophy of the tissues of the limb, however, give the articular ends of the bone the appearance of being considerably enlarged. In the meantime there is no redness of the skin ; hence the name tumor albus, or white stvclling. Pain at first may be absent, or on!v present on movements of the limb, but gradually increases till the patient, in the case of the lower extremity, is prevented by it from walking. There is usually but little heat. In this condition the joint may remain for many months, and under appropriate treatment the disease may completely subside. If neglected, however, the ar- ticular surfaces of the bones, as the ligaments becomes softened, are slowly displaced, and painfiil startings of the limb at night in- dicate that the bones are involved. Now tenderness followed by fluctuation may be detected at one or more spots ; the skin be- comes red in these situations ; and the abscess if not opened, TREATMENl' OF CHRONIC TUBERCULAR ARTHRITIS. 245 bursts externally, allowing of the escape of curdy pus. Thus, by the formation of successive abscesses, the tissues around the joint are slowly undermined, and sinuses and fistulse are formed. The general health becomes more markedly affected, and although even now the sinuses and fistulse may heal and the patient ulti- mately recover, though almost certainly with an ankylosed joint, suppuration as often continues, hectic sets in, and the patient dies of exhaustion, or succumbs to phthisis or lardaceous disease. The treatment must be both local and constitutional. The local indications are (i), to place the joint at absolute rest in a position in which it will subsequently be most useful should anky- losis occur; (2), to keep it at rest, not only till all signs of the disease have disappeared, but for some months afterwards, to prevent a relapse ; (3), to open and drain antiseptically any ab- scess that may form, or fully expose the cavity of the joint and re- move the diseased tissues; and (4) in advanced and intractable cases to save the patient's life by the sacrifice of the limb. For keeping the joint at rest, splints may be employed similar to those mentioned under chronic synovitis ; and in the case of the lower extremity, where there may be flexion of the hip or knee, the patient should be placed in bed, and extension made by a stirrup, weight and pulley, or by a Bryant's double splint, till the de- formity has been overcome. The time the splints should be worn will vary in each individual case according to the progress of the disease. Roughly, it may be said that they will generally be required for many months, perhaps for several years, and that they must be worn three months after the disease has ceased. The constitittional means which must be adopted, are those that have already been described under the treatment of Tubercle (p. 46). Should the disease progress in spite of treatment, aspiration and the injection of iodoform-glycerin emulsion may be tried ; the aspirations and the injections being repeated at frequent intervals. This failing, the joint may be freely opened, the diseased synovial membrane scraped or cut completely away {arthrectomy), the cavity well flushed out with an antiseptic solution, filled with iodoform emulsion, and the wound closed. A convenient instrument for scraping out the joint will be found in Barker's flushing spoon, which admits of a stream of water or antiseptic solution flowing through the joint whilst the scraping is in progress. If the wound breaks down, the operation should be repeated, or if the whole of the diseased tissues cannot be re- moved an antiseptic drain may be employed. If the cartilages and articular ends of the bone are found much diseased, the joint should be excised. Where, however, notwithstanding the above treatment, abscesses and sinuses continue to form, and the patient 246 DISEASES OF SPECIAL TISSUES. is becoming exhausted by long-continued suppuration and hectic, or where signs of incipient phthisis or lardaceous disease are be- coming manifest, the question of amputation must be raised. Should recovery ultimately occur, but with the joint ankylosed in a faulty position, an osteotomy or osteoclasia may be of service. Tubercular disease of the hip, though essentially similar to tubercular disease of other joints, requires separate mention, as owing to the depth and conformation of the articulation it is at- tended with special symptoms, and calls for certain modifications in the method of treatment. Signs. — In the early stages there is slight lameness, some limi- tation in the range of movement of the joint, generally pain, and often quite early some atrophy and wasting of the muscles. The pain, though at times severe, is more frequently slight, "^nd may only be elicited on making certain movements of the '^oint. It may be felt in the hip, or as is commonly the case, be referred to the knee or to other parts supplied by the obturator nerve, as the inner side of the thigh. At times it may be felt in both hip and knee simultaneously. The ^'°- ^^- joint is slightly stiff, not only on flexion and extension, but also on rotation and on abduction and adduction, especially in the semi-flexed position. There is often some fulness about the front of the joint, loss of the gluteal fold, and perhaps tenderness on pressure. The joint be- comes at first slightly flexed, everted, and abducted, /. e., it assumes the position in which the ligaments of the inflamed joint are most relaxed — the position of greatest ease. In order to bring the flexed and ab- ducted limb to the ground, the pelvis is depressed on the affected side, and hence the limb appears when placed parallel to its fellow slightly lengthened (P^ig. 82, a and n). Later, the joint becomes further flexed ; but inverted instead of everted, and adducted instead of abducted, a change of position which has been variously attributed to erosion of the posterior part of the acetabulum, a yielding of the ligaments, or exhaustion of the ex- ternal rotator and abductor muscles. To overcome this position of adduction in which the limb is useless, the pelvis is raised on the affected side, so that the limb, if brought parallel to the other, now appears slightly shortened (Fig. 82, c and i;) in place of To show the effects of abduction (.\', and ab- duction (CI in causing apparent lengthening (B), and apparent shortening 'V of the limb in hip-joint disease, when the affected limb is placed parallel to the opposite limb. TREATMENT OF TUBERCULAR DISEASE OF THE HIP. 247 To show the lordosis of the lumbar spine when the limb is placed in the straight position. P. Psoas muscle. being lengthened. Whilst the position of abduction and adduc- tion is overcome by depressing or raising the pelvis respectively on the affected side, /. e., by laterally bending the lumbar spine, flexion is overcome by rolling the pelvis forward, /. e., by increas- ing the normal lumbar curve. Hence when the patient is laid on his back and the limbs are brought down parallel to each other, there is always considerable lordosis of the lumbar spine (Fig. 83), which, however, disappears on flexing the affected limb to the angle at which it is held flexed by the ^'""-^ contracted muscles (Fig. 84). Later in the disease real shortening ensues, owing to the destruction of the joint and the dislo- cation of the head of the bone on to the dorsum of the ilium. The pus usually makes its way towards the surface between the tensor vaginae and sartorius, and a fluctuating swelling is produced in this situation a Fig. 84. little below and external to the joint. Finally sinuses may form and the disease progress in the way described under Tubercular Arthritis. Not infrequently the aceta- bulum may become perforated and the suppuration extend into the pelvis. Pointing may then occur above Poupart's ligament, or the pus may make its way into the rectum, ischio-rectal fossa or through the sciatic notch. Treatineut. — As regards constitutional treatment nothing need be added to what was said on pp. 46, 224. The indications for the local treatment are similar to those for tubercular disease of the joints generally, but require certain modifications in the methods of carrying them out. Thus if the symptoms are acute the patient should be placed in bed, and extension made by the stirrup, weight and pulley in the direction in which the joint is displaced, the limb being gradually brought down in this way to a straight position. If the child is restless a long splint should be placed on the opposite limb to keep him from rolling to one or other side, whilst the foot of the bed should be raised by blocks to prevent him slipping down, or Bryant's double sphnt may be used with great advantage in some cases (Fig. 193). Subse- quently, or at once in subacute cases, a Thomas' splint (Fig. 77) should be applied, and after the limb has been brought into the To show effect of flexing the limb on the lumbar lordotic curve. P. Psoas muscle. 248 DISEASES OF SPECIAL TISSUES. Straight position, the patient may be allowed to get about on crutches. If in spite of treatment, the disease progresses and pus forms, aspiration and the injection of iodoform- glycerine emulsion may first he tried, the aspiration and injection being repeated at frequent intervals. This failing, the abscess should be opened, the diseased tissue scraped away, the cavity filled with the iodoform emulsion and the wound closed. The head of the bone if loose or carious should be removed, as should also any carious bone that can safely be got away from the acetabulum. When all the carious bone cannot be removed, or the suppura- tion has extended into the pelvis, an antiseptic drain should be employed, the wound being stuffed with iodoform gauze daily. One advantage of early incision is that the pus in some cases may at first be outside the joint, being dependent upon disease about the great trochantor, lower end of the neck or upper end of the shaft, and so extension to the joint may be avoided. In intractable cases amputation at the hip joint is often the only chance of saving the patient's life. In lieu of amputation at the hip, Mr. Howse has proposed amputation through the thigh, either as a preliminary to the more serious amputation or alto- gether instead of it. He argues that such a measure by reducing the length of lever having its fulcrum at the hip joint promotes rest, and by removirg a mass of tissue, chiefly blood- consuming, and very little blood- producing, favours the production of blood of better quality and larger am.ount ; whilst should amputation at the hip become absolutely necessary later there would be less shock and the patient would be better able to bear it. Should the patient recover but with the limb ankylosed in a flexed or other faulty position, the division of the femur subcutaneously with the chisel or Adams' saw below the trochanters will be re- quired to put it straight. Disease of the sacro-ieiac joint also requires a separate, brief notice. It is generally of tubercular origin, but is sometimes ap- parently due to injury. It usually occurs in young adults, rarely, if ever, in children. There is pain, swelling, and later redness over the joint, followed by the formation of abscesses which may open posteriorly or through the sciatic notch, above Poupart's ligament, in the ischio-rectal fossa, or in the rectum. The pain may be reflected along the sciatic nerve, simulating sciatica, or along the obturator nerve to the hip or knee, and may then be increased on moving the hij). The thigh, moreover, in conse- quence of the irritation of the ])soas, may be slightly flexed. The disease may thus have to be diagnosed from hijj-disease and spinal caries. C)n fixing the pelvis, however, the hip and spine move freely and without pain, but pain is felt on making pressure DISEASE OF THE SACRO-ILIAC JOINT. 249 inwards or outwards on the iliac crests or over the sacro-iliac joint. When sinuses have formed carious bone may sometimes be detected on probing. The prognosis is unfavorable. The treatment consists in keeping the parts at absolute rest by fixing the pelvis and thigh in a moulded leather sphnt reaching to the knee, and after sinuses have formed, in scraping and gouging away as much as possible the tuberculous granulations and carious bone and dressing with iodoform. Chronic osteo-arthritis, also called rheumatoid arthritis, or arthritis deformans, is an incurable and progressive disease lead- ing to great deformity and at times to complete disablement of the joint. It is characterized by gradual degeneration and de- struction of the cartilages, eburnation and alteration in the shape of the articular ends of the bones, and formation of nodular osteophytes in the fibrous tissue around the joint. It is a disease of middle and advanced life, and may be confined to one or more of the larger joints — the hip, knee or shoulder {monarthritis), or it may affect many joints, including the smaller articulations {^polyarticular rheumatism). Though most frequently met with in the joints of the extremities, it may affect other joints, as those of the lower jaw, spine, etc. The catise is not known. The disease, however, has been at- tributed to deficient or perverted innervation, depressing nervous influences, exposure to cold and damp, improper feeding, insuf- ficient clothing, etc. At times a slight injury appears to be the determining cause. Pathology. — The disease is variously believed to begin as a chronic inflammation of the synovial membrane, a fibroid degen- eration of the cartilages, or as an inflammatory affection of the ligaments. In whichever way it begins, however, the earliest characteristic changes are found in the cartilages. These at first appear nodular and cracked, but subsequently become roughened, fibrous and villous-looking, and are finally rubbed away by the friction of the articular surfaces of the joint on each other. Such changes appear to be due to fibroid degeneration, or splitting of the matrix into fibres, and the multiplication, enlargement, and fatty degeneration of the cartilage cells. Thus it will be per- ceived that the process by which the cartilages are destroyed in chronic osteo-arthritis differs materially from the so-called ulcer- ation of cartilage which occurs in the inflammatory joint-affections previously described, and in which the matrix undergoes liquefac- tion and softening consequent upon its invasion by the granula- tion-tissue derived from the synovial membrane and bone. In chronic osteo-arthritis the synovial membrane, at first dry, be- comes slightly thickened and vascular, and moderately distended 250 DISEASES OF SPECIAL TISSUES. with turbid synovial fluid which at times resembles train oil. In the meanwhile the synovial fringes become hvpertrophied, and assume the form of pedunculated processes, often containing little masses of cartilage or bone. These little masses may subsequently become detached and form loose bodies ^■'^•85. in the joint (Fig. 85). The articular surfaces of the bone become smooth, hard, polished, eburnated or porcellan- eous in appearance and variously altered in shape — changes apparently depend- ing in part on friction and mechanical pressure, and in part on the formation of new bone in the cancellous spaces, whereby the bone is rendered harder and is capable in consequence of receiving a higher polish. Whilst, how- ever, new bone is being formed immedi- ately beneath the polished surface, rare- faction and atrophy are going on a little deeper in the bone leading to the short- ening and distortion so commonly ob- served. Hence, for example, the flat- tening and enlargement of the aceta- bulum and glenoid cavity, and the absorption of the neck and flattening of the head of the femur and humerus, seen in osteo-arthritis of the hip (Fig. 86) and shoulder respectively. At times the new bone in the can- cellous spaces and Haversian canals is not formed as quickly as the polished layer of bone is worn away, and the open ends of the enlarged Haversian canals give the articular surf^ice a worm- eaten appearance. In the meantime out-growths of cartilage take place around the articular surfaces and undergo ossification, forming the low nodular flattened osteophytes and the "lipping" of the articular ends of the bone so characteristic of the disease. Ossification may also occur in the ligaments, tendons, and other soft structures around. S(ii>/s. — When the disease is fully established it may be known by pain, increased on movement, and often worse at night and during changes of the weather; a characteristic -creaking and harsh grating felt on moving the joint ; the detection of masses of bone around ; the limitation of the movement of the joint ; and absence of heat and redness. In the hip there may be eversion, shortening and much lameness ; in the knee, swelling and thick- ening of the synovial membrane, and deformity of the patella ; and in the shoulder, enlargement or displacement of the head of Chronic osteo-arthritis of the knee-joint. The articular sur- face of the tibia is shown in the upper part of the figure: the patella is turned down. I St. Bartholomew's Hospital Museum.) Charcot's disease. 251 the bone. In the hip the disease may closely simulate intracap- sular fracture of the neck of the femur ; in the shoulder, disloca- tion of the humerus. (See Fracture of Femur and Dislocation of Shoulder.^ Treatment. — Although the disease cannot be cured, and may -4.". Chronic osteo-arthritis of the hip. (St. Bartholomew's Hospital ^luseum.) get steadily worse as the patient grows older, much can be done in the way of relief. Thus the whole body should be warmly clad, the diet carefully regulated, stimulants prohibited or re- stricted in quantity, and a periodical visit paid to such spas as Buxton, Harrogate, Bath, Wiesbaden, Aix-les-Bains, or Wildbad. Locally, massage, friction, and passive movements, should be from time to time employed ; the joint should be enveloped in wool or flannel, but should not be kept at rest on a splint, since this will only tend to increase the stiffness. In the way of drugs, cod-liver oil, iodine, iodide of potassium, arsenic, and guaiacum, are of most service. Blisters and fumigations of sulphur are recommended for reheving the pain. Charcot's disease is an affection of the joints closely resem- bling osteo-arthritis. It is believed by some to depend upon degenerations in the spinal cord (locomotor ataxia) and there- fore to be the result of trophic changes in the joints. Others, however, regard it merely as an osteo-arthritis occurring accident- ally in a patient the subject of locomotor ataxia. The patholog. 252 DISEASES OF SPECIAL TISSUES. ical changes are similar to those already described under osteo- arthritis, but the destruction of the joint is more marked. Briefly they may be said to consist in erosion of the cartilages, softening of the ligaments, grinding away of the articular surfaces and often of the contiguous portions of the shaft of the bone, induration of the remaining portions of the articular surfaces, thickening and at times pouchings of the synovial membrane, and formation of osteophytes around. Suppuration is very rare. These changes may affect one joint only, or may occur successively in several joints. The signs in a typical case are as follows : — Sudden swelHng of a joint, usually without much pain or any marked signs of inflam- mation, followed, on the subsidence of the sweUing, by preter- natural mobility, and the formation of processes of bone about the articular surfaces and in the surrounding muscles and tendons. There is great deformity, but not much pain either on movement or handling. Along with the local signs there are generally symptoms of locomotor ataxia, such as an unsteady gait, a ten- dency to fall on placing the feet together with the eyes closed, a jerking movement of the limbs, absence of the patella-tendon- reflex, lightning pains, spasmodic muscular contractions, local anaesthesia and sweating of the limbs, loss of response of the pupil to light, but no loss of the power of accommodation ( Argyll- Robertso7i pupil) , sometimes optic neuritis, bladder troubles, and loss of sexual power. The joints most often affected are the knee, hip, and shoulder. In the tarsus the bones on the sub- sidence of the swelling of the synovial membrane, though at first felt to be loosened by the softening of the ligaments, may ulti- mately become ankylosed. Tieatmcfii. — Beyond keeping the part at rest during an acute attack, and adopting the same gen- eral treatment as is appropriate for osteo-arthritis and locomotor ataxia, little can be done. To relieve the pain antipyrin and antifebrin may be tried. Suspension has at times been of service. Loose Bodies in a joint may be formed in several ways, of which the following are the chief: — i, by the jiroliferation of the cartilage cells that normally exist in the synovial fringes, and the subsequent detachment of the little mass of cartilage so formed through the rupture of its peduncle in the movements of the joint (Fig. 87) ; 2, by thickening or hypertrophy of a synovial fringe, or by extravasation and subsequent organization of blood in a synovial fringe, detachment occurring in a manner similar to that in the former case ; 3, by necrosis of a portion of the articular cartilages ; and 4, by chipping off of a portion of the articular cartilage during some injury to the joint. Loose car- tilages are most common in the knee, but may be met with in LOOSE BODIES. 253 Fig. 87. any joint. They are generally single, but may be multiple, and vary in size from a pea to a walnut. Symptoms. — The chief symptom is pain, due to the loose body slipping between the ligaments and articular surfaces during the movements of the joint. In the knee this occurs during flexion ; and on the patient attempting to straighten the joint the loose body, by forcing the articular surfaces apart, stretches the liga- ments, and thus gives rise to a sudden and excruciating pain, perhaps so severe as to cause him to fall. At times the loose body remains fixed between the articular surfaces, the patient being then unable to straighten his limb. Such an attack may be followed by synovitis. On examination the body may often be felt somewhere in the synovial pouch, probably on the outer side of the joint in the case of the knee. If attached, its movements will be lim- ited, but if free it can frequently be made to move round to the opposite side of the joint. It may perhaps disappear by passing into some of the synovial re- cesses, though it can generally be felt again on moving the joint. lyeatnient. — If the loose body gives rise to little or no trouble, and can be easily fixed by a pad and bandage or knee-cap, it should not be interfered with ; nor should any operation be un- dertaken where the joint is disorganized by osteo-arthritis, or where the synovial membrane is studded with masses of car- tilage. Under other circumstances the loose body should be removed. This may be done either by the direct or the indirect method. The former consists in transfixing the loose cartilage by a strong needle on a handle thrust through the skin, so that the loose body may not slip away or be lost dur- ing the operation, and then cutting down on the capsule, and when all bleeding has been stopped, opening the joint. The body if loose will generally slip through the opening ; if attached, its pedicle must be ligatured and divided. The operation should be performed with the strictest antiseptic precautions, and the patient prepared by a week's rest in bed, in the case of the knee with his joint on a splint. The splint should be continued after the operation, or the joint placed in a plaster-of- Paris bandage till the wound has healed and all fear of inflammation has passed.- The formation of a loose car- tilage in a joint. A little mass of cartilage attached by a slender stalk. (St. Bartholo- mew's Hospital Museum.) 254 DISEASES OF SPECIAL TISSUES. The indirect method consists in incising the capsule subcutane- ously with a tenotomy knife, forcing the loose body through the incision into the connective tissue around the joint, and then either allowing it to lemain there permanently, or removing it after the hole in the capsule has healed. The operation is diffi- cult to perform, and since the introduction of antiseptics pos- sesses no advantage over the direct method. Ankylosis or stiff joint may be divided into the fibrous and the bo7iy. A spurious form of ankylosis, due to the contraction of the surrounding muscles or of cicatrices after burns, may also occur, but is generally associated with some amount of fibrous ankylosis. Fibrous ankylosis, also called ligamentous, or by some authors, false, in contradistinction to the bony which they then term true, is the union more or less complete of the articular surfaces of the joint by fibrous tissue. Thus, it may consist of — I, a mere thickening of the cap- sule ; 2, a thickening and shortening of the ligaments ; 3, the formation of fibrous bands within the joint ; 4, the partial removal of the cartilages and the union of the bones by fibrous tissue; and 5, the above conditions variously combined. It may be the result of joint-disease, or of keeping an inflamed joint too long in a state of rest. Sometimes it may terminate in bony ankylosis. Bony ankylosis is the firm union of joint by bone. It is often a further 'J'he articular surfaces may be united evenly and uniformly, or by irregular bridges of bone, or partly by bone and partly by fibrous tissue. The union may occur with the articular surfaces in contact in either the extended or the flexed position, or at an angle between the two (Fig. 88) ; or it may occur with the articular surfaces dislocated from each other. The way in which it is produced has already been described under Arthritis : all that need be repeated here is, that in tuber- culosis disease, ankylosis and caries may often be observed at the same time. The sii^ns of ankylosis are obvious — /. ass!ve clot) . SYMPTOMS AND SIGNS OF EXTERNAL ANEURYSM. 275 Rupture when it occurs into a serous cavity is generally by a rent or fissure ; into a mucous canal, by a small round ulcerated open- ing ; on to a cutaneous surface, by sloughing of the skin covering the sac. In the first case the rupture is generally rapidly fatal from excessive haemorrhage ; in the last two, as a rule, only after repeated haemorrhages, the slough having at first a tendency to cause the coagulation of the blood and block the opening. P?-essure effects. — The pressure of the sac of an aneur}'^sm may cause — I, inflammation and condensation of the parts around, which thus become blended with the sac ; 2, diminution or ob- literation of the lumen of a large vein ; and hence 3, oedema and dilatation of the superficial veins ; 4, irritation or interruption of the conducting power of nerves giving rise to pain, spasm, or paralysis ; 5, erosion of the bones and cartilage ; 6, obstruction of the oesophagus, trachea, or thoracic duct. Effects on the circulation. — Hypertrophy of the left ventricle of the heart : obstruction of vessels and enlargement of the anasto- motic channels ; syncope, and gangrene. Symptoms and signs of external aneurysm. — The attention is usually first drawn to the disease by pain, swelling, and a feeling of muscular weakness, or by stiffness in a joint. On examination a tumor is discovered in the course of the main artery. It pul- sates, and the pulsation is expansile, that is, on placing the hand upon the aneurysm, it is felt at each systole of the heart to enlarge in every direction, or if the hands are placed on either side of the tumor, they are seen to be slightly separated at each pulsation. If the artery on the cardiac side of the tumor can be compressed, the pulsation of the tumor is felt to cease, and the Fig. 95. tumor itself to become per- ceptibly smaller and less tense. On cessation of the pressure, however, it quickly fills again in two or three forcible pulsations, and resumes its former Sphygmosraphic tracing of the pulse in an artery , y^ • • 1 below an aneurysm f^B) compared with that of the characters. On raising the pulse on the sound side (a). (After Mahomed.) limb the pulsation is less forcible ; on lowering the hmb more forcible, the tumor at the same time becoming more tense. The pulse below the tumor is smaller on the affected than on the sound side, and a sphygmo- graphic tracing, if taken, shows the pulse is delayed on the dis- eased side and diminished in force, the tracing being less abrupt in its rise and more rounded (Fig. 95, b). On listening with the stethoscope, a bruit is heard in most cases. In consequence of 276 DISEASES OF SPECIAL TISSUES. pressure on the vein corresponding to the artery, there is often oedema of the part below, and sometimes varicosity of the super- ficial veins. In internal aneurysms, no tumor may be felt ; the signs are then often obscure, and the diagnosis will depend upon the effects the aneurysm produces by pressing upon important parts. Thus, in thoracic aneurysms, there may be pain, dyspnoea, dysphagia, cough, aphonia, dilatation of the pupil on one side, enlargement of the superficial veins, and oedema of one arm ; signs readily ex- plainable by the pressure on the nerves, trachea, bronchi, oesophagus, and arteries and veins of the thorax. But for a more detailed account of the symptoms of internal aneurysm, a work on Medicine must be consulted. The signs of an aiieurysm undergoing spontaneous cure are usually obvious. The tumor decreases in size, and the pulsation in it gets gradually less and finally ceases. At times a rapid cure may ensue ; the pulsation then ceases suddenly, and the tumor is felt to be hard, the patient often complaining of great pain at the moment of consolidation. The signs of a leaking aneuiysm, i. e., an aneurysm in which blood is beginning to be slowly effused into the tissues, are as follows : The pulsation is less distinct, the outline of the tumor less circumscribed, the growth progressive, and the pressure-signs are more urgent. The signs of sudden rupture of an aneurysm. — i. If the rupture is into a serous cavity, the signs are those of internal haemorrhage, rapidly followed by death. 2. If into a mucous canal there will be sudden hremoptysis in the case of the trachea or bronchus, hsematemesis in the case of the oesophagus or stomach, melrena, if the patient lives long enough, in the case of the intestines. 3. If the blood is effused into the tissues, there will be pain, faint- ness, loss of pulsation and bruit, rapid increase in the size of the swelling, oedema, coldness, and cessation of the pulse in the parts below, followed by increasing syncope from loss of blood, or if death does not soon occur, by gangrene. 4. Rupture externally is very rare ; the signs are evident. Diagnosis. — An aneurysm may have to be diagnosed from sim- ple dilatation of an artery, an abscess or tumor over an artery, a pulsatile tumor of bone, and enlargement of the thyroid gland. In a simple dilatation, there is an absence of bruit. In an abscess or tumor over an artery, the pulsation is not expansile, there is no bruit, and the swelling is not emptied or made less tense on com- pressing the artery above. A tumor can often be lifted from the vessel. In the case of an abscess, there will probal)ly be a history or signs of previous inflammation. In a tumor raising an artery TREATMENT. 277 over if, the pulsation is only felt in the course of the artery, and there is no expansile pulsation in the swelling. In pulsatile tumor of bone, the pulsation is not equally expansile all over; and although pulsation is stopped on compressing the artery above, the swelling does not become smaller like an aneurysm, or refill on removal of the pressure in two or three beats of the heart. Portions of expanded bone may also be felt in parts of the tumor, and there may be glandular enlargement and other signs of malignancy. From an enlarged thy )'o id gland, a carotid aneurysm may be distinguished by the gland moving with the larynx on deglutition. Treatment. — In no disease, perhaps, has an accurate knowl- edge of its pathology done more to ensure success in treatment than in aneurysm. The older surgeons, beheving that the clot possessed vicious properties, directed their efforts to the empty- ing of the sac ; and it was not until the fact became fully recog- nized that nature's method of curing an aneurysm was by filling the sac with organizable clot, that the lamentable results attend- ing the treatment of aneurysm in olden times gave place to the brilliant successes of modern surgery. Our treatment at the pres- ent day is therefore directed rather to aiding or promoting na- ture's efforts than to thwarting them. Thus, the modern surgeon, by means of rest, low diet, recumbency, and certain medicines, endeavors to lessen the force of the blood-current through the sac, and thus to aid nature in the deposition of laminated fibrin. By compression or hgature of the artery between the aneurysm and the heart he aims at diminishing the flow of blood through the artery leading to the aneurysm, and in this m.anner seeks a like result. By manipulation and the use of the distal ligature, he endeavors to copy the method of spontaneous cure that is sometimes brought about by the plugging of the artery beyond the aneurysm ; whilst by flexion, he imitates nature's method of cure by the pressure of the aneurysm itself on the artery either above or below the sac. The treatment of aneurysm, therefore, may be divided into the medical or general, and the surgical or local. Medical treatment. — Both internal and external aneurysms have been cured by medical treatment alone. Indeed, in some forms of internal aneurysm, it is the only means at our command. In external aneurysms, however, local treatment in addition is nearly always expedient or necessary. Absolute rest, both bodily and mental, should be enjoined ; the patient must lie in bed, and must not move for any purpose whatever, not even to feed him- self. The diet should be limited in quantity, unstimulating but nutritious in quality, and the fluid portion restricted as much as 278 DISEASES OF SPECIAL TISSUES. possible. The following diet scale is advised by Mr. Jolliffe Tufnell : Bread and butter, 4 ozs. ; meat, 3 ozs. ; potatoes, 3 ozs. ; fluid, 8 ozs. in the twenty-four hours. Small repeated bleedings, where there is excessive action of the heart, or the patient is plethoric, may occasionally be useful. Medicines seem to have little efficacy, but iodide of potassium in large doses, acetate of lead, aconite, and digitalis have been recommended, either for promoting the coagulation of the blood, or retarding the heart's action. Where there is a history of syphilis, iodide of potassium should certainly be given Surgical treatment. — In all suitable cases of external aneurysm, pressure, when it can be applied between the aneurysm and the heart, should first be tried, aided under certain circumstances by the method of flexion. But these failing, or appearing unsuitable, the artery should be tied, if practicable, on the proximal side, and preferably at some distance from the sac where the artery is more likely to be healthy. Where pressure or ligature cannot be used on the proximal side, as for instance, in aneurysms at the root of the neck, it becomes a question whether we should try distal pressure or ligature, scratching the wall with needles (^Maceweti' s method), manipulation, galvano-puncture, coagulating injections, or the introduction of wire or horsehair; or fall back on medical means alone. In some varieties of traumatic aneurysm where the artery is presumably healthy, and in certain forms of aneurysm, as gluteal, where a ligature of the artery at a distance from the sac is attended with excessive risk, it may even be expedient to resort to the old method of opening the sac, turning out the clot, and securing both ends of the bleeding vessel by ligature. Each of these methods requires discussion. Before resorting to surgi- cal methods, however, the circulation through the aneurysm should have been previously quieted as much as possible by rest, recum- bency, restriction of the diet, and regulation of the secretions. Where the aneurysm is on an artery of the lower extremity, any embarrassment of the venous circulation and consequent oedema that may be present, should be lessened or removed by elevating and lightly bandaging the limb. Prkssukk, — This method of treating aneurysm was known to the older Surgeons, but in consequence of their efforts being directed either to the emptying of the sac by direct pressure upon it, or to the obliteration of the artery leading to it by adhesive inllammation, it was attended with such unfavorable results that it fell into disuse. To the Dublin Surgeons, who recognized the fact that it was not necessary to obliterate the artery in order to cause consolidation of the aneurysm, is due in chief part the credit of reviving treatment by pressure. The object of pressure as now PRESSURE. 279 employed, is to produce consolidation of the aneurysm by the formation of either a laminated or an ordinarj- coagulum. The methods of bringing this about maybe considered under i, direct pressure on the aneurysm ; and 2, indirect pressure, either on the artery above, on the artery below, or on both simultaneously. 1. Direct pressure is now seldom used, exxept in as far as flex- ion may be considered as in part a method of direct pressure, although several successful cases have of late been reported. It will not receive further notice. 2. Indirect pressure, whether applied to the artery above, the artery below, or to both at the same time, may be considered under the heads of — {a) Digital pressure. {d) Instrumental pressure, {c) Pressure by Esmarch's bandage, {d) Pressure by flexion of the limb. {a) Digital pressure, where it can be applied to the artery on the proximal side at some distance from the sac, is undoubtedly the safest and probably best method of treating an aneurysm ; and it is the one, other things being favorable, which should usually first be tried. There are some Surgeons, however, who, now that the healing of the wound for the ligature of an artery can practi- cally be assured by the first intention, prefer ligature to pressure as the more certain though perhaps the more risky method. The advantages claimed for digital pressure are — i, that it causes less pain than other forms of pressure \ 2, that the artery can be com- pressed with little or no interference with the venous circulation ; 3, that it is less liable to injure the tissues ; and 4, that in com- mon with other methods of pressure, it does not expose the patient to the dangers of an open wound. Pressure treatment requires a relay of intelligent assistants, acting in pairs and alter- nately compressing the artery for about ten minutes at a time. Whilst one presses the artery, the other should have his hand on the aneurysm, to ascertain if pulsation is being properly controlled. The fingers of the one assistant should not be removed till the other has taken his place, as the artery must on no account escape compression for a single moment. The pressure of the fingers may be aided by a shot-bag, and the spot at which pressure is appUed may be slightly varied from time to time. Opinions dif- fer as to whether the circulation should be completely, or only partially, stopped through the artery, and whether the pressure should be continued both day and night, or only during the day. Aneurysms have been cured by digital pressure in a few hours, but some days are usually necessary ; and to obtain success, much care and attention to detail is required. {b) Instrumental pressure may be appHed so as only partially to control the circulation through the artery, and thus induce the 28o DISEASES OF SPECIAL TISSUES. gradual obliteration of the aneurysm by the deposit of laminated fibrin in the sac {s/ow pressiire) ; or it may be applied so as to completely control the flow of blood through the vessel, and in- duce rapid coagulation in the sac {rapid pj-essto-e). The latter method can only be done under an anaesthetic, but has been at- tended with some brilliant results, especially in cases of abdom- inal aneurysm. As a rule for external aneurysms, however, the milder measures will suffice, and it is a question if these fail whether it is not better treatment to ligature the artery than sub- ject the patient to further attempts at cure by rapid pressure. Both kinds of pressure may be applied by one or other of the many forms of compressors and tourniquets which have been in- vented for the purpose (Figs. 96, 97, and 98). It is better when possible to apply the pressure to one artery, though slightly vary- ing its position, than to change from one artery to another, as Fig. 96. Fig. 97. Fig. 98. De Carte's Tourniquet. Lister's Abdominal Tourniquet. Skey's Tourniquet. from the superficial to the common femoral, since by so doing different sets of anastomosing arteries are enlarged, and the col- lateral circulation may become too free. Cases U7isititable for pressure. — i. Where the aneurysm is of very large size, or is rapidly increasing. 2. Where the sac is thin, contains but little fibrin, and appears likely soon to burst. 3. Where there is much oedema from venous obstruction. 4. Where the patient is of an irritable disposition, is intolerant of pain, or has been addicted to the abuse of alcohol. It is considered by some that even if pressure fails, good may have been done by causing a deposit of fibrin in the sac, and by enlarging the collateral vessels. By others these advantages are thought to be outweighed by the irritation and disappointment to the patient of failure, and the bruising and injury of the tissues at the situation where the artery will have to be tied. LIGATURE. 281 (r) Pressure by Esmarch''s bandage {Reid^s method) aims at simultaneously compressing the artery above and below the aneurysm, and thus causing the blood contained in both the aneurysm and the artery to coagulate. The elastic bandage, in the case of popliteal aneurysm, in which this method of compres- sion has most often been used, should be evenly applied from the foot as far as the aneurysm ; a turn should be then made over the tumor, so as only lightly, if at all, to compress the sac, and the bandaging then continued firmly half way up the thigh. The bandage should be kept on for an hour to an hour and a half. The elastic cord should not be used at all. On removing the bandage digital pressure should be kept up on the main artery from thirty-six to forty-eight hours, so as to control the circula- tion and prevent the clot, while still soft, from being washed out of the artery and sac. The patient must be placed under an anaesthetic during the use of the bandage, as it causes great pain. Many cases have been cured by this method ; but on the other hand there have been many failures, and it is far from being un- attended with danger. Thus, gangrene of the limb and rupture of the sac have ensued, and aneurysms of internal arteries have been produced apparently by the prolonged increase of blood- pressure in the rest of the arterial system. {d) Pressure by Flexion {Harfs melhod) consists in flexing the limb so as to compress the artery by the aneurysm, in imita- tion of that form of spontaneous cure which is brought about by the pressure of the aneurysm itself on the artery above and below. It is obviously applicable to aneurysms in but very few situations, and has been most successful in those of the popliteal artery. It may be used either alone, or in conjunction with digital or other pressure, or with medical treatment. This treatment causes much pain, and can seldom be endured. Ligature, like pressure, is a very old method of treatment, but to Anel and John Hunter is due the credit of havmg placed it on a scientific basis. The older surgeons laid open the sac and turned out the clots, and endeavored to staunch the hsemorrhage by ligaturing the artery above and below the aneurysm. Antyllus, it is true, applied his ligatures before opening the sac ; but it was not until centuries afterwards that Anel recognized the fact that it was unnecessary to open the sac at all, and tied the artery immediately above the aneurysm. Many years later Hunter per- ceived that the more or less complete stoppage of the circulation obtained by Anel's method was not necessary, and that the liga- ture of the artery close to the sac was attended with the risk of secondary haemorrhage and inflammation of the sac. He, there- fore, applied his ligature at a distance from the aneurysm, wheie 13* DISEASES OF SPECIAL TISSUES. Fig. gg. Different positions of ligature for aneur- ysm. A. Antyllus's method; B. Anel's; c- Hunter's; d. Brasdor's; and e. War- drop's. he had observed moreover that the artery was likely to be in a healthier condition. For aneurysms so situated that a ligature cannot be placed on the cardiac side, Brasdor proposed tying the trunk of the artery on the distal side of the aneurysm ; whilst War- drop suggested tying one or two of the terminal branches of the artery on the distal side of the aneurysm, where neither Brasdor's /\ 17 I r f \ { ] operation nor the proximal liga- ( ) Pv ( ] \ J [J ture was applicable. Hence liga- ture for aneurysm may be apphed (Fig. 99), 1. On the proximal SIDE of the aneurysm either at a distance {Hunter's method), or immediately above it {Anel's method). 2. On THE distal side of the aneurysm, either to the main trunk {Brasdof''s method), or to one or more of the main branches {Wardrop's method). 3. Immediately above and below the aneurysm, either opening the sac {the old operation), or without opening the sac {Antyllits' method). I. The proximal ligature. A. Hunter's method. — This ope- ration, when applicable, is the one now almost universally adopted. The chief merits claimed for it are — i. That the artery at the spot selected for hgature is not only more likely to be healthy, but is also more easily tied than the artery in close proximity to the sac, in which latter situation, moreover, its anatomical relations are liable to be disturbed by the aneurysm. 2. That the sac is not interfered with, and hence is less likely to become inflamed and suppurate ; and 3. That as several branches will probably be given off between the ligature and the aneurysm, the circulation through the sac, though lessened, will not be completely arrested, and the clot is therefore more likely to have a laminated, and hence a permanent character. Effects of the proximal liffatnre. — After the successful ap])lica- tion of a ligature by the Hunterian method, the ]julsation in the aneurysm immediately ceases, and for a time the circulation through the limb is diminished. Hence the temperature becomes lower and the surface pale. Soon, however, the collateral circula- tion becomes established, and a faint pulsation may be felt again in the aneurysm ; but this recurrent pulsation usually grows less from day to day, and shortly ceases, and the aneurysm slowly shrinks and is finally absorbed, or remains as a small, hard, THE DANGERS OF LIGATURE. 283 Fig. 10:1. I fibrous mass. The artery leading to the aneur}'Sm may remain pervious, but it more frequently becomes obliterated as far as the first collateral branch above and below the sac. The artery on either side of the ligature also becomes ob- literated as far as the first collateral branch. This condition of an aneurysm and artery after ligature is seen in the accompanying diagram (Fig. 100). The blood passes the ligature by the collateral channels ; re-enters the artery below ; passes the obstruction where the artery is closed at the seat of the aneurysm, also by collateral channels ; and then again enters the main artery. Treatment afte)' ligature. — The limb should be completely swathed in the cotton- wool and flannel bandages (which, before the operation, should have already been carried up as far as the seat of the ligature), and kept at perfect rest. In the case of popliteal aneurysm, the limb should be slightly raised on a pillow, and placed on its outer side, with the knee a little flexed, care being taken that no pressure is made on the heel, malleoli, or other points of bone, for fear of local sloughing. If the weather is at all cold, hot bottles should be appUed, near, but not in con- tact with, the limb. The patient must be kept in bed till the aneurysm is thoroughly consolidated, and the operation wound has healed. The dangers of ligature. — These are — {ji) secondary haemorrhage ; (^) gangrene ; (^) re- current pulsation ; {d) suppuration and slough- ing of the sac ; {e) phlebitis; (/) great enlarge- ment of the aneurs'sm without pulsation ; and {g) the other dangers that may attend any open wound . (^) Secondary hce??ior?-hage is liable to occur at any period be- fore the wound is soundly healed. The causes, symptoms, and treatment, are discussed under "Haemorrhage," see p. 134. {[>) Gangrene \5 more common in the leg than in the arm; indeed, in the latter situation it is very rare. It may be due to — I, failure of establishment of the collateral circulation, when it usually supervenes within a few days ; or 2, venous obstruction, the result of plugging of the vein in consequence either of injury at the time of operation, or of pressure on the vein by a swollen and suppurating sac. When due to the latter conditions, it may be delayed for some weeks. When extensive and spreading rap- ii Diagram to show the condition of the arterj' and aneu- rysm after the Hunterian liga- ture, and the es- tablishment of the collateral circula- tion. The arrows indicate the direc- tion of the blood current. 284 DISEASES OF SPECUL TISSUES. idly, amputation at the seat of ligature must be performed. The Surgeon, however, should not be in too much haste to amputate, as the gangrene may involve only a toe or two, or part of the foot, and spread no further. When, therefore, it is limited in extent, and spreading slowly, a line of demarcation should be waited for before amputation is performed. When the sac is very large, and the gangrene appears to be due to pressure on the vein, the sac may at times be opened with advantage, the clots turned out, and any bleeding vessels secured. {c) Recurrent pulsation, when slight, is a good sign, as it shows that the collateral circulation is becoming established, and conse- quently that the danger of gangrene is lessened, if not passed. If, however, instead of ceasing, as it usually does in a few days, it becomes more pronounced, the hmb should be raised, and care- fully bandaged from the foot upwards, and pressure applied to the artery leading to the sac. If this does not suffice, and the pulsa- tion returns as strongly as ever, and the aneurysm again begins to increase in size, it is clear that the ligature has failed ; and it be- comes a grave question what further treatment should be under- taken. Should it appear that a large branch is feeding the aneurysm, this should undoubtedly be secured ; otherwise the choice will probably lie between — i, pressure upon the artery and aneurysm ; 2, the use of Esmarch's bandage ; 3, flexion in the case of a popliteal aneurysm ; or if these fail, 4, tying the vessel either just above the aneurysm, or above the former ligature; 5, cutting down upon the sac, and securing both ends of the artery ; or 6, amputation. Much will turn on each individual case, but the discussion as to a choice of method is too long to be entered upon here. {d) Inflanunation and suppuration of the sac may be met with after pressure, as well as after ligature ; and although it may occur after the Hunterian operation, is more frequent in cases where the ligature has been applied close to the sac, or where rapid pressure has been used. It appears to be due to — i, the spread of inflammation to the sac from the wound ; 2, the formation in the sac of a soft coagulum ; or 3, excessive manipulation before the operation. It is ushered in with redness, heat, pain, and swelling of the sac (which has not undergone the usual process of shrinking),, and oedema of the surrounding parts. Later the skin gives way and a mixture of jjus and broken-down coagula escapes. It may be accompanied l)y haemorrhage ; but more commonly the vessel has become sealed and no bleeding occurs. The abscess should be opened as soon as pus has formed, a grooved needle being previously inserted if there is doubt on this point. Should haemorrhage occur, the clots must be turned out, THE DISTAL LIGATURE, 285 and the artery secured above and below, or amputation per- formed. ((?) Phlebitis may occur from injury to the vein in passing the aneurysm needle. Should the vein be pricked, an accident which may be known by venous blood welling up by the side of the ligature, the artery should on no account be tied at this spot, as the ligature would act as a seton in the vein, and death possi- bly ensue from phlebitis or pyaemia. The ligature, if already passed, should be withdrawn, pressure applied to the vein, and the artery tied higher up. Where this treatment has been adopted I have never seen any ill results follow the injury. B. Anei.'s operation is seldom done except where the Hun- terian method is inapplicable, as for aneurysm in the groin, aneurysm of the upper part of the common carotid, etc. The disadvantages said to attend it are — i, that the artery is likely to be diseased, and hence there is greater risk of secondary hsemor- rhage ; 2, that its anatomical relations are apt to be disturbed by the contiguity of the sac ; 3, that the sac itself is liable to be injured during the operation, and to become inflamed and sup- purate ; and 4, that the clot which forms in the sac is of the soft or passive variety in consequence of there being no circulation in the sac. Recently this method has been revived at St. Bartholo- mew's for the treatment of popliteal aneurysm, and the popliteal artery is there now frequently tied. It has been found to di- minish the risk of gangrene, and holds out a greater certainty of cure. Gangrene is less likely to occur when only the popliteal is obstructed close to the aneurysm than when both the popliteal and femoral are blocked. Recurrent pulsation and failure after liga- ture of the femoral are due to too free a supply of blood flowing into the artery below the ligature (Figs. 100, 104) ; when the popliteal is tied this is prevented. Moreover the poptiteal has been found quite as healthy as the femoral ; it is easily tied at its upper part without disturbing the sac ; and there appear to be sufficient small vessels given off from the artery between the liga- ture and the aneurysm to ensure by their anastomosis with other small vessels given off above the ligature some circulation in the sac and the formation of an active clot. 2. The distal ligature should- only be used where the Hun- terian or Anel's method cannot be apphed. Brasdor's method, which consists in securing the main trunk on the distal side of the aneurysm, may be employed in aneurysm of the carotid at the root of the neck. It copies that method of spontaneous cure in which a clot blocks the artery beyond the aneurysm. After the ligature the clot that forms in the artery may extend to the aneurysm, which thus becomes filled by a coagulum ; or the blood 2 86 DISEASES OF SPECIAL TISSUES. pressure in the sac may become so diminished that laminated fibrin is deposited. Unfortunately, however, in practice the blood-pressure in the aneurysm appears in some cases to be in- creased rather than diminished. Wardrofs method consists in securing two or more of the main branches of the artery on the distal side of the aneurysm. It aims at cutting off part of the blood-stream through the aneurysm, and so, by reducing the blood-pressure, promoting the deposition of laminated coagulum. It has been applied to the subclavian and carotid arteries for aneurysm of the innominate ; but the success attending it has not been great. The chief risks are passive enlargement and subse- quent bursting of the sac, or inflammation and suppuration of the sac. 3. The double ligature. — Ligature above and below the sac, either, i, by the old method of first laying the sac open and then securing the bleeding ends of the artery ; or, 2, by the method of Antyllus, of first securing the artery and then laying the sac open, is only employed in exceptional' cases. Thus the old method is sometimes resorted to in traumatic aneurysm of the axillary artery in preference to tying the subclavian, and also in gluteal aneurysm where the Hunterian method of tying the common or internal iliac is attended with so much risk. The great danger is the patient dying under the operation, of haemorrhage. During the operation, therefore, in the case of the axillary artery, pres- sure should be made on the subclavian, an incision through the skin and fascia above the clavicle being made to ensure its better control. In the case of the gluteal, Davy's lever or the abdom- inal tourniquet should be used. The true method of Antyllus may, in rare instances, be required, as in some forms of aneurysm at the bend of the elbow. Manipulation. A spontaneous cure, as we have seen (p. 274), is sometimes brought about by the impaction of a portion of clot either in the mouth of the sac or in the artery below. Manipula- tion of the sac aims at breaking up and displacing such clot as may have formed in the hope that a portion may become im- pacted in this way, and so lead to consolidation. Sir William Fergusson, who first introduced this method, used it with success, and others have done so likewise. It is far from being unat- tended with danger, however, since a portion of the clot may be carried away by the blood-stream and become lodged in a vessel leading to an important organ, as the brain. It should, there- fore, only be tried when other means are impracticable or appear attended with even greater risk. Irritation of thk interior of the sac by needles (Mac- ewen's method). This method aims at so irritating the walls of ANEURYSM AT THE ROOT OF THE XECK. 287 the aneurysm as to induce slight inflammation and the formation of white thrombus. The skin having been made aseptic, long needles are passed into the sac and the walls systematically scratched all around the aneurysm. It is applicable to aneurysms where pressure or proximal hgature cannot be employed. Con- solidation occurs very slowly. Our experience of this method is at present ven,- hmited. In a case of aneurysm at the root of the neck in which I tried it, the results were such as to lead me to think it has a future. GaLV.^^O-PUXCTURE, ELECTROLYSIS, IXJECIIOXS OP PERCHLORIDE OF IRON, tanxix, and the like, and the ixtroductiox of foreign BODIES as horsehair or irox wire, which have all for their object the coagulation of the blood in the sac, are highly dangerous procedures, and have not hitherto been attended with much suc- cess. SPECIAL AXELTRYSMS. IxTERXAL AXEURYSMS, falling as they do under the care of the Physician rather than of the Surgeon, will be referred to only in so far as an aneurysm of the arch of the aorta, of the innominate, of the first portion of the subclavian, and of the portion of the left common carotid within the chest, may present as a pulsating tumor at the root of the neck, and as such may call for surgical treatment. Aneurysm at the root of the neck. — The differential diag- nosis of aneurysm in this situation is always difficult, at times im- possible. Indeed the aneurysm may involve inore than one artery, perhaps all three of the main branches of the aortic arch, and even the arch itself as well. The sign common to all forms, whatever the artery implicated, is a pulsating tumor at the root of the neck, in which a loud bruit can generally be heard. When the aneurysm involves the aorta, it generally presents just above the suprasternal notch, and there are symptoms within the chest of the aorta being affected. When the innominate is implicated, the aneurysm projects between the two heads of origin of the sterno-mastoid muscle ; and the pulse in the temporal and radial arteries is smaller on the right than on the left side, and is aneur- ysmal in character. (See p. 275.) When the aneurysm involves the common carotid, it presents beneath the inner head of the sterno-mastoid, and tends to extend upward in the neck by the side of the trachea ; the bruit is transmitted up the carotid, and the pulse in the temporal is smaller on the affected than on the sound side and is aneurysmal : but the pulse in the radial is the same on both sides. When the subclavian is involved the tumor is external to the sterno-mastoid ; it extends in the direction .of 288 DISEASES OF SPECLA.L TISSUES. the subclavian artery ; the bruit is transmitted towards the axilla ; and the pulse at the wrist is diminished in volume and is aneur- ysmal. Such is a brief outhne of the differential diagnosis of these aneurysms ; but there are many other signs due to the pres- sure of the aneurysm on the veins, nerves, oesophagus, trachea, etc., which have to be taken into consideration, and for an ac- count of which a work on Medicine must be consulted. Treat- menf. — When the aneurysm is aortic medical means alone must be relied on. When the innominate is involved, Macewen's method of scratching the interior of the sac with needles should certainly first be tried. This faihng, medical means and pressure on the carotid, or distal hgature of the carotid and subclavian arteries simultaneously may be employed. If these do not prove successful, or are impracticable owing to the large size of the aneurysm, nothing is left but the desperate resort to galvano- puncture, electrolysis, or the introduction of iron wire. When the carotid or subclavian is affected, Macewen's method and medical means may also in the first instance have due trial ; afterwards, in the case of the carotid, distal compression or liga- ture may be tried ; and in the case of the subclavian, distal com- pression or ligature if practicable, direct pressure on the sac, or the terrible expedients of amputation at the shoulder-joint, liga- ture of the innominate, manipulation, galvano-puncture, injection of coagulants, or the introduction of iron wire. Carotid aneurysiM. — Aneurysm of the carotid at the root of the neck has been alluded to above. Aneurysm of the common trunk higher in the neck presents the ordinary signs of aneurysm, and in this situation has to be diagnosed from — i, simple dilata- tion of the artery at its bifurcation; 2, enlarged glands; 3, ab- scess or tumor over the artery; 4, pulsating goitre. In simple dilatation there is no bruit ; in enlarged glands and tumors there is also no bruit, and the pulsation is not expansile, and ceases when they are lifted up from the vessel ; in abscess, in addition to the absence of the above signs, there is the history or presence of inflammation ; in pulsating goitre the tumor moves up and down with the larynx on deglutition. The treatment consists in pressure or ligature of the artery below the aneurysm, or if there is not room in this situation, distal ligature. Aneurysm of the external and in'jernal caroiids requires no special mention. Pressure or ligature of the common carotid is the treatment generally indicated. Orbital aneurysm. — Several conditions may give rise to the group of symptoms to which the name "orbital aneurysm" has been applied. In only one instance has the existence of a circum- scribed aneurysm in the orbit been verified by an autopsy. In the AXILLARY ANEURYSM. 289 Other cases that have proved fatal the following conditions were found: i. Thrombosis of the cavernous sinus. 2. Communication between the carotid artery and cavernous sinus. 3. Dilatation of the carotid artery. 4. Aneurysm of the ophthalmic artery luithin the cranium. The general symptoms are : Pulsation over the whole or part of the orbit ; protrusion of the eyeball, with loss or impairment of sight ; more or less pain ; and a loud bruit, which can also often be heard by the patient himself. The differential diagnosis of the several conditions producing these symptoms is one of great difficulty, and cannot be entered upon here. Treat- me}it. — The symptoms have been known to subside spontaneously. Where they have not done so, hgature of the carotid has been at- tended with the best results. Injection of perchloride of iron has been recommended, but I should hesitate to use it myself for fear of venous thrombosis and embolism. Where the pulsation has followed a punctured wound of the orbit, it has been advised to extirpate the globe and secure the bleeding vessel in the orbit. In a case of the kind recently under the care of my colleague, Mr. Power, ligature of the common carotid was attended with perfect success. Axillary aneurysm is not uncommon as the result of sprains or of attempts to reduce long-standing dislocations of the shoulder. The diagnosis, as a rule, presents no difficulty, except the aneur- ysm has become diffused, when it may be mistaken for abscess. Treatment. — 1. When the aneurysm is spontaneous, small, and well circumscribed, pressure or ligature of the third part of the subclavian should be practiced. 2. When more or less diffused, as when the result of an injury to the artery in the reduction of a dislocation, the aneurysm should be cut down upon, the clots turned out, and the vessel secured above and below. If this ope ration is decided on, an incision should be made over the sub- clavian artery through the skin and fascia, so that pressure may be made on it more directly, and the circulation through the aneurysm during the subsequent operation better controlled. xA. small incision is then made over the aneurysm, two fingers are introduced into it, and placed on the bleeding spot in the artery, which may be known by the hot arterial blood issuing from it. An assistant in the meantime enlarges the wound, turns out the clots, and helps the surgeon to tie the artery above and below the rupture before the fingers are removed. This method is less dan- gerous than that practiced by Syme, who made a free incision over the aneurysm, rapidly turned out the clots, and seized with for- ceps the bleeding point in the artery. 3. Where the aneurysm is of great size and involves the subclavian, Macewen's method may be employed or the first part of the subclavian or the innominate 13 290 DISE.\SES OF SPECIAL TISSUES. may be ligatured, or iron wire introduced, galvano-puncture or manipulation tried, or amputation at the shoulder-joint performed. Space does not permit of a discussion of the cases in which one or other of these methods is the more suitable. All, however, with the exception of Macewen's method, are desperate expedients. Aneurysms at the bend of the elbow were formerly common when venesection was in vogue, and were then generally arterio- venous in character (see p. 202). Gluteal aneurysm is the term applied to aneurysms of the gluteal artery itself, the sciatic, or the pudic where it winds over the spine of the ischium. Aneurysms in this situation may be the result of a wound or other injury, or may occur spontaneously. They are frequently attended with pain and interference with the movements of the hip-joint. The pulsation and bruit will gener- ally serve to distinguish them, but there may be no pulsation, as where the aneurysm has burst, or blood has been effused into the tissues as the result of a wound of the artery ; a tumor of bone, moreover, may also pulsate. Under such circumstances, explora- tion with a grooved needle will be necessary. Treatment. — When of traumatic origin, an incision should be made over the tumor, the clots turned out, and the bleednig vessel secured, the haemorrhage during the operation being controlled by pressure on the common iliac by Davy's lever or by the hand in the rectum. ^^'hen spontaneous, the internal iliac may have to be tied if the aneurysm encroaches on that vessel within the pelvis — a point which may perhaps be determined by exploring with the hand in the rectum. Before, however, resorting to ligature of the internal iliac, Macewen's method or compression of the abdominal aorta or common iliac, and carefully applied direct pressure on the swelling, should be tried. Galvano-puncture and the introduc- tion of coagulants have been employed successfully in this aneurysm. Inguinal aneurysms are those which involve either the termina ■ tion of the external iliac, or the commencement of the femoral. They may extend either upwards along the course of the iliac into the abdomen, or downwards in the course of the femoral into the thigh. They may have to be diagnosed i'rom enlarged inguinal glands over the artery, tumors, esix-cially pulsating tumors of the pelvic bones, and abscesses. From abscess and tumor they may be distinguished by the signs already several times alluded to.. Their diagnosis from ])ulsatmg tumors of bone is often very diffi- cult, and the external iliac has before now been tied by the most able surgeons under the impression that such a tumor was an aneurysm. The diagnostic points have already been given under Pulsatile Tumors of Botie and Diagnosis of Aneurysm (pp. 235, POPLITEAL ANEURYSM. 29 1 276). Treatment. — i. When the aneurysm is of moderate di- mensions, and involves only a small portion of the external iliac, this vessel should be tied, or if preferred, an attempt may first be made to compress it. 2. Where there is apparently not room to apply a ligature to the vessel, rapid compression of the abdom- inal aorta may be employed, combined in some cases with distal pressure. 3. Where there is not room for the tourniquet on the aorta, medical means must be relied on, or Macewen's method tried. This faihng, the common iliac may be tied; or the des perate experiment made of tying the aorta, or injecting coagulants, or passing iron wire into the sac. On the whole, if pressure or Macewen's method fail, ligature of the common ihac by the in- traperitoneal method perhaps holds out the best chance of success. Femoral aneurysm requires no special remark other than that when situated in Hunter's canal, the femoral should be com- pressed or tied in Scarpa's triangle. When situated in Scarpa's triangle, the external iliac may be treated in the same way. In either situation Esmarch's bandage may be used if this method of treatment commends itself to the Surgeon's judgment. Popliteal aneurys^l — The frequency of aneurysm in this situa- tion is attributed to — i, the bifurcation of the popliteal artery into the anterior and posterior tibial, whereby the circulation through it may be slightly obstructed, or an embolus be readily impacted ; 2, the artery being unsupported by muscles, and in contact with the bone ; 3, the strain en the artery in the move- ments of the knee-joint; 4, the compression that may be exerted on the end of the artery by the strong fibrous arch of origin of the soleus muscle. A popliteal aneurysm is not usually difficult to diagnose, but should it become diffused, suppurate, or break into the knee-joint, it may be mistaken for a malignant tumor of the bones, an abscess, or an affection of the joint. The history of the case, the consideralion of the diagnostic signs of aneurysm, already given, and the introduction of a grooved needle into the knee when blood has been effused into the joint, will usually clear up any doubt as to the nature of the affection. A popliteal aneu- rysm is often bilateral. Treatment. — Little need be added here to what has already been said on the general treatment of aneu- rysm, as such especially applies to aneurysm in this situation. Flexion, combined with appropriate medical treatment, is often successful ; and digital and instrumental compression are especi- ally applicable to this aneurysm, or an Esmarch's bandage may be used if preferred. These methods failing or not being con- sidered advisable, the popliteal in the upper part of its course or the femoral artery in Scarpa's triangle should be tied. The opera- 292 DISEASES OF SPECUL TISSUES. tion of tying should be done at once under the following circum- stances : — I. When the aneurysm is rapidly increasing in size, leaking, or threatening to burst. 2. When the aneurysm is in- flamed but has not suppurated. 3. Under some circumstances when it has burst into the knee-joint. 4. When the limb is oede- matous, showing that the vein is being seriously compressed. 5. When the patient is of an irritable disposition, addicted to alco- hol, and impatient of control. Amputation, on the other hand, is, as a rule, called for: — i. If the aneurysm has burst. 2. If gangrene has set in. 3. If suppuration attended with profuse haemorrhage has occurred ; and 4. If the knee-joint is disorgan- ized. LIGATURE OF ARTERIES. The ligatia-e of arteries requires a knowledge of their relational anatomy and of the position and appearance of the various struc- tures which serve as guides to them. Such a knowledge can only be gained in the dissecting room, and by the frequent practice of operations on the dead body. Here only the chief rules that should guide us in applying a ligature, and a short account ot the methods of tying the more important arteries, can be gii'en. General rules for ligature : — i. The incision should generally be made parallel to the course of the artery, and the skin divided evenly to promote union by first intention. 2. Each successive cut through the underlying tissues should be made the same length as that through the skin, and bruising of the parts avoided as much as possible. 3. The sheaths of muscles and tendons should not, if possible, be opened. 4. The sheath of the vessel having been exposed and the artery felt pulsating with the index finger, the sheath should be pinched up with forceps and opened by cutting with the blade of the knife on the flat. 5. The sheath being opened, it must be separated from the artery in the whole of its circumference, either by careful dissecting with the knife turned with its edge from the artery, or by the director insinuated by a gentle to-and-fro movement between the sheath and the artery. If this part of the operation is not done very delicately, too much of the sheath in the long axis of the artery will be sejj- arated, and there will be danger of secondary hseniorrhage from cutting off of the blood supjjly which the vessel receives from its sheath. 6. Having separated the sheath, one side of it should be seized with the forceps and the needle passed, unthreaded, between it and the artery, and the point, by a gentle to and fro movement, carried round the vessel without injuring or including any of the contiguous structures. It should, save in exceptional cases which will be mentioned, be passed from the side on which LIGATURE OF SPECIAL ARTERIES. 293 the vein lies. 7. When the point of the needle projects on the opposite side, it should be cleared from any loose cellular tissue of the sheath it may have carried before it, by scratching with the finger-nail, or cutting on the needle with the edge of the scalpel directed from the artery. 8. The artery should be gently pressed between the curve of the needle and the finger to ascertain that no other structure is included, and that pressure controls the pul- sation in the aneurysm. 9. The needle should now be threaded with the ligature which is carried round the artery as the needle is withdrawn ; the ligature should then be tied in a reef knot and its ends cut off short. 10. Should much of the sheath have been unavoidably separated from the artery, two ligatures had better be passed, and the artery divided between them. I question if this will not always be found the safer method : it is now the one always used by myself and by several of my colleagues at St. Bar- tholomew's. II. Some form of aseptic ligature should be used, as silk, chromicized catgut, ox-aorta, or kangaroo- tail tendon, but the best material can hardly be said to have been determined. I have always used kangaroo-tail tendon myself, and have found it answer admirably. 12. The wound should be accurately united, drained if deep, and dressed antiseptically. Ligature of special arteries — The common carotid artery may require tying for — i. Wound of the artery; 2, a punctured wound near the angle of the jaw or tonsil ; 3, aneurysm of the upper part of the artery or of one of its branches ; 4, orbital, in- tracranial and cirsoid aneurysm; and 5, aneurysm at the root of the neck (distal ligature). The artery may be tied either above or below the omo-hyoid. When practicable it should be tied above, as it is here more superficial, and the risk of suppuration extending beneath the deep fascia into the chest is avoided. The high operation, or ligature above the omo-hyoid. — Make an incision three inches in length with its centre opposite the cricoid cartilage, along the anterior edge of the sterno- mastoid muscle, /. ^., in a line drawn from the sterno-clavicular articulation to a point midway between the angle of the jaw and the mastoid pro- cess (Fig. 273, i). Divide the skin, superficial fascia, platysma and deep fascia. Draw the anterior edge of the sterno-raastoid gently outwards, and the artery will be felt pulsating in the angle formed by the omo-hyoid with the sterno-mastoid. Open the sheath on its inner side, and pass the aneurysm needle from with- out inwards to avoid injuring the vein which slightly overlaps the artery on its outer side, and keep its point close to the vessel lest the pneumo-gastric nerve be included in the ligature. The small descendens noni nerve runs superficial to the sheath, and if seen, should be avoided. The superior thyroid, lingual and facial veins J94 DISEASES OF SPECIAL TISSUES. Fig. ioi. cross the artery to open into the internal jugular vein. Should they impede the operation, divide them, having first applied two ligatures. The low operation, or ligature below the omo-hyoid. — Make an incision in the same line as for the high operation, but lower in the neck. Draw the sterno-mastoid outwards and the sterno-hyoid and thyroid inwards, and the artery will be felt beat- ing in the angle formed by the omo-hyoid with the sterno- thy- roid. Pass the needle as before from without inwards, taking es- pecial care not to injure the'^vein which on the left side slightly overlaps the artery. The head should be kept fixed after ligature by sand bags or some form of splint. The chief dangers after ligature are — i. Cerebral mischief from partial cutting off of the blood supply to the brain ; 2, a low form of pneumonia from in- terference with the blood supply of the pneumo-gastric centre ; 3, suppuration descending into the mediastinum ; and 4, suppuration of the sac when tied for aneurysm. The collateral circulation (Fig. loi) is carried on by the anas- tomosis of — I. The vertebral with the opposite vertebral. 2. The inferior with the superior thyroid. 3. The internal carotid with the opposite internal carotid through the circle of Willis. 4. The deep cervical with the princeps cervicis of the occipital. 5. Branches of the external carotid with the cor- responding branches of the oppo- site side across the middle line of the neck. The exteknai, and in'iernai, CARO'iin aki fries may be tied by an incision similar to that for the common carotid, but higher hi the neck. A point to remember is that the internal carotid is in Diacram to show the collateral circulation after ligature of common carotid, sub- clavian and axillary arteries. A. C'om- mon carotid; ii. Internal carotid; C. E.\ternal carotid; D. Vertebral; E. Circle of Willis; F. Basilar; c;. Sub- clavian; H. Thyroid axis; I. Inferior thyroid; j. Superior thyroid; K. Occipi- tal; L. Princeps cervicis; M. iJecp cervical; N. 'I'ransvcisalis colli; ovale, laying that foramen into the trephine hole by cutting away the intermediate bone with forceps, and raising the dura with an elevator. The posterior part of the ganglion can now be cut away by means of forceps, sharp spoons and curettes. Tumors ok nkrvks, v/hatever their structure, were formerly called neuromata. This term, however, should be restricted to that rare form of tumor composed of nerve elements ; whilst other tumors of nerves should be called fibromata, sarcomata, etc., as in other situations, according as they consist of fibrous tissue, sarcoma elements, etc. PERFORATING ULCER OF THE ROOT. 319 Fig. 107. A median nerve, with a tumor over which the fila- ments are spread out. St. Barthol- omew's Hospital jNIuseum.) The true neuromata are exceedingly rare, and call for no fur- ther mention. The fibromata, though, like other tumors of ner\-es, far from common, are the variet}^ most frequently met with. They grow from the connective tissue, either of the sheath, or its prolongations within the nerve ; in the latter case the nerve-fibres will be spread out over them (Fig. 107). They are generally single, or there may be several on the same or on different nerves. Signs. — They occur as painful, more or less globular tumors in the course of a nerve, and are often accompanied by numbness, tingling, and perhaps muscular spasm in the part it supplies. They can be swayed from side to side, but cannot be moved up and down in the long axis of the nerve. Another form of fibrous tumor connected with nerves is the so-called painful subcutaneous tumor of Paget, which occurs as a small nodule beneath the skin, and causes the most exquisite pain when handled. The treatment consists in dissecting the tumor out, or if this is impracticable, remov- ing it along with the affected portion of the nerve, and then sutur- ing the divided nerve-ends. If the divided ends cannot be brought into contact, an attempt may be made to graft a piece of nerve between them. The painful subcutaneous tubercle is readily removed by dissection. The myxomata are the next most common tumors of nerv^es, and give rise to similar symptoms. The sarcomata, though more rare, may also be met with in nerves, and are sometimes multiple. Convulsive or mu.scular tic, or histrionic spasm as it is some- times called, is a convulsive twitching of the muscles of the face, due to some form of irritation of the facial nerve the nature of which is not known. It is at times associated with neuralgia of the fifth nerve. Stretching the facial nerve just after it emerges from the stylo-mastoid foramen may be undertaken in severe cases, as, for instance, where the spasm interferes with sleep, etc., and with a fair prospect of success. Perforating ulcer of the foot. — Though the pressure of a corn can generally be traced as the exciting cause of the ulcer, it would appear in many cases to depend upon changes in the peripheral nerve?, leading to trophic changes in the part and a consequent lowered resisting power of the tissues to injury or pressure. It is sometimes associated with locomotor ataxiaj at 320 DISEASES OF SPECIAL TISSUES. times with diabetes, and mere rarely with spina bifida. The usual situation of the ulcer is the ball of the great or little toe. It is attended with but slight inflammation, and probing causes hardly any pain. It may lead to destruction of the metatarso-phalangeal joint, necrosis of the bones, and perhaps complete perforation of the foot ; it is sometimes the starting point of gangrene. There is usually local sweating, lowering of temperature, and impairment of sensation of the foot and lower third of the leg. The patella- reflex is often lost. Treatment. — Though the ulcer will often yield to prolonged rest, the removal of dead bone, scraping, tak- ing off pressure by cutting a hole in a thick cork sole, and other local treatment, amputation is sometimes called for. Nerve- stretching has also been recommended. Relapses are common. SURGICAL DISEASES OF THE SKIN. Verruce or WARTS, are small excrescences on the skin formed by the hypertrophy of the papillae and epidermis. The following varieties are described : t. Verrucce vulgares, or comm.on warts, so frequent on the hands of children and young adults. 2. Ver- rucce seniles, which occur as brownish elevations, generally about the back, neck and arms of old people. 3. VerruccR necrogeniccc, common on the hands of dissecting-room porters and morbid anatomists. 4. Venereal tvarts, met with on the genitals as the result of the irritation of gonorrhoea or other irritant discharges. 5. Soot warts, which affect the scrotum of chimney-sweeps, and are freqr.ently the starting point of "sweep's cancer." 6. Con- genital warts, which take more the form of irregularly-shaped growths than the true warts, are not very common. Treatment. — Common ivarts often disappear spontaneously. They may be readily destroyed by such caustics as salicylic, acetic, and nitric acid, or nitrate of silver. Venereal warts may be snipped off with the knife or scissors. Senile warts, when large, had better be excised. The soot wart ought to be removed at once by the knife. The acid nitrate of mercury is highly spoken of as an ap- plication to vejTJUOi necrogeniccE. Clavus. — ('orns consist of localized thickenings of the epider- mis, and although they may occur on any part of the body that has been subjected to intermittent pressure, are most common on the feet, where they are produced by tight or badly- fitting boots, especially when high heels have been worn, and the weight of the body has tiuis been unnaturally thrown upon the toes ; they are for the same reason frequently met with in talipes cquinvis. Two varieties are described, the hard, occurring on exposed parts. ])articularly the dorsum of the toes, and the soft, situated between ONYCHIA. 321 the toes, where, in addition to pressure, the parts are subjected to moisture. A hard corn, on section, is seen to be more or less conical ; and it is the pressure of the apex of this cone upon the papillary layer of the corium that causes the pain. At times a bursa is developed beneath the corn. At other times suppuration occurs, and the pus being prevented from escaping by the hard- ened cuticle, gives rise to great tension, pain and consequent inflammation of the skin and -subcutaneous tissue around, and may even terminate in ulceration, which may extend deeply into the foot. Treatment. — A hard corn should be pared down, and then painted night and morning with sahcylic acid and collodion. In the meantime all pressure should be removed by means of a corn-pad, or a hollow moulded in the leather of the boot. Soft corns should be allowed to become dry and hard by separating the toes with cotton-wool, and dusting them with a mixture of oxide of zinc and iodoform, or ether form of astringent and anti- septic powder, and then treated in the same manner as hard corns. Should suppuration occur beneath a corn, an incision through it to evacuate the pus will give immediate relief, or the corn may be pared down with a sharp scalpel, till the pus is reached, without giving any pain. Chilblains are local congestions of the skin caused by exposure to cold and damp in young persons with a feeble circulation. They commonly occur on the fingers and toes ; less frequently on the nose and ears. They present a sharply-defined, bluish-red blush of erythema, disappearing on pressure, and slowly return- ing. In severe cases the skin becomes dusky and purplish in color, and the cuticle gives way, leaving a raw surface {^broken chilblains). They are attended with intolerable itching. Treat- ment. — The general circulation should be promoted by exercise and good food, and the local by stimulating hniments, the parts being kept warm by woolen gloves or socks. When the chilblain is broken, it may be dusted with iodoform, or dressed with oxide of zinc or soap-plaster. Arsenic internally appears sometimes of service. Onychia, or onychia maligna, as in severe cases it is some- times called, is a chronic unhealthy inflammation of the matrix of the nail, attended with ulceration and a horribly foetid purulent discharge. It is most frequently met with in strumous children as the result of a crush of the finger or some slight injury ; but it may depend on syphilis, or more rarely on eczema or psoriasis of the matrix, or its inoculation with the parasite of ringworm. In a typical case the end of the affected finger is swollen and in- flamed and of a dusky or livid red color, whilst the nail is blackened, shrunken, loosened from its matrix, surrounded by a 32 2 DISE-\SES OF SPECIAL TISSUES. crescent of unhealthy ulceration, and bathed in a very foetid dis- charge. It is exquisitely tender to the touch. In severe cases the ulceration may extend to the bone and neighboring joint, and the last phalanx be lost. Treatment. — The nail, if black and shriveled, should be removed by forceps, the wound powdered with iodoform or nitrate of lead, or dressed frequently with a lotion of liquor arsenicalis or nitrate of silver. In strumous sub- jects appropriate constitutional r'emedies must be given. If there is a suspicion of constitutional syphilis, the part should be dusted with calomel, or dressed with blackwash, and mercury or iodide of potassium given internally. In some inveterate cases it may be necessary to scrape or shave away the matrix of the nail, or destroy it by caustics. FuRUNCULUS, or BOIL. — A boil is a circumscribed inflammation of the skin and subcutaneous tissue, terminating in gangrene of the central part, which is then cast off in the form of a slough, popularly called the core. Boils generally occur in crops, one coming out after the other has healed ; or several small boils form around a larger central one. They are usually situated on the neck, nates, back of the hand, and back. Though most common in the young, they may occur at all ages. The causes are numerous. As predisposing may be mentioned change of habit, a too exclusive meat diet, diabetes, albuminuria, alterations in the blood depending on acute disease, the emanations of sewer gas, change of season or air, and cachectic conditions however in- duced. The exciting cause is any local irritation, such as chafing of the neck by the collar, or of the nates in rowing, the irritation of morbid fluids in making post-mortem examinations, etc. But frequently no efficient cause, either constitutional or exciting, can be discovered. The staphylococcus pyogenes aureus, which is always present in boils, is generally thought to be the essential cause. Signs. — A boil begins as a red pimple, usually with a hair in the centre, and as it increases in size forms a painful, dusky, purplish-red and conical swelling, with a flattened apex. The inflammation may at times subside, and the boil gradually disap- pear {blind boil^. More often the cuticle separates at the apex, a vesicle forms, bursts, and leaves a yellow slough exposed, which is cast off as a central core through a single opening. Treattnent. — A boil may sometimes be aborted by plucking out the central hair, injecting with carbolic acid, applying nitrate of silver, or painting it over with a thick layer of collodion. Should these fail, a linseed-meal poultice or hot fomentations, and, where there is much pain, glycerine and belladonna may be applied, and after it has broken, a simple healing ointment. An incision may occa- sionally be necessary. The constitutional treatment consists in CARBUNCLE. 323 attention to hygiene, regulation of the diet and secretions, ad- ministration of tonics, etc. Arsenic, yeast (gj.) and sulphide of calcium (gr. li to Vz) have a;t times been found useful. Carbuncle is a spreading inflammation of the subcutaneous tissue involving, to some extent, the overlying skin and terminat- ing in gangrene of the affected tissue, which is discharged in the form of sloughs. It differs from a boil in that it is of larger size, has a tendency to spread, and is flattened instead of conical ; there is greater brawniness of the surrounding tissues ; the skin gives way at several places instead of at the apex; the gangrenous tissue is discharged in the form of sloughs instead of as a core ; and it is accompanied by severe constitutional symptoms. Cause. — Any vitiated state of the constitution, such as may be induced by too high or too poor living, gout, diabetes, albuminuria, typhus or other acute fevers, prolonged lactation, and the like. Friction and pressure are mentioned as exciting causes, and are said to explain the frequency of its occurrence on the nape of the neck, back, and nates. The presence of the pyogenic micrococci is the essential cause. It is more common in men than in women, and does not usually occur till after the middle period of life. It is especially dangerous when associated with diabetes, and when it occurs on the face or scalp. In the former situation, suppurative phlebitis of the angular vein, wnth extension of the infective thrombi through the ophthalmic vein to the cavernous and other blood sinuses in the skull, and consequent meningitis or general blood-poisoning, is the danger to be apprehended. Symptoms. — It begins as a hard painful swelling, accompained by fever, generally of a low type and with marked depression. The sweUing rapidly spreads, and forms a flattened, generally more or less circular, elevation of the skin, surrounded by considerable brawny induration and redness. At first red, it soon becomes purplish-red, dusky or livid. Vesicles form over its surface, and on bursting, leave a number of apertures in the skin through which a greyish-yellow slough is seen. The apertures then coalesce, and the slough is gradually thrown off, leaving a granulating wound ; or the inflammation continues to spread, and the patient may sink into a low typhoid or delirious state and die of asthenia or of blood-poisoning (saprjemia, septicaemia, or pyaemia). Treat- ment. — The strength must be supported by fluid nourishment, and stimulants as indicated by the pulse and temperature ; the patient should have abundance of fresh air, and should not, if it can be avoided, keep his bed. Opium should be given when there is much pain. Locally, a crucial incision was formerly a favorite practice, but it is attended with so much haemorrage that unless the patient's powders are good it should not be made. Some re- 324 DISEASES OF SPECIAL TISSUES. commend the introduction of potassa fusa or the injection of car- bohc acid into the carbuncle, and speak highly of both plans as a method of arresting its progress while still small. Others apply strapping firmly over it, leaving an aperture for the escape of the discharge through the centre. Others again make a subcutan- eous incision when there is much pain and tension ; whilst by the majority of surgeons the expectant treatment of merely poulticing is followed. Poultices are open to the objection that they tend to produce putrefaction of the sloughs, and as their chief use is the application of heat and moisture, a better substitute is some hot antiseptic lotion, or spongio-piline steeped in hot antiseptics. Scraping away the sloughs and diseased tissues with a Volkmann's spoon and afterwards swabbing with pure carbolic acid is recom- mended for preventing septic poisoning. I have tried this method and can speak well of it. The hsemorrhage attending the scraping is much less than might be imagined. Healing rapidly ensues. When the sloughs have separated or have been removed, the wound should be treated as a granulating ulcer ; but as it is often slow in healing it may require stimulation with resin oint- ment, Peruvian balsam, etc. Lupus Vulgaris is a disease of childhood, and seldom begins after the age of puberty. It is characterized by the formation ot yellowish- red nodules in the skin or mucous membrane, and sub- sequently by scarring and often great destruction of the affected tissues and much deformity. Cause. — It is generally believed to be of the nature of a local tuberculosis depending on the pres- ence of the tubercle bacillus. Pathology. — The deeper layers of the corium become infiltrated with small round cells, amongst which new capillaries are formed. In this granulation-like tissue are found non-vascular areas resembling in structure miliary tubercles, and in them the tubercle bacillus has been discovered. The small-celled infiltration extends along the vessels, sweat- ghnds, sebaceous glands and hair-follicles, and may finally involve the whole of the corium. The granulation-like tissue may then either undergo atrophy and be partially absorbed without ulcera- tion, though leaving, nevertheless, a permanent scar ; or it may undergo caseation, and the cuticle giving way, break down into an ulcer. Signs. — I'he disease begins as reddish or amber-colored, semi- transparent, jelly like nodules, the color of which does not com- pletely disappear on pressure. The nodules later become slightly elevated, and several coalesce, forming l:uger nodules or tubercles, over which the cuticle forms slight scales. The centre of the patch may now undergo atrophy and partial absorption, leaving a slightly-depressed whitish cicatrix. In this way the disease LUPUS ERYTHEMATOSUS. 325 may become cured ; or while cicatrization is taking place in the centre the disease may continue to spread at the margins. Or the lupus patch may break down and ulcerate, the surrounding skin often becoming inflamed. The edges of the ulcer are raised, whilst its base is smooth, red, and spongy-looking. The ulcera- tion may proceed gradually or rapidly, and extend through the skin or mucous membrane to the underlying structures, destroy- ing, as when the nose is attacked, skin, mucous membrane, muscle, cartilage, in fact everything except bone. The favorite seat of lupus vulgaris is the face, especially the ala of the nose ; but it may attack the skin and mucous membrane of almost any part. It is more common in females than in males. From tubercular syphilis, the affection for which it is perhaps most likely to be mistaken, it may be distinguished by the age at which it began, the history of the case, and the absence of concomitant signs of syphilis. Treatment. — The lupus patch should be thoroughly scraped with a Volkmann's spoon, the scraping being continued as long as any^soft lupoid material comes away, and until the tissues feel hard and resisting to the spoon. The actual cautery, or some form of caustic, is then by some applied to the raw surface, but it is not necessary. The wound should be dressed with iodoform or other antiseptic, and healing is quickly accomplished with com- paratively little scarring. Any small lupoid tubercles around the main patch may also be scraped or touched with the galvano- cautery point. Internally, cod-liver oil, arsenic, or the phosphate or the iodide of iron, may generally be given with advantage. Lupus erythemajosus is a chronic inflammation of the seba- ceous follicles and surrounding connective tissue. Pathology. — The capillaries of the follicles become dilated, and the tissues infiltrated with small round cells. The follicles then become en- larged and distended with sebaceous material, which exudes and forms greasy scales on the surface of the lupus patch. The scales, on removal, are found continuous with the plugs of sebaceous material filling the follicles. Later, the follicles are destroyed, and the infiltrating ceils converted into cicatricial fibrous tissue. The cause is unknown, but it is believed to depend neither on syphilis nor on tubercle. It has not been proved to be hereditary, and it is not contagious. Signs. — It begins most commonly on the cheeks or nose, in the form of one or more erythema-like red patches, which fade momentarily on pressure, and are often at- tended with itching. The patches become covered with greasy scales continuous with the sebaceous matter in the enlarged folli- cles. They usually spread by their slightly raised edges, leaving dry, pale, depressed scars in their centre, which are productive 320 DISEASES OF SPECIAL TJSSUES. of considerable deformity, but ulceration does not occur. The disease is nearly always symmetrical, affects most commonly the cheeks and nose, less commonly the ears, lips, backs of the hands and fingers, and after an apparent cure is liable to a relapse. It is most frequent in women, begins in young adult life, is very chronic in its course, and is often complicated by attacks of ery- sipelas. Treatment. — The general health should be attended to, and arsenic, cod-liver oil, or iron should be given if indicated. Local treatment, however, is the only efficient means. Very numerous applications for relieving the itching and promoting absorption have been recommended, such as mercurial plaster, iodine, and oleate of zinc ; but the best method is linear scarifi- cation, which must be repeated from time to time for consider- able periods. Ingrowing nail is most frequently met with in the great toe as the result of wearing tight boots and of cutting the nails square. The tight boot presses the skin over the sharp corner of the nail on each side, and ulceration, attended by the formation of ex- quisitely tender and exuberant granulations, results, giving the part the appearance as if the nail had grown into the flesh. The condition is a very painful one, and troublesome to cure. The treatment consists in wearing square-toed boots, so as to provide plenty of room for the toes, and then pressing a piece of tinfoil or lint between the edge of the "ingrowing" nail and the over- hanging portion of skin. Should this not succeed, a longitudinal strip of nail should be removed, and the prominent granulations and redundant skin shaved away to the level of the nail, together with that portion of the matrix corresponding to the strip of nail removed. As the operation is excessively painful, it should be done under an anaesthetic (gas is sufficient), or the ether spray may be used, or the part injected with cocaine. Hypertrophy of the toe-nail occasionally occurs as the result 'of neglect or chronic congestion of the matrix, and may assume the form of a horn. The treatment consists in cutting away the hypertrophied portion, or in removing the whole nail. INJURIES OF THE HEAD. 327 SECTION V. INJURIES OF REGIONS. INJURIES OF THE HEAD. Fig. 108. cephalhjema- a depressed dark shading Injuries of the Scalp. Contusions of the scalp are very common as the result of falls or blows on the head, and are frequently followed, especially in children, by extravasation of blood, and the consequent formation of a hcBmatoma or blood-tumor. In new-born infants such tumors are of frequent occurrence in consequence of severe pres- sure on the head during birth, especially when instruments have been used, and are then known as cepJial- hcematomata . The- blood may be ex- travasated ( i ) between the aponeurosis and the pericranium : and (2) between the pericranium and the bone. In the latter situation the resulting tumor is generally circumscribed in consequence of the pericranium being firmly attached along the lines of the sutures; in the former it is generally diffuse, and in some instances extends over the whole of one side of the head. The diffuse form can only be mistaken for an abscess, from which, however, it may be distinguished by its sudden formation and the absence of signs of inflammation. The circumscribed, which gives rise to a soft fluctuating tumor with hard and often sharp margins, is sometimes very difficult to diagnose from a depressed fracture. In the case of the blood- tumor the hard margins (which are due to the coagulation of the blood at the circumference — the central part remaining fluid) are raised above the level of the surrounding bone, as may be de- tected by passing the finger along the scalp ; while on pressing upon them with the finger-nail the blood may be displaced and the bone be felt beneath. As a rule, the blood becomes absorbed, but ossification at times occurs in the angle where the pericranium is raised from the bone. Treattrient. — Under the use of evapo- rating lotions the more superficial h^ematomata will usually subside. It may sometimes be necessary, however, to aspirate those more Section of a toma; and B fracture. The in A. represents the coagulated blood. 328 INJURIES OF REGIONS. deeply situated. If suppuration occurs a free incision should be made. Wounds of the scalp vary in extent from a mere scratch to an extensive denudation of the bone, and, like other wounds, may be incised, lacerated, punctured, or contused. Though large por- tions of the scalp may be torn up from the bone, sloughing is very rare, as the arteries which supply the scalp run between the skin and the aponeurosis, and hence are contained in the flap. Scalp- wounds are frequently attended with sharp hcemorrhage ; they are also often associated with fracture of the skull, search for which should always be made by passing the finger into the wound. Moreover, they are apt to be complicated by erysipelas or cellulitis, with the formation of pus between the aponeurosis and the pericranium, and where the bone has been much contused, by suppuration beneath the pericranium, in the diploe, or be- tween the bone and dura mater. Suppuration in any of these three situations may be followed by necrosis of the bone, by sep- ticaemia or pyaemia, or by inflammation of the brain and its mem- branes. When a flap of the scalp has been completely detached, and even when the pericranium has also been lost, necrosis need not necessarily occur, since granulations may spring up from the bone, and cicatrization follow. Treatment. — The scalp should be shaved for some distance around the wound, well washed with soap and water, then with ether or turpentine, and finally with an antiseptic, whilst the wound should be carefully cleansed from all loose hairs, dirt, grit, etc., then flushed out with the antiseptic, and, if small and in- cised, closed with adhesive strapping over a pad of sal alembroth gauze and supported by a capeline or other form of bandage. When large portions of the scalp have been stripped up but not detached, the flaps after cleansing should be carefully replaced, and secured by aseptic sutures. Hasmorrhage is usually readily controlled by pressure, though occasionally it may be necessary to completely divide a partially torn artery or to apply a ligature. If the wound is extensive the scalp should be completely shaved and cleansed as above mentioned, whilst the patient shouUl be kept at rest for a few days, placed on low diet, a smart ])urge given, and a careful watch made for signs of sujjpuration. ShouUl such oc- cur, the adhering margins of the wound should be separated to per- mit the free escape of the pus, and the wound be allowed to heal by granulations. If pus forms at some distance from the wound, an incision must be made at that spot through the scalp, of course avoifling the track of any large vessel. FRACTURES OF THE VAULT. 329 Injuries of the Cranial Bones. Contusions of the cranial bones are always serious, espe- cially when attended with a wound of the scalp, inasmuch as they are liable to be followed by — i. Inflammation of the pericranium, which may terminate in suppuration between it and the bone and necrosis of the external table or even of the whole thickness of the skull ; 2. Suppuration in the diploe, with implication of the large diploic veins, and probably septicaemia or pyaemia ; 3. Sup- puration between the bone and dura mater, and subsequent gen- eral meningitis ; 4. Chronic inflam.matory thickening of the cranial bones or dura mater, giving rise to constant headache, impair- ment of one of the special senses, epilepsy, or even insanity ; and 5. Cerebral abscess. Signs. — ^^Contusions of the skull are attended by no primary symptoms, but should any of the above-mentioned conditions supervene there will be the usual signs of inflammation localized to the injured spot, with more or less constitutional disturbance. I. In simple pericranial inflammation the symptoms will usually subside in a few days. 2. Should pus form between the peri- cranium and the bone, there may be chills, and perhaps rigors, with local signs of suppuration ; whilst the bone, should necrosis occur, will become dry and yellowish-brown or greenish-white in color. 3. Should suppuration ensue in the diploe, there will be rigors, followed by high temperature, and probably later, signs of pyaemia or septicaemia. 4. Pus between the bone and dura mater will be indicated by headache, vomiting, rigors, monoplegia or hemiplegia, delirium, or stupor, followed by convulsions or coma (see ijitracranial suppuration) ; whilst locally a circumscribed swelling may form over the injured spot {Pott's puffy tumor), or if there be a wound it will become dry and the bone discolored. Treatment. — When, from the account of the injury, it is prob- able that the bone has been contused, measures should be taken to prevent inflammation by rest, cold to the head, free purging, and, where there is a wound, by strict antiseptic precautions. Should suppuration be suspected between the pericranium and the bone, free incisions to let out the pus should at once be made ; whilst should the signs point to the formation of pus between the bone and dura mater, the trephine should be applied. For sup- puration in the diploe. and the consequent septicaemia and pyaemia, little or nothing can be done. Fractures of the bones of the skull may be divided into — I. Fractures of the vault ; and 2. Fractures of the base. I. Fractures of the vault. — Causes. — Generally direct violence, as a blow on the head with a sharp-pointed body, or fall 14* 330 INJURIES OF REGIONS. on a sharp edge. (Blows with soft bodies or falls on soft ground on the head more often cause a fracture of the base, or a fissured fracture extending over the vault to the base.) Occasionally in- direct violence, as a blow, say on the front of the head, causing a fracture at the back {fracture by contrecoup). Varieties. — The fracture may take the form of a simple fissure {fissured fracture), or of several fissures radiating in various di- rections {stellate or radiated fracture) ; or the skull at the seat of injury may be broken into several pieces {comminuted fracture) , one or more of which may be pressed inwards below the surface of the rest of the bone {depressed fracture) ; or a portion of bone in rare instances, as in some forms of sabre-wounds, may be raised above the surface of the skull {elevated fracture). At times the fracture consists of a mere puncture of the bone, with driving inwards into the membranes or brain of the sharp frag- ments of the inner table {punctured fracture) ; and, lastly, the fracture may be limited either to the outer or to the inner table of the skull {partial fracture). In any of these varieties, except, perhaps, in the punctured, the scalp may remain whole, when the fracture, as in other situations, is said to be simple ; or there may be a wound of the scalp leading to the fracture, when it is said to be compound. In children the bone may be depressed without fracture. State of the parts. — In simple fissure there is no displacement of the bone, but a mere crack extending from the part struck for Fig. log. ■ I i pro .i/.-n ■;■■■■.■ ■■ . C;,' . ■ .', .. . ■:;: -'^^V Depressed fracture (ponrt variety). Elevated fracture, probably from the cut of a (St. Bartholomew's Hospital sabre. (St. Bartholomew's Hospital Mu- Sluseum.) scum.) a variable distance over the vault, and frequently running through the base of the skull. In the stellate fracture several fissures radiate over the vault from a certain point, at which the bone is fref|uently punctured. The comminuted fracture is ' generally compotmd, anrl one or more of the fragments may be completely FRACrURES OF THE VAULT. 331 detached or driven through the dura mater into the brain, which itself may protrude through the external wound. In the depressed fracture the depressed fragments may be loose, or firmly locked together, often forming a shallow or deep rounded or oval depres- sion, — pond and gutter fractures, as they are sometimes called (Fig. 109). Ek coated fractures (Fig. no) are not often met with in civil practice. They are the result of oblique cuts, as by a sabre, and only occur in young adults whilst the bone is com- paratively soft. In punctured fractures (Fig. in), which are generally produced by a blow with a sharp instrument, as a pick- axe or a fragment of a falling chimney-pot, or by a fall on a spike, etc., the splinters of the internal table are often driven into the dura mater or brain at right angles to the rest of the bone. When the membranes are not injured at the time of the accident, the irritation of these sharp fragments, if not removed, is nearly cer tain to set up meningitis. At times the inflicting body has been found broken off flush with the surface of the skull. Fracture of the external tabic alone is most common over the frontal sinuses, where it is separated for some distance from the internal. In Fig. III. Fig. Punctured fracture. fSt. Barthol- omew's Hospital Museum.) Fracture of the internal table. iDruitt's Surgery.) fracture of the internal tad/e (Fig. 11 2), which is a rare accident, there may be merely a splintering of the bone, or a fragment may be completely detached or driven into the dura mater or brain. Any of these fractures may be complicated by laceration or other injury of the brain or its membranes, or by rupture of the middle meningeal artery or one of the venous sinuses. In all fractures involving both tables, except in the simple fissure, there is usu- ally greater splintering of the internal than of the external table. In fractures, however, produced from within the cranium, as by a bullet passing through the skull, the external table at the aperture of exit is more splintered than the internal. The reason for the 332 INJURIES OF REGIONS. greater splintering of the internal table (or the external table when fractured from within) is, that the force is broken in per- forating the external table, and becomes more distributed over the internal. It was formerly said to be due to the internal table be- ing more brittle than the external. Signs. — Whatever the form of fracture, it may be accompanied by signs of concussion, compression, or other injury of the brain. Here only are given the principal local signs of the various forms of fracture of the vault. In a simple fissured fract:i)-e there is no sign, but in the compoiind variety the fissure may be detected by the finger in the wound. A sharp edge of the torn pericranium, a suture, or a natural inequahty, may, however, if care is not exer- cised, be mistaken for such a fissure. In the depressed fracture, the depression in the bone in the simple variety may be obscured by extravasated blood either in the scalp or under the pericranium, but in the compound \3.x\tty it can be felt by the finger and, if the wound is large, seen. In both varieties, when the bone is much depressed, signs of local compression of the brain may be present. In iht punctured fracture the sharp fragments maybe detected, with the finger or with a probe, projecting into the interior of the cranium, and signs of local compression may or may not be pres- ent ; later, symptoms of inflammation of the brain, if the frag- ments are not removed, w-ill almost certainly supervene. In both the compound depressed and punctured fracture there may be comminution or loss of bone, and portions of lacerated brain substance may at times exude through the fracture. Fractuix of the inner tabic is very difficult to dingnose, but later it may be indicated by an increase of local temperature, signs of local com- pression, and localized pain from irritation of the dura mater. It is said that a friction sound may sometimes be heard, from the nibbing of the brain and pia mater on the sharp fragments. When a fracture is situated over the frontal sinuses there may be emphysema from escape of air into the connective tissue, or if the fracture is compound air may be forced out of the wound on blow- ing the nose. The treatment of fracture of the vault will necessarily vary accor- ding to the nature of the fracture and of any cerebral complica- tions that may be present. The general indications are to prevent inflammation of the brain and its membranes, and to relieve any existing brain complication. Thus the patient should be placed at perfect rest in a darkened room, every source of cerebral irri- tation avoided, an ice-bag api)lied to the shaven head, the bowels acted on by a calomel purge, and the i,diet restricted to slops. When the fracture is compound every care should be taken to render the wound aseptic, and to promote healing by the first in- FRACTURE OF THE BASE. 333 tention. i. In ^ssu fed iracime uncomplicated by cerebral mis- chief little more will be required ; but when symptoms of cer- ebral compression are present the question of trephining may be raised, and will turn upon the probable nature of the cerebral lesion (see Compression of the Brain). 2. In depressed fracture the treatment will differ according as the fracture is simple or com- pound, and according as symptoms of local compression of the brain are or are not present. In the simple form, unless the de- pression is deep and there are signs of local compression, no operative interference should be undertaken. In the compound form, any fragment found loose or penetrating the membranes of the brain should be removed, or if slightly depressed, raised, pro- vided the elevator can be readily inserted beneath it. If a frag- ment is deeply depressed and cannot be raised by the elevator, the trephine had better be applied. When, however, the depres- sion is but slight, and the fragments are interlocked, as m pond and gutter fractures, the case, unless there are signs of local com- pression of the brain, should, as a rule, be left to nature. The patient, however, should be carefully watched lest inflammation supervene, on the first signs of which the depressed bone should be removed by the aid of the trephine. In both the simple and compound varieties the depressed bone, if it is apparendy causing compression of the brain, must be raised by the elevator, or by means of the trephine. It may here be remarked that some Surgeons recommend the raising of the depressed fragments under nearly all circumstances, even when there is no external wound ; as although many cases of depressed fracture undoubtedly recover, nevertheless, inflam- mation of the brain and its membranes, or if this danger is escaped, subsequent trouble, such as long-continued headache, progressive mental inability, or even epilepsy and insanity, may ensue from the irritation of the depressed bone. In punctured fracture the trephine should always be applied, as here the frag- ments are driven vertically inwards (see Fig. m), and though they may not have punctured the dura mater, will invariably set up inflammation if not removed. In fracture of the internal table, too, the trephine ought to be applied ; but this form of fracture is seldom diagnosed. After any kind of fracture the patient should be carefully watched for a month or six weeks, and even though no comphca- tions are present as first, the greatest care should be exercised, and any indiscretion in diet, abuse of stimulants, or undue mental excitement, should be avoided. 2. Fracture of the base is generally caused by a blow or fall upon the vault, the fissure extending from the part struck to the 334 INJURIES OF REGIONS. base ; or it may be due to a fall upon the feet or nates, the frac- ture being then produced by the shock transmitted to the occipi- tal bone through the spine. Rarely it has been caused by a sharp instrument, as a sword thrust through the roof of the orbit or nose, or by a blow on the lower jaw fracturing the glenoid cavity or forcing the condyle through it. As a rule the anterior, middle or posterior fossa is found fractured, according as the blow falls upon the anterior, middle, or posterior part of the vault of the skull. Should the force, however, be very severe, fissures may radiate from the seat of injury to two, or even to all three fossa;. Frac- tures through the middle fossa generally involve the petrous por- tion of the temporal bone on one or both sides of the skull. Thus they frequently extend through the internal and external auditory meatus and walls of the tympanum, lacerating the prolongation of dura mater contained in the internal auditory meatus, the reflex- ion of the arachnoid around the seventh pair of nerves, and the membrana tympani, and so allow of the escape of the cerebro- spinal fluid from the external auditory meatus. The fracture may also involve the lateral sinus or middle meningeal artery, in which case blood may be found mixed with the cerebro-spinal fluid that escapes from the ear. Fracture of the posterior fossa extends through the foramen magnum of the occipital bone, and frequently through the petrous portions of the temporal bones. Fracture of the anterior fossa involves the roof of the orbit and nose. One or more of the nerves that escape through the bony foramina in the base of the skull, the lateral sinus, the middle meningeal artery, or one of the smaller blood-channels are frequently torn or other- wise injured in a fracture of the base ; whilst the inferior lobes of the brain are often extensively lacerated and contused, or com- pressed by extra vasated blood. It should be remembered that a fracture of the base, if the membrana tympani or the mucous membrane covering the cribriform plate of the ethmoid bones is ruptured, is really of the nature of a compound fracture, and hence is liable to be followed by septic inflammation, which, moreover, may spread to the membranes and brain. Signs. — At times there may be none, and the nature of the in- jury may be quite overlooked. Generally, however, symptoms, such as compression, indicative of a severe lesion of the brain, co- exist, and these, together with the history of the way in which the injury occurred, should lead us to suspect that the base is frac- tured. The signs, however, which when present may be consid- ered diagnostic of the injury are — i. The escape of cerebro-spinal fluid from the ear, nose, or mouth, or from a wound if one exists. 2. The escape of blood from similar situations. 3. Effusion of blood under the conjunctiva, about the mastoid process, or in the FRACTURE OF THE BASE. 335 sub-occipital region ; and 4. Injury of one or more of the cranial nerves. 1. Cerebro-spinal fluid consists principally of water holding in solution a large amount of chloride of sodium. It has a low specific gravity (1002), and contains little or no albumen, but sometimes a trace of sugar. When it escapes in considerable quantities (several pints in the twenty-four hours) immediately after an injury, it is pathognomonic of fracture of the base. Es- caping from the ear, it indicates fracture of the middle or posterior fossa ; from the nose or mouth, generally the anterior fossa, though in fracture of the middle or posterior fossa it may, by passing along the Eustachian tube, or through a fracture of the basilar process with laceration of the mucous membrane of the pharyn- geal vault, also come from the nose or mouth. 2. Blood may escape from the same parts and by the same channels, but has not the like diagnostic value, since bleeding from the ear, and especially from the nose, may occur from causes other than fracture. Still when blood escapes in considerable quantities, and for some time after the injury, it is when combined with other evidence of severe cerebral mischief a sign of import- ance. It should not be forgotten that blood coming from the nose or roof of the pharynx may be swallowed and afterwards vomited or passed per rectum. 3. Effusion of blood under the ocular conjunctiva, and ecchy- mosis about the mastoid process and sub-occipital region, are signs of less value ; the former may indicate fracture of the ante- rior, and the latter fracture of the posterior fossa, the blood pass- ing along the floor of the orbit in the one case to the conjunctiva, and in the other draining through the fracture and appearing under the skin. 4. Injury to one or more of the cranial ner\'es will be indicated by paralysis, loss of function, or spasm of the parts which they supply. Thus there may be dropping of the upper eyelid {pfosis) , external squint, loss of accommodation, double vision {diplopia) , and dilatation of the pupil, when the third nerve is affected ; spasm or paralysis of the facial muscles {BelVs paralysis'), deafness or loss of sight if the facial, auditory or optic is injured, etc., but as the patient is frequently comatose these signs may not afford much information. The paralysis when the facial nerve is affected may come on immediately after the accident or not for some days. In the latter case it is due to inflammatory effusion about the nerve as it passes through the aqueduct of Fallopius over the tympanum. The prognosis is always grave, the lesion generally, though not invariably, terminating fatally from concomitant injury to the brain, or from septic inflammation of the brain and its membranes. 336 INJURIES OF REGIONS. The treatment should be directed towards the prevention of in- flammation of the brain, in the way described under fracture of the vault (p. 332). When the membrana tympani is ruptured, an attempt should be made to prevent septic inflammation by syring- ing out the auditory meatus with carbolic or corrosive sublimate lotion, and applying an antiseptic dressing over the cleansed ear and shaven scalp around. It is true that even when this is done a way still remains open to the tympanum by the Eustachian tube ; but it is thought that the cilia prevent the access of micro- organisms by this channel. Should intra- cranial inflammation supervene, it must be treated in the way indicated under that head (p. 346). Injuries of the Brain and its Me?nbranes. Concussion of the brain. — This term is applied to a collection of symptoms supposed to depend on a shaking or commotion of the brain substance. It is popularly spoken of as "stunning.'' Pathology. — The exact condition of the brain that gives rise to the symptoms which go by the name of concussion is not known. By some it is believed that they depend on the mere shock to the brain — that there is some vibration or molecular disturbance of its particles, or anaemia of its substance induced by spasm of the small arteries, and that the shock may prove fatal in this way without any lesion being discovered after death. Generally, how- ever, a slight contusion or laceration of the brain, or punctiform extravasations of blood in its substance have been found, and to such some attribute the symptoms of concussion. In the few cases that have been immediately fatal after a blow on the head without any obvious lesion having been discovered in the brain, the post-mof-tetn examination has been unfortunately incomplete. Hence it is maintained by those who hold that there is always an obvious lesion, that death in these cases might have resulted from other mischief, such as fracture of the cervical spine. Symptoms. — Concussion may be divided into two stages : i. Insensibility; 2. Reaction, i. The first stage corner on imme- diately on the receipt of injury; it may be quite transitory, the y)atient merely losing consciousness for a few minutes, and then recovering com[)letely ; or it may last for a few hours or a few days, or even longer. The patient lies in an unconsious condi- tion, but can be roused momentarily on shaking him, or shouting in his ear. There is loss of all power of motion ; the pulse is feeble, fluttering, often frequent ; the respirations are shallow, and quiet or sighing ; and the syrface is cold, often clammy, the tem- perature sometimes being as low as 97 or 96. The pupils are COMPRESSION OF THE BRAIN. 337 variable, but sensitive to light. The sphincters are often relaxed at the time of injury, allowing the involuntary passage of faeces and urine, but are not paralyzed. This condition, after lasting for a variable time, usually passes gradually into the second stage — that of reaction; or symptoms of compression or of inflamma- tion of the brain may come on without the patient recovering consciousness. 2. The second stage, or that of reaction, is marked by a gradual return to consciousness, and is usually preceded by vomiting, which is therefore regarded as a favorable omen. The skin becomes warm, the pulse increased in frequency, and the temperature slightly raised. These symptoms commonly termi- nate in complete convalescence, or they may run into those of inflammation of the brain. At times, however, the patient may relapse into a state of unconsciousness and die, or certain impair- ments of brain function may remain. The remote effects of concussion may be enumerated as head- ache, confusion of thought, mental irritability, impaired virility, optic neuritis and atrophy, epilepsy, or even insanity. These after- effects are more likely to occur if there is an inherited predispo- sition to nervous diseases, and appear to be brought on by excite- ment, abuse of stimulants, or excesses in diet. In some of these cases the brain has been examined after death, but no organic lesion has been found. Treatment. — The chief indication is to restore the cerebral functions by promoting the cerebral circulation, taking care not to produce too violent a reaction. Thus the patient should be placed at perfect rest; warmth applied to the surface by means of blankets, hot bottles, and, if necessary, by friction ; and small quantities of diffusible stimulants, as ammonia or warm tea, ad- ministered. Alcohol should not as a rule be given. When reac- tion has come on, inflammation must be warded off by gentle purgatives, low diet, and the avoidance of stimulants and of mental exertion. Compression of the brain may be caused by: i. A fragment of depressed bone ; 2. Extravasated blood; 3. Pus, or other in- flammatory products ; and 4. A foreign body, such" as a bullet. The signs of compression, i.e., of pressure on the brain, vary according as the compression is made over a wide area oris local- ized to a particular part. Thus, when the pressure is diffused over a considerable portion of the brain, the patient lies in a com- pletely unconscious state, and cannot be roused either by shouting in his ear or by shaking him. The extremities on one or both sides are paralyzed ; the face is livid, at times flushed ; the tem- perature is usually low, but at times raised ; the pulse is full and slow, often not beating more than 40 to the minute ; the respira- 15 338 INJURIES OF REGIONS. tion is slow, labored, and stertorous, /. e., a peculiar noise is made during expiration by the flapping of the paralyzed soft palate ; the cheeks and lips puff out at each expiration in consequence of paralysis of the buccinator and muscles of the lips ; the pupils are fixed (/.'/(;7// vary according to the nature and size of the foreign body. A large portion of meat arrested over the .entrance of the larynx will give rise to urgent symptoms of suffocation, and endeavors should be made to re- move it instantly by the finger plunged into the throat. If this fails, laryngotomy should be done at once, and artificial respira- FOREIGN BODIES IN THE PHARYNX. 359 tion resorted to if the patient has already ceased to breathe. A fish-bone or pin may give rise to pricking sensation with difficulty or pain on swallowing, and the patient will often be able to indi- cate the position where it has lodged. A search should be made for it in the mouth and throat, aided by the laryngoscopic mirror ; but it must not be forgotten that the symptoms in consequence of the body having scratched the mucous membrane may persist even after it has been dissolved or swallowed. If in the tonsil or about the fauces, it may be removed with the dressing forceps, or it may be hooked out from the upper part of the pharynx by the finger nail. If a foreign body is beyond reach of the finger, an attempt must be made to extract it by pharyngeal forceps (Fig. i2i) or by some of the various forms of coin-catchers (Fig. 122), or the expanding horse-hair extractor (Fig. 123). If, after a Fig. 121. Pharyngeal forceps. Fig. 122. Coin-catcher and sponge probang. Fig. 123. E.xpanding horse-hair extractor. thorough trial, with the patient under chloroform, these means fail, pharyngotomy must be performed, and the body removed through the opening in the neck. \¥hen situated lower down the oesophagus, 'and it cannot be extracted by gentle means, it had better be left alone in the hope that it may become loosened in a day or two by ulceration, and be expelled or passed down into the stomach. Should this not occur, an endeavor may again be made to extract it, or to push it onwards into the stomach with the sponge probang (Fig. 123). In these manipula- tions the greatest care must be taken, as if the body is sharp the oesophagus iTiay easily be lacerated. Recently it has been shown 360 INJURIES OF REGIONS. that the cesophagiis may be reached as it lies in the posterioi mediastinum by cutting vertically midway between the scapula and spine, turning in the ilio-costalis, and resecting a portion of the third, fourth and fifth ribs. When the foreign body has been pushed into the stomach, the patient should be fed on oatmeal porridge, and made to swallow portions of hair, and the like, in the hope that the body, if angular, may become surrounded by this soft material and travel through the intestines without injur- ing them. Should it be too large to pass the pyloric valve, gas- trotomy is the only resource. FoRKiGN BODIES IN THE AIR PASSAGES. — A foreign body may be- come lodged in the larynx, the trachea, or in one of the bronchi. Foreign bodies in the larynx. — A foreign body may be lodged above, IdcIow or between the vocal cords, or in the ventricles. When a voluminous body, as a piece of meat, becomes impacted at the entrance of the larynx, it may block up the passage, causing instant suffocation. Smaller bodies, wherever situated, may also cause fatal dyspnoea by setting up reflex spasm of the muscles of the glottis ; though in some cases a foreign body, such as a tooth- plate, may be so lodged between the cords as to prevent them closing. A foreign body in the ventricle may cause the same urgent symptoms. At other times the foreign body may give rise to severe, but not fatal, attacks of dyspnoea and spasmodic cough, though if not removed, inflammation and oedema will probably be set up and the patient ultimately succumb. Treatment. — Where the symptoms are urgent and the body cannot be removed by the finger, instant laryngotomy should be performed. But when less urgent, a deliberate attempt should be made to remove it by means of laryngeal forceps aided by the laryngoscope. Sometimes, where extraction would be otherwise impossible, this may be accom- plished by cutting the body in two by the use of the laryngeal cutting-pliers. These means having failed, an external operation must be undertaken. Thus, when the foreign body is above the cords, it may be removed by sub-hyoid pharyngotomy ; when be- tween the cords or in the ventricle, by thyrotomy ; when below the cords, by laryngo-tracheotomy or tracheotomy, the forceps in the last instance being passed up through the wound in the trachea. Foreign bodies in the trachea and bronchi. — Small objects such as coins, buttons, orange-pips and fruit stones are liable to be drawn into the trachea during a sudden inspiration, while the patient is swallowing or is holding such in his mouth. The acci- dent is most common in children. The foreign body may remain free, or become impacted either in the trachea or a bronchus (Fig. 124). It is usually .said to most frequendy enter the right FORETGN BODIES IN THE AIR PASSAGES. 361 Fig. 124. bronchus, that being the larger, and the spur-like projection at the bifurcation of the trachea directing it that way ; but the left is the more direct route, and the direction it takes would seem to depend in great part on the shape and size of the foreign body. Thus an elongated body as the metal cap of a cedar pencil would probably enter the left — a rounded body, as a coin, the right bronchus. The symptoms vary somewhat, according as the body is free or impacted, light or heavy. When it is free and light, and, as is usually the case, has fallen into one of the bronchi, there will be sudden and paroxysmal attacks of suffocative cough and dyspnoea, in consequence of the foreign body being driven upwards against the glottis, which then closes spasmodically. On listening over the trachea it may be heard to strike the cords, whilst a whist- ling sound may sometimes be detected as it passes up and down. During the in- tervals of the cough and dyspnoea, whilst the body is at rest in the bronchus, as is 'also the case when it is permanently im- pacted in it, there will be an absence of the breathing sounds over the whole or part of the lung on that side, according as the main bronchus or one of the secondary bronchi is obstructed \ the resonance, however, will be normal or dull in places, according to the position and nature of the foreign body. If any air can pass the obstructing body, bronchial or sibilant sounds may be heard, due in part to the bronchitis set up by it. Over the opposite lung puerile breathing may be detected. When the foreign body is heavy and of a rounded shape, it may act as a ball-valve, /. e., it may allow air from the lung to be forced past it during expiration, but then fall back into a narrower part of the bronchus, and so prevent air en- tering during inspiration. In this way collapse of the lung is brought about. If the foreign body is not removed, or does not escape spontaneously, sudden death may occur during an attack of spasmodic dyspnoea ; or it may set up bronchitis, pneumonia, or gangrene or abscess of the lung. At other times it induces more chronic changes, such as phthisis, or it may become en- cysted and no harm follow. In rare instances it may make its way out through the chest-walls by perforation or ulceration. Treatment. — The patient should be inverted. Before doing this, however, everything should be in readiness for instant trach- 16 Foreign body in the right bronchus. The trachea is opened from the front. (St. Bartholomew's Hos p i t a 1 Museum.) 362 " INJURIES OF REGIONS. eotomy, in case the foreign body becomes lodged in the larynx and gives rise to spasm of the glottis. Children may be held up by the legs, but for adults some special contrivance may be nec- essary, as, for instance, Brunei's table. Inversion failing, trach- eotomy should be peiformed, as the patient is in danger of suf- focation at any instant. On opening the trachea, should the foreign body not be expelled at once, either through the wound or, as sometimes happens, through the mouth, the patient may be again inverted, or search made for it through the wound with tracheal forceps, wire variously bent, etc. These means failing, the tracheotomy wound must be kept open to allow of future trials being made if the foreign body is not expelled during the interval. Pharvngotomy or CEsophagotomy is the operation of opening the lower part of the pharynx or upper part of the oesophagus for the purpose of removing a foreign body. As the oesophagus inclines to the left, the operation by choice is done on that side, unless the body be felt distinctly on the right side. Make an incision about four inches long, having its centre opposite the cricoid cartilage, parallel to the sterno-mastoid, over the inter- space between the great vessels and the larynx. Divide the pla- tysma and deep fascia ; draw the sterno-mastoid outwards, and the sterno-hyoid and sterno-thyroid inwards; and divide the omo- hyoid if in the way. Gently draw the larynx and trachea across the middle hne in order to separate them from the great vessels; and then open the pharynx or oesophagus, as the case may be, by cutting on the foreign body if felt, or on the point of a sound passed through the mouth and made to project in the wound. Avoid injuring the superior and inferior thyroid arteries and the recurrent laryngeal nerve. The incision in the oesophagus should be united by sutures passed through the muscular coat only. The external wound should then be closed, drained and dressed anti- septically. The patient should be fed entirely by the rectum for some days after the operation, or by a tube passed down the oesophagus and retained in situ. Opening the oesophagus in the posterior mediastinum has re- cently been proi)osed for the extraction of a foreign body in the thoracic portion of the tube. (See Stricture of Oesophagus.) INJURIES of the 15ACK. Sprains of the spine are exceedingly common, and may be caused by any violent twist or bend of the back. '\\\& pathology of these injuries is hardly known. 'J'hey are said to depend upon a partial tearing or rupture of the spinal ligaments, muscles or fasciae, but oi)portunities for verifying this statement seldom oc- DISLOCATION AND FRACTURE. 363 cur. Sprains of the back may be complicated by concussion of the spinal cord, extravasation of blood in the subcutaneous tissue, er contusion or rupture of the kidney. They mny, moreover, be folljwed by inflammation of the inteivertebral joints and fibrous tissue about the spine; the inflammation may then at times spread to the membranes and cord, or be the starting-point of vertebral caries. Symptoms. — The patient usually complains of having ricked his back, /. e., of severe pain localized to one spot, commonly the lumbar region, and mcreased on movement and pressure. On examination no definite injury beyond, perhaps, some obscure swelling about the tender spot, or more rarely blood- extravasation, is discoverable. In the cervical region a sprain may sometimes simulate a dislocation, the pain causing the patient to hold the head in a fixed and one-sided position, thus rendering the transverse processes on one side of the neck more prominent than natural. In the lumbar region a severe sprain may sometimes simulate an injury of the spinal cord, inasmuch as the patient may complain of vi^eakness of the legs or inability to move them, or may even experience some difficulty in defae- cating or passing urine. It will be found, however, that in these cases no true paralysis exists, but that the apparent loss of power is due to the pain which is mduced on attempts at movement. The tt'eatment consists in rest, and the application of hot fomen- tations to relieve pain, and later of stimulating liniments. In severe cases the patient should be kept in bed for a week or so, and subsequently shampooing, massage and galvanism may have to be em.plcyed to overcome the pain and stiffness which often last for some time. Wounds of the spinal* membranes and cord may be inflicted by stabs in the back, falls on sharp bodies, etc. When the mem- branes alone are wounded, there may at first be no signs except perhaps an escape of ceiebro-spinal fluid; but later, should in- flammation be set up, there will be the usual signs of spinal men- ingitis. A wound of the spinal nerves may be known by paraly- sis of the parts which they sup|)ly ; a wound of the cord, by par- alysis of the parts below the seat of mjury. When division is complete the knee-jerk is quite lict, when incomplete the knee- jerk may be exaggerated. The /, ^^/w,?;// consists in placing the patient at absolute rest, and in keeping the wound perfectly aseptic to prevent inflammaucn ; but if the cord has been di- vided, permanent paialybis will necessarily ensue. Should in- flammation occur, the appropiiate remedies for meningitis must be administered. (See Work on Medicine.) Dislocation and feaciukk. — Li'docaticn of the spine without fracture is exceedingly rare ; indeed, except in the cervical region, 3^4 INJURIES OF REGIONS. Fig. 125. it is said never to occur. Fracture unaccompanied by dislocation is also uncommon ; but uncomplicated cases of fracture of the spinous process and laminae, and more rarely of the transverse antl articular processes, are sometimes met with. In the majority of cases fracture and dislocation are combined. Thus, usually there is fracture of the body and articular processes of one or more of vertebrae, with dislocation of the whole of the spine above the seat of injury from the spine below. This common form of injury is in the context spoken of 2& fracture-dislocation. Fraciure-Dislocation. Causes. — It is either the result of direct violence applied to the spine, or of indirect violence, as a fall upon the head. i. When the result of ^///rr/ violence, which can only be applied to the posterior part of the spine, one or more of the spinous processes may be detached without implicating the vertebral canal. When the violence is very great, as in a fall from a height on the back across a beam or rail, or a severe blow as from a crane, the spine is bent violently back- wards, tearing asunder the structures forming the anterior segment of the column, and crushing those forming the posterior. Hence the vertebral bodies are generally uninjured, but wrenched apart, the intervertebral cartilages are ruptured, the anterior common ligament is torn, and the arches of the vertebrae and the articiilar and spinous processes are crushed. The vertebrae above the injury are dislocated forwards, as the articular processes being fractured and the intervertebral cartilages torn, nothing remains to keep them in position. 2. In fracture from indirect v\o\enct (Fig. 125), such as may be received in a fall from a height upon the head, or catching the head whilst passing under an arch, or from a weight frilling upon the head or shoulders, the spine is bent violently for- wards, crushing the anterior j)art of the column and tearing the posterior asunder. Here one or more of the bodies and inter- vertebral cartilages are crushed between the vertebrcC above and the vertebrae below, one of the fragments of the fractured body being frccpiently driven backwards into the vertebral canal, whilst the arches and the spinous and articular ])rocesses are wrenched asunder. Fracture of the sternum is occasionally combined with this injury, in consequence, it is said, of the chin coming into violent contact with the sternum as the spine is doubled forwards. Fracture-dislocation of the spine. (.St. Bartholomew's Hospital Museum.) FRACTURE DISLOCATION. 365 Condition of the spinal cord. — The importance of fracture-dis- location of the spine lies not so much in the fact that the vertebrae are fractured as that the cord is generally injured. When the vertebrse are not displaced, the cord may at times altogether escape. More commonly, however, it is compressed, or, perhaps, completely divided, or again so bruised that it rapidly undergoes inflammatory softening. When the injury is situated below the second lumbar vertebrce, the cord necessarily escapes as it terminates at that spot, but the nerves of the cauda eqaina may then be injured. Signs and symptoms. — The local signs are often but little marked. There may be pain at the seat of injury, or some in- equality in the spinous processes ; but as often as not these are absent. The general signs depend upon the condition of the cord, and none will be present when it has escaped injury. But when it is compressed or crushed there will be paralysis of the parts below, more or less complete according to the extent of the lesion. Taking as an example a case of fracture in the lower cer- vical or upper dorsal region — the most common situation — with severe compression or crushing of the cord, there will be paraly- sis of both motion and sensation of the whole of the parts below the seat of injury {paraplegia), and perhaps a zone of hyper- sesthesia immediately above the injured part. The intercostal muscles being paralyzed, respiration can only be carried on by the diaphragm, this muscle receiving its nerve-supply through the phrenics which are given off above the seat of injury. Hence, while the chest is motionless, the abdomen rises and falls during respiration. The bladder and rectum and their respective sphincters share in the paralysis, so that there is at first retention of urine and faeces, followed by passive overflow of urine as the bladder becomes distended and will hold no more, and by invol- untary passage of fteces. Priapism, or involuntary erection of the penis, is frequently present, or is induced by the use of the cath- eter. The temperature varies ; sometimes it may be lower than normal, but often it is considerably raised, even reaching as high as 107° shortly before death. Consciousness, unless any head- injury has been received at the same time, is not affected. The reflexes in the lower limbs are usually at first in abeyance, but may return if the patient does not succumb to the shock of the injury. If the reflexes remain quite lost the probabilities are that the conducting power of the cord has been completely destroyed. If they return it is a sign that some power of conductivity is left in certain portions of the cord at the seat of injury. Death oc- curs, as a rule, from twenty-four hours to a few days from bron- chial trouble ; but the patient, if the fracture is in the upper 366 IN7URIES OF REGIONS. dorsal region, may linger from two to three weeks. The second- ary troubles which are then generally met with are bed-sores and chronic cystitis, i. The bed-sores occur in situations subjected to pressure, and depend in great part on the congestion and low- ered vitality of the tissues induced by the impairment of the nerve-influence ; but they may also to some extent be due to the soddening of the part with the urine and fceces, from which it is very difficult to keep the patient free. 2. The chronic cystitis is probably also due in part to impaired neive influence, and in part to slight injury in the passage of a catheter, or to the introduction by the catheter of a micro-org:ini>m — the micrococcus urese. The urine, which is at first acid, hecoaies amraoniacal from the conversion of the urea mto c rbonate of ammonia, and thick from the deposit of phosphates and the presence of ropy mucus. The inflammation may then extend up the ureter to the kidney, where suppuration of the pelvis ar,d substance of the kidney {pye/o-nephritis) may be set up. Such may be taken as a typical example of fracture of the spine as commonly met with in surgical practice. But the nature and gravity of the symptoms will depend upon the situation of the fracture, and the amount of injury to the cord. Thus in some cases of fracture there may be n > pirjlysis ; in others the paraly- sis may be incomplete, /. t way of preventing death from haemorrhage. In rupture of the stomach or intestines, the abdo- men should be opened, the rent sewn up by a Lembert's suture, and the peritoneal cavity thoroughly cleansed by irrigation with a weak boracic solution. Subsequently the patient should be kept under the influence of opium if there is much ])ain, and nothing whatever be given by the mouth for the first twelve to twenty-four SIMPLE PENETRATING WOUNDS OF THE VISCERA. 379 hours. Nutrient enemata and stimulants, if the strength flags, should be administered. In rupture of the kidney an incision in the loin or nephrectomy may become necessary. The swelling following rupture of the ureter may require tapping or free drainage. Wounds of the abdomen may be divided into the penetrating and non-penetrating, according as they do or do not involve the peritonea] cavity. Non-penetrating wounds should be treated like wounds in other situations, especial care, however, being taken to establish a good drain, as should they extend deeply they are apt to be com- plicated by eiTusion of blood or suppuration in the sub-peritoneal tissue. They are liable to be followed by ventral hernia. Penetrating wounds are such as involve the peritoneal cavity. They may be divided into the following : — i. Simple penetrating wounds without injury or protrusion of the viscera. 2. Penetrat- ing wounds without injury, but without protrusion of the viscera. 3. Penetrating wounds with protrusion, but without injury of the viscera. 4. Penetrating wounds with both protrusion and injury of the viscera, I. Simple penetrating wounds without injury or protrusion of the viscera. — When the wound is large, there will usually be no difficulty in ascertaining the fact that the viscera have escaped injury. If, however, the wound is very small — a mere puncture, or made obhquely, it may be difficult or impossible to say whether any injury to the viscera has been done, or, indeed, whether the abdominal cavity has been penetrated. In such a case it has hitherto been taught that the wound should on no ac- count be probed for the purpose of settling the point, but the patient treated as if the wound had penetrated, and had not in- jured the viscera. If all antiseptic precautions are taken, how- ever, it is questionable whether the safer course is not to thor- oughly explore the wound, not only by probing, but by enlarging it if necessary, so as at once to ascertain whether it has penetrated the peritoneum, and whether the viscera have escaped injury, and not to wait till the diagnosis is settled by the onset of peritonitis. Where there are signs of internal hcemorrhage no surgeon would, I presume, hesitate to search for the bleeding vessel. Treatment. — Large wounds should be thoroughly cleansed with w-eak boracic acid lotion (2 per cent.), and united with fishing- gut or silk sutures, which should be passed through the peritoneum as well as the edges of the wound, so as to bring the two free surfaces of the serous membrane into contact. If this is not done, the discharge from the deep part of the wound may make its way into the peritoneal cavity and set up peritonitis. In the case of 380 INJURIES OF REGIONS. punctured wounds, it has usually been the custom to merely close them and apply some antiseptic dressing. As a rule, however, it will probably be safer to enlarge them, and having ascertained that the viscera have escaped, to treat them as described above. In any case the patient should be placed at absolute rest in bed and fed by the rectum or by small quantities of iced milk for the first few days. Many surgeons would give opium in small doses, but it is not necessary unless there is pain. Should peritonitis supers'ene, it must be treated as described under that head. II. Penetrating wounds with injury, but without protrusion OF THE VISCERA. — When the wound is large, and the injured viscus can be seen, the nature of the injury will probably be obvious. When, however, the wound is small, unless there be an escape ex- ternally of fseces, gas, bile, urine, or the contents of the stomach, there are no primary signs, with the exception perhaps of emphy- sema about the wound, absolutely diagnostic of a viscus having been injured. Intense pain, and extreme collapse, if present, no doubt point to such an injury having probably occurred ; but both pain and shock are so variable as really to afford little guidance. Later the presence of free gas in the peritoneal cavity and the escape of blood from the anus make it highly probable the intestine has been wounded. In a doubtful case of wound of the intestine the rectum may be inflated with hydrogen by Senn's rubber balloon. If a gut is wounded the gas will escape through the rent into the peritoneum and thence through the ex- ternal wound, where it will ignite on applying a light, thus settling the diagnosis. In a doubtful wound of the stomach this viscus may be inflated by a tube passed through the mouth. The tympanites will be confined to the stomach if the viscus is sound, or spread to the rest of the abdomen and eftace the liver dulness if it is injured. Any of the viscera may be implicated ; but wounds of the liver, gall-bladder, spleen, and stomach, are much less common than wounds of the intestine. The danger to be apprehended is haemorrhage in the case of the liver or spleen, extravasation in the case of a hollow viscus, and in all, peritonitis. The amount of extravasation will depend upon the size of the wound, and whether the viscus was distended or empty at the time of injury ; when the wound is a mere puncture, there may be none. If the extravasation is but slight, or escapes externally through the wound in the parietes, it may be cut off from the general peritoneal cavity by a local peritonitis, and the patient recover. An extensive extravasation is always followed by diffuse septic peritonitis, which, unless surgical measures are undertaken, will certainly prove fatal in a few days. Treatment — i. If the wound in the parietes is extensive, the injured viscus, if the PENETRATING WOUNDS WITH INJURY OF THE VISCERA. 38 1 stomach or hrtestine, should be drawn gently through the aperture and the wound of its coats united by Lembert's sutures. Should the intestine be torn completely across, its continuity should be restored by some form of circular enterorrhaphy, as Senn's, Maunsell's, or Paul's, or by Senn's bone-plates, or by Murphy's button. If its coats are much lacerated, the lacerated portions should be iirst excised. These methods have so reduced the time required for restoring the continuity of divided intestine that only in exceptional cases should the patient's general condition render it necessary to draw the injured gut into the wound, stitch it to the parietes, and make an artificial anus. In gunshot wounds of the intestines Senn's inflation method is useful in de- termining if there be one or more wounds. The rectum is first inflated and the lowest wound detected by the escape of the gas. This wound is then sutured, the inflation repeated, and the gas extends up to the next wound, and so on. If the liver is wounded an attempt may be made to unite the peritoneal surface by sutures, or if the wound is deep it may be plugged with iodoform- gauze and the wound in the parietes be left partially open for the purposes of drainage and the subsequent removal of the plugs. If the gall-hladder is penetrated the wound should be sewn up, or the edges of the wound if lacerated stitched to the abdominal parietes, or the gall-bladder removed. If the spleen is injured, extirpation of the organ appears to be the best method of arrest- ing the otherwise fatal haemorrhage. After the wounded viscus has been treated in one or other of the ways described above, the peritoneal cavity should be thoroughly cleansed from all blood and other extravasation by irrigation with warm water or boric acid solution (2 per cent.), and the wound in the parietes closed as after a simple penetrating wound ; or if it remains doubtful how far the cleansing has been successful, a Keith's drain-tube should be inserted, packed round with iodoform gauze, and the wound in the parietes left partially open. 2. If the wound in the parietes is small, the safer course is probably to enlarge the wound, and treat the wounded viscus as described above. The genej-al treatment consists in the administration of opium if there is much pain ; abstinence from all nutriment taken by the mouth for the first day or so, and subsequent feeding with small quan- tities of iced milk, etc., and the employment of nutrient enemata. Absolute rest is imperative. Should peritonitis supervene, it must be treated as described under that head. Method of uniting wounded intestine. — If the wound is small (a mere puncture) it has usually been taught that no suture will be required, since the mucous membrane will protrude, block up the wound, and prevent extravasation until the woimd has healed by 382 INJURIES OF REGIONS. inflammatory exudation from the peritoneal surface. Gross's ex- periments on dogs show, however, that the protrusion of mucous membrane is not always sufficient even in minute wounds to pre- vent the escape of faecal matter. It would, therefore, appear to be the better practice in all cases to sew up the wound, however small. This is now usually done by interrupted sutures, the two peritoneal surfaces being placed in contact. The sutures are best applied by Lembert's method, as shown in the accompanying diagram (Fig. 127), in which it is seen that the suture passes Fig. 128. Fig. 127. /M \ \ Section of intestine united by Lembi:rt's suture. ' " ' • r ■ f 1 ' '• I Intestine united by Lembert's suture. through the peritoneal and muscular coats only, avoiding the mucous membrane, since if this is included there is danger of peritonitis from leakage along the thread. The sutures, which may consist of fine China silk, should be introduced about two lines from the edge of the wound and brought out at the margin of the serous coat, and then passed in the same manner on the opposite side (Fig. 128). If, however, the edges are lacerated the sutures should be introduced further from the wound, and brought out a good line from the margin, so as not to include the bruised tissues. Sufficient sutures should be passed to ensure the parts being everywhere in apposition, and should not be tied too tightly, lest gangrene, the commonest cause of non-union, ensue. The peritoneal surfaces thus pUiced in contact unite by adhesive inflammation. The sutures either remain encysted, or ulcerate through the mucous membrane, and drop into the interior of the bowel. It is not safe to suture the wound — (i) when the wound runs longitudinally along the mesenteric aspect, inasmuch as gangrene of the part cut off from its vascular supply will inevi- tably ensue ; (2) when suturing would reduce the lumen of the gut to less than half its normal size; (3) when there is much bruising of the gut ; (4) when there are several wounds close to- gether. In such cases the injured portion of the intestine should PENETRATING WOUNDS WITH INJURY OF THE VISCERA. 383 be excised and the two ends united by some form of circular enterorrhaphy, or an intestinal anastomosis may be formed. Circular enterorrhapliy is the union of the ends of the com- pletely-divided intestine with the peritoneal surfaces in contact by a row of sutures around the circumference of the bowel. The Lembert method of a single row and the Czerny-Lembert method of a double row have in recent years usually been employed. The objection to these methods is the great number of sutures required, and hence the length of time consumed in the operation Fi( i2g Fig. 130. RS Senn's method of circular enterorrhaptiy. R. Rubber rings, s. Continuou;. suture. M. Mesentery. RS. Retaining suture. The margin of intestine, i in Fig. 129, is shown turned in at I.I in Fig. 130. — a serious drawback in abdominal cases — and the danger of ex- travasation at the mesenteric attachment. Many, therefore, em- ploy Senn's modification of Jobert's suture, or Maunsell's, or Paul's method of suture. Senn's method. — Having determined which is the upper end of the intestine, as by applying to the sur- face of the peritoneal coat a little common salt, v/hich causes ascending peristalsis (Ncthnagel's test), line the lower end of the upper portion of the bowel with a soft, pliable rubber ring half an inch wide, made by stitching together the ends of a rubber band by two catgut sutures. Fix the ring by sewing its lower margin with a continuous catgut suture to the cut end of the bowel ; the ring prevents bulging of the mucous membrane and causes the end of the bowel to slightly taper, and thus aids its subsequent 384 IXTURIES OF REGIONS. invagination (Fig. 129). Pass two catgut sutures with a needle at each end from within outwards through the upper margin of the ring and all the coats of the bowel, one suture near the mesenteric, one near the convex surface of the bowel. Pass the other end of the sutures through the peritoneal and muscular coat of the distal portion of the bowel about a third of an inch from its cut margin. Whilst an assistant draws on the four ends of the two sutures, turn in the margin of the upper end of the distal por- tion of the gut evenly by the aid of a director, and at the same time invaginate the ring-lined proximal portion of the intestine into the distal portion (Fig. 130) to the extent of the whole width of the ring. Tie the sutures only sufficiently tightly to prevent disinvagination. The two peritoneal surfaces are thus held in close contact by the rubber ring. The intestinal contents, says Senn, pass freely through the lumen of the ring from above down- wards, and escape from below is impossible, as the free end of the intussuscipiens secures accurate valvular closure. The catgut sutures fixing the ring are absorbed, and the ring, reconverted into a band, is passed per anum. The invagination sutures are believed by Senn to be removed by substitution on the part of the tissues. Hence the punctures of the bowel remained closed and extravasation is prevented. MaunselPs method. — Bring the two ends of the divided bowel together by two temporary sutures passed through all the coats, one suture at the mesenteric attach- FiG. 131. iJU^i4^j ' t:s:^jWj5'itmjvilJ Maunsell's method of circular enterorrhaphy. a n c. rcritoneal, muscular and mucous cents. F. Mesentery, d d. Temporary sutures uniting proximal and distal portions ol divided intestine, and passed out througli longitudinal slit made in the proximal or larger segment in the intestine. ment, the other opposite. The mesenteric suture should close the little triangle where the mesentery is reflected from the gut. Leave the long ends of the sutures intact. Pass them up the lumen of the proximal portion of the bowel and out through a longitudinal slit previously made in its wall opposite the mesen- tery, and about an inch from its cut end (Fig. 131). Draw on maunsell's method. 385 the sutures, and the distal or smaller end g (Fig. 133) will be invaginated into the proximal or larger end h, and thence pulled out of the longitudinal incision in the wall of the proximal portion H. From Fig. 132 it will be seen that the serous surfaces of the two portions are in accurate apposition all round. Whilst an assistant holds up the intestine by the temporary sutures, drawing them gently apart so as to render the lumen of the invagination an oval slit, pass a straight needle armed with fine silk across the slit a quarter of an inch from the cut ends through the whole thickness of the four walls of the intestine (Fig. 133). Hook up Fig. 132. Maunsell's method of circular enterorrhaphy. G. The interior of the distal portion. H. The interior of the proximal portion of the bowel. Fig. 133. Maunsell's method of circular enterorrhaphy. o. The distal portion. H. The pro.ximal por- tion of the intestine, a. The needle in transit. the suture, divide it and tie each half. In this way twenty sutures can be passed in ten transits of the needle. When sufficient sutures have been applied, cut short the temporary sutures and reduce the invagination by traction on the two portions of the gut 17 \S6 INJURIES OF REGIONS. and close the longitudinal slit by a continuous Lerabert suture. On the completion of the operation the peritoneal surfaces are accurately in contact, and the knots are all inside (Fig. 134). Fig. 134. U ^L U A^V/4ti ;v Maunsell's method ot circular enterorrhaphy Appearance of intestini. at (.onipletion of oper- ation. G. I)ibtal portion, n. ProMiiial portion of intestine. Maunsell paints the wound with Wolfler's mixture of alcohol, glycerine and colophonium, and dusts it with iodoform. The only objection to the method is the infliction of the longitudinal wound. PauPs method. — Insert a Paul's decalcified bone-tube, to which is attached a needle and double silk ligature to form a traction thread (Fig. 135), into the proximal end of the intestine; Fig. 135. Paul's bone-tube, with double silk ligature for forming traction thread fixed to holes in the tube at 3 3. I. Distal end perforated, with holes for sewing to bowel. 2. Needle. sew this end of the intestine to the tube, closing the triangular interval at the mesentery. Pass the needle and traction thread through the lumen of the distal portion of the intestine, and bring it out through the wall three inches down (Fig. 136) ; unite the Fig. 136. Gut ready for invagination in Paul's method of enterorrhaphy. i. Proximal end of gut, with tube sewn in. 2. Distal end, with traction thread {3) passed through its wall. INTESTINAL ANASTOMOSIS, 3S7 cut ends of the bowel by continuous suture ; draw on the traction thread, and thus invaginate the upper into the lower portion, be- ginning the invagination immediately below the line of union ; fix the invagination by Lembert's sutures (Fig. 137). Pull the Condition of parts in Paul's method of enterorrhaphy when operation is completed, i. The intussuscipiens. 2 2. Lembert's sutures. traction thread tight ; cut it off, and allow ends to pass back into the bowel. The condition of the parts at the end of the opera- tion is seen on section in Fig. 138. The bone-tube is disinte- grated and passed per anum. Intestinal anastomosis, or the restoration of the continuity of the intestine after complete division or excision of a portion, may be done by Senn's plates and Muiphy's button. Semi's Method. — Having let what faeces will escape from the proximal portion of the intestine, clamp both the proximal and distal portions about five inches above and below the divided spot by passing a piece Section of parts shown in Fig. 137. i. Bone-tube. 2. Traction thread cut short. 3. Proxi- raaf end of bowel. 4. Distal end invaginated. of India-rubber tubing through a small incision in the mesentery and tying it sufficiently tightly to prevent any further faecal soiling of the parts, or if the rubber tubing is not at hand the bowel may be clamped by a large safety-pin. Invaginate the divided ends with the peritoneal surfaces in contact and unite them by a con- tinuous suture passed through the peritoneal and muscular coats (Fig. 139, A a). Make an incision about an inch in length along the convexity of each portion of the intestine between the sutured end and the rubber clamp. Insert into each incision a Senn's bone-plate properly threaded, as shown in Fig. 141, with four fine aseptic china silk sutures. Pass the lateral sutures from 388 INJURIES OF REGIONS. within outwards through all the coats of the intestine a line or two from the margin of the incision, and bring the longitudinal sutures out through each end of the incision (Figs. 139, 140). Fig. 139. Method of forming an intestinal anastomosis by Senn's bone-plates after complete division of the bowel. The divided ends closed by a continuous Lembert's suture, A A. Fig. 140. Di.ngram of intestine united by Senn's plates. The arrow shows the way in which the con- tents of the bowel pass ihrough the plates and incision in the wall of the bowel from the proximal into the distal portion. Now place each portion of the intestine corresponding to the situation of the bone- plates opposite to each other, and having scarified the serous surfaces lightly with the point of a needle to aid subsequent adhesion, tie each of the four sutures coming from one bone-jjlate to the corrcs|)onding suture from the other, just sufficiently tightly to keep the wall of the intestine between the plates in contact. Tuck in the knots between the approximated INTESTINAL ANASTOMOSIS. 389 serous surfaces and apply round the line of approximation for greater safety an omental graft (Fig. 142;. On removing the clamps the contents flow as shown by the arrow in Fig. 140, through the central hole in the bone-plates and the incision in the walls of the gut from the proximal to the distal portion of in- testine. The bone-plates hold the portions of intestine in contact, preventing any leakage of feeces till firm union has occurred. They ultimately become dissolved, and, together with the sutures, are passed per anum. The advantages of this method over circu- lar enterorrhaphy as practised by the Lembert and Czerny- Lembert suture are that it can be done in a much shorter time (a quarter of an hour?), and hence greatly minimizes the risk from shock. It also appears attended with less danger of septic peritonitis, from the possibility of leakage between the sutures or the penetration of the mucous coat by one of the Lembert stitches. The omental graft is made by cutting a piece of omentum about an inch wide sufficiently long to encircle the intestine (Fig. 142). It is placed over the line of union and fixed by cat- FiG. 141. Fig. 142. A Senn's decalcified bone-plate threaded ready for use. A fine china silk suture with a loop at one end, the size of the aperture in the plate, is passed through one of the suture holes, and to this loop the three other sutures passed through the three remaining holes are securely tied. The plates should be kept in alcohol. Portion of intestine with line of suture cov- ered by omental graft, i. Intestine. M. Mesentery. o. Graft, s. Suture fi.xing graft. gut sutures to the mesentery, the stitches being parallel to the mesenteric vessels. It adheres very rnpidly to the intestine, but this adhesion may be accelerated by lightly scarifying the peri- toneal coat of the intestine to which the graft is to be applied. 390 INJURIES OF REGIONS. It is of sen-ice in preventing extravasation should a leakage occur through a stitch-wound, etc. Alurphys method of uniting completely divided intestine by an anastomosis button. — By this contrivance an end-to-end approxi- mation or a lateral anastomosis may be quickly accomplished with- out sutures. The button consists (Fig. 143) of two halves. The male half a has a spring flange p for keeping up pressure on the approxi- mated intestine. The two springs J s, projecting through openings in the hollow stem, act as the male thread of a screw when the shank is telescoped within the stem of the female half b. The intestine having been clamped, as previously described, pass the running thread (Fig. 144) by the overhand stitch {b) round the cut end of the irites- tine, beginning and ending opposite the mesenteric attachment. One re- turn stitch {a) should be taken at Fig. 143. Miirnhy's lUitton. A. Male half. n. Female half. p. Sprlne flange, .y j. Springs projecting through openings in h( How stem. Part of the cap of the male half has been cut away at r to show circular spring which acts on flange. The round holes in the caps are for drainage. M<:lhi)d of applying " puckering thread" {b) preparatory to inserting the button. At n the method of ap- plying the return stitch so as to close the triangular interval ic) at the re- flection of the mesentery is shown. the merjenteric attachment to close the triangular interval {c) which exists at the reflection of the mesentery from the gut. Insert one- half of the button in the end thus jjrcpared, tighten the running thread so that the intestine is puckered uj) round the stem of the button, tie the ends of the thread and cut them short. Secure the other half of the button in a like manner in the other end of the intestine (Fig. 145). The method of holding the button dur- INTESTINAL ANASTOMOSIS. 391 ing insertion is shown in Figs. 147, 148. Press the two halves together, and the peritoneal surfaces are held in close and accurate Fig. 145 -'^- i\Iurphy's method of end-to-end approximation of divided intestine. The male and female halves of the button are secured in the ends of the divided gut by the " puckering threads," and ready to be pressed the one into the other. Fig. 146. To show the method of passing the running thread for fixing the half-button in Murphy's method of lateral anastomosis of intestine. contact. The great advantage of the operation is the rapidity and ease with which the union of the intestine can be effected. The disadvantages are — i. That a large foreign body is left in the intes- FlG. 147. Showing method of holding male half of button for insertion. tine, where it may become a source of danger during its passage to the rectum, and 2. That since the button frees itself by causing 392 INJURIES OF REGIONS. gangrene of the compressed portions of intestine, whilst the ad- hesion of the serous surfaces occurs outside the grasp of the instrument, there is perhaps a risk of the gangrene spreading too Showing method of holding female half of button for insertion. far and of perforation or non-union. However, whilst condemned by some surgeons the method is highly spoken of by others who have used it. The technique of lateral anastomosis with Murphy's button is similar to that of the end-to-end approximation, and requires no separate description. (See Fig. 146.) III. Penetrating wounds with protrusion but without injury OF THE viscera. — The protruding viscus is nearly always a portion of intestine or omentum. It should be cleansed with some weak antiseptic lotion, and returned by gentle uniform pressure into the abdomen, care being taken not to force it between the peritoneum and fascia transversalis. If the wound of the parietes is too small to allow the viscus to be returned easily, it should be cau- tiously enlarged. The wound should then be closed in the way already described. If the portion of intestine is congested or inflamed, it should still be replaced. If gangrenous, however, it should on no account be returned, but the gangrenous portion excised and the continuity of the gut restored by one of the methods already described, and replaced in the abdomen. In exceptional cases it may be left /;/ situ, an incision made into it, and an artificial anus thus formed. A congested portion of omentum should be ligatured and cut off, and the stump returned ; a gangrenous portion should be cut off, and the stump, which is probably already adherent, separated from the parietes, ligatured at a healthy spot, the diseased part cut away, and the stump re- turned. The general treatment should be the same as that before described. IV. PeNETRA'JING wounds with r.OTH PROTRUSION AND INJURY OF 'IHE VISCERA. — The protruded viscus is nearly always a portion of the small intestine. 'i"he wound should be united by suture in the way already described^ and the intestine then replaced, TRAUMATIC PERITONITIS, 393 If the intestine is completely divided it may be united by one of the methods already described, and returned j or an artificial anus, under some circumstances, may be made. If the wound is high up the intestine the former procedure should be the one adopted. Traumatic peritonitis may be set up by any of the injuries above described, and may either remain localized as a simple in- flammation to the neighborhood of the wound or other injury, or as is more frequently the case, may become diffused over the whole peritoneal cavity, when it assumes a septic character, and terminates in blood-poisoning from the absorption of the chemi- cal products of putrefaction. The simple localized variety, after gluing the parts together, and thus preventing the spread of the inflammation, usually subsides ; but it may terminate in suppuration and the formation of a cir- cumscribed abscess, which may burst externally, into the intestine, or into the general peritoneal cavity, then setting up diffuse peri- tonitis. The diffuse variety is generally due to extravasation of urine, blood, bile, or the contents of the stomach or intestine, or the breaking of an abscess into the peritoneal cavity ; and when there is an open wound, or a wound or rupture of the bladder, stomach, or intestine, it assumes a septic character. It usually terminates fatally, sometimes in a few hours, usually within a week or ten days, either from collapse, or from blood-poisoning due to the absorption of septic products. Should recovery occur, death may subsequently ensue from intestinal obstruction consequent upon the gluing, together of the intestines or the strangulation ot a loop by a band of adhesion. Symptoms. — In the local fo7-m there is severe pain at one part of the abdomen, increased on pressure, on deep inspiration, and on coughing, with perhaps vomiting, and a slight rise of tempera- ture, followed should an abscess form by a circumscribed swelling, rigors, and fever. In the diffuse variety the pain, which at first may be localized to the seat of wound or injury, becomes general and of a lancinating character, and so increased by the slightest pressure that the weight of the bedclothes in a severe case cannot be borne. The patient lies on his back with his legs drawn up to relax the abdominal parietes, his breathing being entirely thoracic. The abdomen is at first hard, owing to the spasmodic contraction of the muscles, but soon becomes distended and tympanitic, the paralysis of the muscular coat of the intestines allowing them to become inflated with gas. Later, as effusion occurs, the abdomen becomes dull in the flanks. The general symptoms are obstinate vomiting, usually constipation, hiccough, a furred, dry, and brown tongue, a small, quick, and wiry pulse, and exhaustion and col- 394 INJURIES OF REGIONS. lapse. The temperature may register 103° or 104°, but it gener- ally falls before death, or may remain little, if at all, raised throughout. The treatment may be divided into the preventive and the curative. Preventive treatment consists in the prompt removal, where practicable, of the conditions which, if allowed to continue, are virtually certain to be followed by inflammation ; and subse- quently in keeping the patient at absolute rest, and allowing nothing to be taken by the mouth save small quantities of ice or hot water. By most Surgeons opium in small and repeated doses is given ; but by others the drug is only used if there is much pain, as it tends to restrain absorption from the peritoneal surface, and excretion from the intestines. Mr. Tait, on the first signs of peritonitis, orders a turpentine enema and a saline pur- gative, with a view to causing the absorption of any serum that may have collected in the peritoneum. This treatment is advan- cing in favor, but it should be borne in mind that it ought never to be employed when there is any serious obstruction in the intes- tine ; in such cases it could only do harm. Where the abdomen has been closed, as after an ovariotomy, the wound may at times be opened with advantage, the peritoneum washed out and a glass drainage-tube inserted. In the way of curative treatment the only chance for the patient, where the inflammation depends on such causes as those above mentioned, is at once to freely open the abdomen, deal with any wounded viscus in the way already described, let out the gas from each distended coil by puncture with a fine trocar and cannula, and faeces through a tem- porary incision, thoroughly irrigate the peritoneal cavity, and establish a free drain. Exhaustion and collapse should be met by strychnine and brandy before the operation, and afterwards by warmth, stimulants and nutrient enemata. In the local variety, leeches, followed by hot fomentations and turpentine stupes, may be employed, whilst, should suppuration occur, the pus should be cautiously let out. INJURIES or THE PELVIS. Fractures of the pelvis. — Cause. — Nearly always severe and direct violence, as the passage of the wheel of a heavy van, or a crush between the buffers of railway carriages. The acetabulum, however, especially in old ])eo[jle, may be fractured from a fall on the great trochanter, or its rim may be chipped off in conjunc- tion with dislocation of the hip. State of the parts. — The injury may be localized to the aceta- bulum, or to the ramus of the pubes or ischium ; or merely the FRACTURES OF THE PELVIS. 395 Fracture of the pelvis. (Bryant's Surgerj\) anterior -superior iliac spine or the crest of the ilium may be splintered off. When the result of a crush, the injury is generally more severe, the line of fracture often extending through the ramus of the pubes or ischium, and thence Fig. 149. backwards through the ilium near the sacro- ihac synchondrosis, thus detaching, as it were, one side of the pelvis from the other. Or the fracture, as shown in Fig. 149, may extend in various di- rections, more or less smashing both the false and true pelvis. The fracture owes its importance to the hability of the pelvic viscera to be injured. Thus the bladder is not infrequently ruptured; or the urethra torn across by a fragment of the pubic arch ; or the rectum or intestines lacerated when the sacrum or the venter of the ilium is implicated. Sig/?s. — The history of the accident, and perhaps the mark of a wheel across the lower part of the body, will commonly direct attention to the possibility of a fracture. On grasping the crests of the ilia firmly, preternatural mobility or crepitus may be dis- covered and pain produced, whilst the patient is usually unable to walk or to turn himself in bed without great suffering. A dis- placed fragment may sometimes be felt through the vagina or rectum. There is usually considerable shock, and where any of the viscera have been ruptured, commonly severe collapse. (See Ritpiure of Bladder-, Urethra, etc. ) Treatment. — As the bone readily unites, little beyond keeping the parts at rest and in apposition is required. This may be done by applying a flannel bandage firmly round the pelvis and confin- ing the patient to bed for three to five weeks, according to the severity of the fracture. Where there has been much ciushing a gutta-percha or poroplastic felt shield should be moulded to the pelvis and hip of the affected side, to prevent any movement of the fragments by the use of the joint. In any case a catheter should be passed in order to make sure that the urinary apparatus is not injured. Fracture of the acetabuliiin. — A word or two in addition may be said of this form of fracture of the pelvis. The rim of the ace- 396 INJURIES OF REGIONS. tabulum, generally the posterior and upper part, may be broken off in some forms of dislocation of the femur on to the dorsum ilii. Besides the ordinary symptoms of the dislocation, crepitus will generally be detected on manipulation, and the head of the femur will slip in and out of the acetabulum. Or the fracture may extend through the floor of the acetabulum, the head of the bone being even driven into the pelvis. Crepitus may then be detected ; or the head of the bone may be immovably fixed and the limb shortened. Pain is present on movement or on attempt- ing to stand on the limb ; also, it is said, on pressing on the pubes. Treatment. — Extensipn may be made by a long splint, or by a stirrup, weight and pulley. Rupture of the bladder can only occur when the viscus is full. It may then be due to a blow or kick upon the abdomen, and is a frequent complication of fracture of the pelvis. Rupture is seldom due to over-distension consequent upon urethral stricture, as the walls of the bladder are then generally thickened and thereby rendered capable of resisting the pressure of the contained urine. Under these circumstances it is commonly the urethra be- hind the stricture that gives way. State of the parts. — The rupture, which is usually vertical, may extend through the posterior part ot the bladder, the urine escap- ing into the peritoneal cavity, or through the anterior part, the urine then being extravasated into the loose cellular tissue of the pelvis. In the former case, which is the more common, acute peritonitis is generally setup, and is, as a rule, fatal in a few days. In the latter, diffuse cellulitis commonly occurs, the patient suc- cumbing either to septic poisoning from the absorption of the products of putrefaction, or to the extension of the inflammation to the peritoneum. Signs. — Intense collapse following a blow over the abdomen or a severe injury of the pelvis, combined with the fact that on pass- ing a catheter (as should always be done in such a case) no urine but only a little blood escapes, whilst the patient states that the bladder was full at the time of the accident, or at least that he had passed no water for several hours previously, should lead us to in- fer that the bladder is ruptured. The catheter, moreover, may at times be felt to be grasped by the empty bladder, and to slip through the rent in its walls ; the point may then be detected more plainly than natural through the front of the abdomen, and blood-stained urine may flow. 'I'he flow, however, is not con- tinuous, but varies with respiration. If the urine has had time to collect in the peritoneum, a sensation of fluid in the abdomen may be detected on palpation. The signs, however, are not always so obvious. Thus, there may be neither collapse nor pain ; RUPTURE OF THE BLADDER. 397 or, again, on passing a catheter, several ounces of clear urine may escape, owing to urine having collected in the bladder in conse- quence of the rent being small or blocked by a portion of in- ^^ ^lU^^i testine. If in doubt,^io*^r 12 ounces of some antiseptic fluid may be injected into the bladder, when, if no rupture exists, the same quantity should flow out again through the catheter. Or the bladder may be inflated with air or hydrogen ; if there is a rupture, the abdomen becomes distended and the liver dulness lost ; if the bladder is sound, a locahzed tympanitic tumor rises from the pelvis. Later, symptoms of peritonitis or of pelvic cellu- litis will probably supervene. Treatment. — The following are the chief plans of treatment that have been adopted : — i. The retention of a soft catheter just within the bladder. 2. Washing out the bladder and adjoining Fig. 150. Fig. 151. Method of applying Lembert's suture in ruptured bladder. (After Sir W. MacCormac.) portion of the peritoneal cavity with an antiseptic solution by a catheter passed through the rent in the viscus. 3. Washing out and drainage through an incision in the perineum. 4. Opening the abdomen, sewing up the rent in the bladder, and washing out the peritoneal cavity if the rupture is intra-peritoneal. Of these methods the last, provided every care is taken to ensure perfect closure of the rent in the bladder and thorough cleansing of the peritoneum by irrigation, holds out, in the intra-peritoneal rupture, the best prospect of success. Several cases have now been treated successfully in this way ; amongst the first of these may be men- tioned two by Sir William MacCormac, one by Mr. Holmes, and one by myself. In sewing up the bladder the peritoneal surfaces should be brought into contact by Lembert's sutures (Figs. 150, 151), which should not pass through the mucous membrane. And one suture at least should be placed beyond the angles of the wound so as to prevent leakage at these spots (Fig. 150). After the rent has been closed an antiseptic fluid should be injected into the bladder to make sure that the viscus is water-tight. A catheter should not be tied in, for fear of its inducing septic 398 - INJURIES OF REGIONS. changes in the urine, but the patient should be made to regularly empty his bladder every four hours to guard against over-dis- tension and the giving way of the sutures. When it is not clear whether the rupture is intra or extra-peritoneal, the fundus of the bladder should be exposed before opening the reflection of the peritoneum. Extra-peritoneal rupture should be treated by a free incision in the perineum, or above the pubes, and an anti- septic drain. Nothing, as a rule, should be given by the mouth for the first twelve or twenty-four hours. Where, however, there is extreme collapse, stimulants may be cautiously administered. As in other peritoneal cases, it is a moot question whether opium should be used as a matter of routine. Rupture of the urephra is a serious injury, as it exposes the patient not only to the immediate danger of extravasation of urine, but also to the lifelong trouble of a traumatic stricture. It is generally caused by a kick on the perineum, a fall astride a joist or rail, or the displacement of a fragment of the pubic arch in fracture of the pelvis. The urethra may also give way behind an old stricture while the patient is straining to empty his bladder. State of the parts. — The rupture usually occurs where the urethra passes under the pubic arch, /. e., either just in front of or just behind the triangular ligament. In the former situation urine and blood will be extravasated in the perineum ; in the latter, about the neck of the bladder. As the triangular liga- ment, however, is generally torn, some urine will, as a rule, in the latter case also pass forward into the perineum. The urethra may be completely torn across, or the rupture may only be partial, the upper wall escaping. The signs are usually quite obvious. Together with the history of an accident, there will be pain, swelling, and ecchymosis of the perineum, and escape of blood, often in considerable quantities, from the urethra. The patient is unable to pass water, and any attempt to do so merely forces more urine into the tissues of the perineum, and gives i)ain. On trying to pass a catheter some obstruction is generally met with, and will often prove insur- mountable ; but if the catheter is finally passed, clear urine will escape. These signs distinguish it from ruptured bladder, in which injury the catheter passes easily, but as a rule (although the bladder is said to have been full at the time of the injury) only a little urine flows. In mere bruising and ecchymosis of the perineum the catheter will pass easily, and there is, as a rule, no escape of blood from the urethra. IVcatment. — A soft catheter should be passed if possible ; if not, a gum elastic or a silver one, and in any case tied in. Fail- ing to pass a catheter and extravasation of urine in any (piantity FOREIGN BODIES IN THE KECTUM. 399 having already occurred, a silver catheter should be passed down to the obstruction, and a free incision through the middle line of the perineum made on its point. If the proximal end of the torn urethra can now be found, the catheter should be passed through it into the bladder and tied in. If now readily discovered, a prolonged search for it need not be made, as with a free incision through the perineum there is no danger of further extravasation of urine. If the urethra is found only partially torn across, an attempt should be made to bring the edges together by suture over a catheter, the external v/ound in the perineum being then united by deep sutures. The catheter should be kept in for a week. In a recently inflicted injury, in which the urethra was pulped from the scrotum to the prostate, Mr. Barnes, of Welwyn, succeeded in this way in establishing a new urethra, the wound healing by the first intention. There was no subsequent trouble. This procedure is attended, however, with some risk of extravasa- tion, and could hardly be done where extravasation had already occurred, on account of the softened condition of the tissues. Should a fragment of the pubic arch be found compressing the urethra, steps must be taken to remove it, the bladder in the meantime being aspirated above the pubes to prevent further ex- travasation occurring. When the wound in the perineum is left to granulate in the ordinary way a silver catheter, as the point of this is more under control than that of a soft one, should be passed daily during the healing of the wound, and the patient en- joined subsequently to pass one for himself at frequent intervals, and warned that if he neglects to do so a stricture will gradually form. Injuries of the rectum occasionally occur from falls upon a sharp-pointed body, or incautious attempts to pass a long enema- tube or bougie. Should the peritoneal cavity be perforated, death is the almost invariable consequence, especially if any in- jection has been thrown into the peritoneum before the mistake is discovered. Treatment. — Opening the abdomen, flushing out the peritoneum, and sewing up the rent in the gut, holds out the only chance of escape. Foreign bodies in the rectum. — Foreign bodies of the most various description have at times been accidentally or intention- ally introduced into the rectum. Fish-bones that have been swallowed not infrequently become impacted just within the anus, there giving rise to much irritation or pain, and often causing an ischio-rectal abscess. The removal of some of these bodies, when of large size, is frequently attended with considerable difficulty, requiring an anaesthetic, dilatation of the sphincter, and the use of various forceps, or even the passage of the whole hand. In a 40P INJURIES OF REGIONS. case recently under the care of Mr. Willett, the foreign body, a Liebig's meat jar, could not be removed till the peritoneal cavity had been opened and the jar forced down by the hand. Injuries of the pudenda. — Contusions and wounds of all kinds may be met with, and require no special remark further than : — that ecchymosis of the loose cellular tissue is often extensive ; that wounds, though apt to be attended with considerable haemor- rhage from the great vascularity of the parts, on this account also heal very readily ; and that serious consequences from such in- juries are exceedingly rare. H/EMATOMA OF THE LABIA MAjORA sometimcs occurs from injury, especially during pregnancy or parturition, the parts being con- gested at those times. The tumor may attain a large size, owing to the laxity of the tissues. The blood generally becomes ab- sorbed, but suppuration may occur or the blood become encysted. The application of ice will generally control the haemorrhage. A hsematoma should on no account be opened unless suppuration takes place, when a free incision will be required. Wounds of the vagina perhaps more frequently fall under the care of the obstetrician than of the surgeon. The surgeon, how- ever, may be called upon to arrest haemorrhage from this canal, consequent upon laceration inflicted by falling upon some sharp object, or the introduction of a foreign body. Washing out, the application of ice, or, if necessary, careful plugging with antiseptic gauze, or cotton-wood soaked in perchloride of iron, will usually suffice. Perforation of the walls of the vagina, with injury of the bladder, peritoneum, or intestines, is the occasional result of wounds of the vagina, and is usually fatal. The vagina should be washed out and the wound plugged with strips of iodoform gauze. Foreign bodies in the vagina. — Pessaries that have been in- troduced and forgotten by the patient, or possibly without her knowledge, are the foreign bodies most frequently found in the vagina, but various other articles have at times been met with. Their long retention here is often productive of a foul-smelling discharge, and may lead to the perforation of the walls of the rectuni or bladder and an incurable fistula. FoRElCiN bodies in THE FEMALE URETHRA AND BLADDER. Hair- pins introduced with the bent end forwards, are not infrequently pushed up the urethra into the bladder, where, if allowed to re- main, they become encrusted with phosphates, and give rise to symptoms of stone. The urethra should be dilated, and the sharp ends of the hair-i)in grasped by forceps, snared in a tube, or in some such way removed. RupiUKED I'EKiNKUM Occasionally occurs during first, and RUPTURED PERINEUM. 401 especially instrumental labors. There may be a mere rent in the fourchette ; or the rupture may extend from the vagina through the sphincter ani into the rectum, and involve more or less of the recto-vaginal septum. Symptoms. — A rupture, when slight, gives rise to no special trouble ; but when more extensive, there may be some prolapse of the posterior wall of the vagina with the contiguous wall of the rectum {recfocele), or of the anterior wall of the vagina and the part of the bladder in contact with it {vesicocele), and, perhaps some prolapse of the uterus. There may also be frequent micturi- tion, and when the sphincter ani is involved, occasional inconti- nence of fccces. Treatment — An attempt to unite the parts should always be made immediately after the rup- ture by introducing several wire or silkworm-gut sutures. Should this fail, no harm will have been done, and a plastic operation can be subsequently performed. Such, however, should not be undertaken until the vaginal dis- charge has ceased, the child been weaned, and the general health Restored. The patient in the meantime should not be allowed to walk about, for fear of a prolapse of the parts. The operation consists in refreshing the sides of the rupture, and uniting them by suture. The bowels having been cleared by an aperient, and the rectum on the morning of the operation by an enema, the patient should be placed in the lithotomy position, and the skin dissected off from the sides of the fissure, and the mucous membrane from the recto- vaginal septum, so as to leave a raw surface of the size and shape shown in Fig. 152. The skin and mucous membrane should not be cut away as shown in the figure, but reflected towards the vagina. Care should be taken that the tissues are clean cut, and that the raw surface of the recto-vaginal septum is at least an inch broad, so that immediate and firm union when the parts are brought together may be obtained. Three or more deep sutures, consisting of thick silver wire, strong silkworm-gut, or China 17* Operation for ruptured perineum. 402 INJURIES OF REGIONS. twist, should be introduced by means of a perineal needle. The first should be passed about an inch from the margin of the rup- ture deeply through the recto-vagmal septum, and out at the corresponding spot on the opposite side. The next two sutures should be passed in the same way, only not through the septum. Fig. 152 shows the appearance presented by the sutures when in situ and ready for tying. They may be fastened over a piece of quill or by split shot, or simply tied, the posterior suture being first secured. Superficial sutures, after the fissure has been drawn together by the deep, should be used to keep the edges of the skin in contact. If there appears to be any tension, "incisions of relief " may be made through the skin on either side. There are many modifications of this operation,' but for the sake of clearness only the most simple method has been here described. The bowels must be kept confined for a week, and the bladder for the same period emptied by the catheter. The patient should lie perfectly quiet on her back with the legs tied together, and the knees over a pillow. The deep sutures should be removed at the end of a week, the parts in the meanwhile being kept clean by gentle syringing with an antiseptic lotion. The bowels should be opened by an enema at the end of a week or ten days, and the patient should keep her bed for at least three weeks. Where the posterior or anterior wall of the vagina is much prolapsed, a wedge-shaped piece of mucous membrane may be remoVed, and the edges of the incision brought together by suture. Injuries of the scrotum and tesiicle. — Wounds of the scrotum and penis are rare. They readily heal in consequence of their abundant blood-supply. Contused wounds of the scrotum are often attended with much extravasation of blood, giving the parts a black and swollen appearance, and are apt to be followed by sloughing. Sh'uild such threaten, free incisions must be made. Extravasation of blood into the tunica vaginalis {iucniiitoccle), and inflammation of the testicle {orchitis), both of which- may follow a blow or other injury of the parts, are described under Diseases of the Testicle. Ligature of the penis. — A piece of string is sometimes tied round the penis by children, either in play, or to prevent them- selves wetting the bed. Great swellmg in front of the constriction ensues, and if the cause is not recognized and removed, the string will soon cut deeply into the penis, and may even divide the urethra. FcjREIGN I5f)DIES IN THE MALE URE'IHRA AND ni.ADDI'.K. — PicCCS of slate pencil, beads, and the like, are sometimes passed by boys into their urethra, and not infrcciuently a piece of wax bougie, or damaged gum-elastic or black catheter, is broken off during WOUNDS OF THE PALM. 4O3 catheterization. An attempt should be made to remove the foreign body by manipulation with the fingers, or by the intro- duction of various urethral forceps, or by asking the patient to first close the meatus with the finger and thumb, to make a forci- ble attempt to pass water, and then suddenly to relax his hold. If the forceps are used the urethra should be grasped, if practi- cable, behind the foreign body, lest the latter be pushed back into the bladder. Failing to remove the body by any of these means, it may be pushed back into the bladder, broken up by a lithotrite, and removed by the evacuator, or, if soft, grasped with the lithotrite and removed whole. If it cannot be pushed into the bladder, it must be cut down upon and extracted through an in- cision in the middle fine of the urethra. A pin introduced head first may have the point thrust out through the skin up to the head. The head can thus be reversed, and may so be pushed out through the urethra. Foreign bodies in the bladder, if allowed to remain, become encrusted with phosphates, and give rise to symptoms of stone (see Stone in the Bladder) . INJURIES OF THE UPPEK EXTREMITY. Bruises, contusions, burns, scalds, and frost-bites of the upper extremity require no special remarks. Sprains of the joints of the upper extremity, especially of the wrist, are very common. Rest, the application of cold, and in the case of the thumb, wrist, or elbow, a wet bandage followed by friction with a stimulating liniment, is the usual treatment. A sprain, however slight, should never be neglected, as inflamma- tion in or around the joint may ensue, leading to fibrous anky- losis, adhesion of the tendons to their sheaths, etc. See Sprains, p. 186. Sprains of the muscles, causing tenderness, slight swelling, and pain on movement, are not infrequently met with after hard rowing or other excessive exercise. Rupture of muscles and tendons, especially the pectoralis major, the rectus femoris, and the long tendon of the biceps, are not uncommon accidents. The last may occur during any sud- den involuntary action, and may be known by sudden pain, loss of power, and a gap in the course of the long tendon, whilst the inner head, on putting the muscle into action, forms a prominent lump. Little or nothing can be done in the way of treatment. Wounds of all kinds are very common. Wounds of the palm only need special comment. Wounds of the palm are frequently attended with severe and troublesome haemorrhage from either the superficial or deep arch. 404 INJURIES OF REGIONS. When the wound is clean cut the bleeding vessel may be tied in the usual way ; but when the wound is of a punctured character such an attempt would inflict severe injury on the tendons and nerves in the palm. A graduated compress in this case should be put on, the hand bandaged over an ordinary roller, pressure ap- plied to the ulnar and radial arteries at the wrist, and the fore- arm flexed forcibly on the arm to control the flow of blood through the brachial artery. The compress should be kept on for about a week. If this fails, or if the patient is not seen until the palm has become infiltrated and sloughy, the brachial artery should be tied. The anastomosis through the interosseous and carpal arteries is so free that ligature of the radial and ulnar is not, as a rule, sufficient to stop the bleeding. Needle in the palm. — It is not infrequent for a needle to run into the hand and be broken off. If it can be felt it should be cautiously cut down upon and extracted with forceps, care being taken not to push it in further, and so lose it in the attempt. If it cannot be felt, an exploratory incision should on no account be made, as the needle will probably do no harm in the tissues, and in course of time will work its way to the surface, whilst a search for it may be attended with irreparable damage. A galvanometer has occasionally been used for its discovery with success. In smashes of the hand requiring operative interference, the thumb and as many fingers — indeed as much of the hand — as possible, should be saved. Dislocations of the Upper Extremity. Dislocations of the clavicle. — I. The sternal end may be dis- located, I, forward ; 2, upwards ; and, 3, backwards. Cause. — The forward and the upward dislocations are produced by in- direct violence, such as a blow or fall upon the front or top of the shoulder ; the backward vari- ety either directly by force ap- plied to the sternal end, or indi- rectly by a blow or fall on the back of the shoulder. Displace- ment. — In the forward disloca- tion the end of the bone lies in front of the sternum, in the up- ward it lies in the suprasternal notch touching the opposite clavicle, in the backward between the sternum and the trachea. Signs. — In the forward dislocation (I'ig. 153) the end of the bone Fig. Dislocation of the sternal end of the clavicle forwards. (Bryant's .Surgery.) DISLOCATION OF THE CLAVICLE. 405 can be felt in its abnormal situation, and can be distinguished from fracture near the sternal end by the length of the clavicle being the same on the two sides, and by the absence of crepitus. The upward variety, which is very rare, may be diagnosed in the same way. In the backward, which is also rare, there is a de- pression at the situation of the sterno-clavicular joint, and there may be dyspnoea, dysphagia, or congestion of the head and face from pressure on the trachea, oesophagus, or veins of the neck. Treattneiit. — The forward and the backward dislocations can gen- erally be readily reduced by simply drawing back the shoulders, the icnee, if necessary, being placed between the scapulae. In the forward variety, indeed, I have always found the end of the clavicle sink into its place on laying the patient on his back. Reduction of the backward variety has at times been impossible, and excision of the end of the bone has been necessary for the rehef of the severe dyspnoea which it has caused by its pressure on the trachea. The upward dislocation may be reduced by placing a pad in the axilla to act as a fulcrum and pressing the arm to the side, thus drawing the clavicle outwards. Direct pressure should at the same time be apphed to the displaced end. All forms are difficult to retain in position. The best plan, perhaps, is to keep the patient constantly on his back for three weeks. If, however, he will not consent to this restraint, an endeavor may be made to retain the parts in as good a position as possible by one of the many methods of bandaging described in the larger text-books. I do not mention any here, as I have never seen any of them of any avail. II. The acromial end may be dislocated either, i, upwards; or, 2, downwards. Both forms are rare, but the upward is the least so. These injuries are sometimes spoken of as dislocations of the scapula. Cause. — Commonly direct violence applied to the acromion. The signs are usually obvious. There is apparent lengthening of the arm with depression and slight flattening of the shoulder, and a projection in the region of the acromio-clavicular joint caused, in the upward form, by the acromial end of the clavicle, and in the downward by the acromion process. In the upward variety, moreover, the end of the trapezius stands out as a prominent ridge, and on pressing with one hand on the shoul- der and with the other on the elbow the articular surfaces are brought into apposition and pseudo-crepitus can be obtained. Reduction is, as a rule, easily effected by drawing the shoulders well backwards ; but it is difficult to retain the bones in position in consequence of the peculiar obliquity of the articulation. This may be attempted by placing a pad over the joint and applying a strap or a bandage over the shoulder and under the elbow, and 406 INJURIES OF REGIONS. then bandaging the arm to the side. I have seen the best results from rest in the horizontal position for three weeks ; few patients, however, will submit to this, nor is it possibly worth their while to do so, as little inconvenience attends the dislocation, though un- reduced. Dislocation of ihe shoulder is very common, a fact explained by the shallowness of the glenoid cavity, the large size and rounded shape of the head of the bone, the looseness of the cap- sule, and the powerful leverage exerted on the joint by the arm in protecting the body in falls, etc. It is most frequent in the old and middle-aged, rare in the young, and more common in men than in women. Cause. — Falls or blows directly upon the shoulder ; falls on the elbow or hand with the arm extended ; forcible twists of the arm ; and occasionally muscular action. Varieties. — Dislocations of the shoulder may be classified ac- cording to the position of the head of the humerus into — i, for- ward and slightly downwards {si/dcoracoid) ; 2, downwards and slightly forwards {subglenoid) ; 3, backwards {subspinous) ; and 4, forwards {subclavicular) (Figs. 154, 155, 156, and 157). An upward dislocation {subacromial) has been described, but this form of displacement is more generally believed to be the result of chronic osteo-arthritis. Other and rarer varieties have also been described, but appear to be merely modifications of those above enumerated. The signs common to all the varieties in addition to the ordi- nary signs of dislocation, viz., pain, swelling, immobility, and absence of crepitus, are — i, flattening of the shoulder ; 2, promi- nence of the acromion ; 3, a depression beneath the acromion, increased when the arm is raised ; 4, a change in direction of the axis of the humerus ; and 5, the absence of the head of the bone from the glenoid cavity, and its presence in an abnormal situation. In doubtful cases the following tests will be found of use: — i, Hamilton'' s test. A straight edge applied to the outer side of the arm, can only be made to touch the acromion and external con- dyle at the same time when the head of the humerus is absent from the glenoid cavity; 2, Calla7vafs test. A tape passed round the acromion and under the axilla will measure about two inches more on the dislocated than on the sound side ; 3, Dugas's test. With the hand placed on the opposite shoulder, the elbow in a dislocation cannot be made to touch the chest. Occasionally a dislocation is complicated by a fracture, and an accurate diag- nosis may be rendered very difficult. In such, and in all cases where there is any doubt, the patient should be examined under an anaesthetic. DISLOCATION OF THE SHOULDER. 407 The sitbcoracoid. — This is the most frequent variety of disloca- tion of the shoulder (Fig. 154)- The head rests on the anterior surface of the neck of the scapula, just below the coracoid pro- cess, the groove between the head and greater tuberosity resting on the anterior margin of th-e glenoid cavity. The capsular liga- FlG. Fig. 153. tSu7)-ccj-acccd Fig. 156. Fig. 157. Sui-sp incus jSuf? - , rlavicular Various forms of dislocalion of the humerus.' (Professor Flower's models.) -ment is lacerated, anteriorly and inferiorly, or detached from the margin of the glenoid cavity in front and below. The subscapu- laris is generally raised by the head of the bone from the scapula, and the supraspinatus, infraspinatus, and teres minor are tightly stretched. Sometimes the muscles are torn across at their inser- 4o8 INJURIES OF REGIONS. tion, or the greater tuberosity is detached, the muscles remaining entire. Under these circumstances the head of the bone rolls inwards so that more of it is internal to the coracoid process, a condition described b}' Malgaigne as a distinct variety {intracora- coid). The long head of the biceps is generally uninjured, whilst the short head and the coraco-brachiahs and the axillary artery and brachial plexus are displaced inwards by the head of the bone. Special signs. — The head of the bone can be seen and felt in its abnormal situation. The elbow projects slightly back- wards and away from the side. The arm is generally shortened or unaltered in length ; occasionally it is said to be lengthened. The truth appears to be that there are all grades between the subcoracoid as here described, in which there is undoubted shortening, and the next form, the subglenoid, in which length- ening as undoubtedly occurs. The subglenoid is the next most common variety. The head rests on the inner aspect of the inferior border of the scapula, be- low and a little in front of the glenoid cavity (Fig. 155). The capsular ligament is ruptured below. The supraspinatus, in- fraspinatus, teres minor, and subscapularis, may or may not be torn. The circumflex nerve is especially liable to be compressed, producing temporary or even permanent paralysis of the deltoid. The signs are similar to those of the subcoracoid, but there is greater flattening of the shoulder, more' prominence of the acromion, and a more marked depression under it, and the elbow points neither backwards nor forwards. The diagnostic marks are: — i, great depression of the anterior fold of the axilla; 2, presence of the head of the bone in the axilla ; 3, lengthening of the arm ; 4, an interval of from one to two inches between the coracoid process and the head of the bone. The subspinous. — This variety is rare. The head rests on the dorsum of the scapula beneath the spine (Fig. 156). The capsular ligament may or may not be ruptured. The infraspi- natus is generally torn up from the bone, and the subscapularis and supraspinatus are either stretched or ruptured, according to the amount of displacement. The teres minor is relaxed, and the long tendon of the biceps stretched or displaced from its groove. Special signs. — There is great flattening of the shoulder ; the elbow points forwards ; -the forearm is in front of the chest in consequence of the inward rotation of the humerus, and the head of the bone can be felt in its abnormal situation, but not in the axilla. The subclavicular is very rare. The head rests beneath the clavicle, internal to the coracoid process (Fig. 157). The capsule is generally extensively lacerated at its inner side. The pectoral • DISLOCATION OF THE SHOULDER. 409 muscles are raised by the head of the bone, which rests on or be- tween the fibres of the subscapularis. The latter muscle is torn up from the subscapular fossa, but retains its connection to the humerus. The supraspinatus and infraspinatus are generally torn, or detached from the humerus, but may retain their' connection to the capsular ligament. The teres minor is not torn. Special sig?is. — The head of the bone forms a distinct prominence below the clavicle, and the shaft only can be felt in the axilla. The arm is pressed tightly to the chest and the elbow projects back- wards. Diagnosis. — A dislocation of the shoulder may have to be diagnosed from a fracture of the neck of the humerus, separation of the upper epiphysis, fracture of the neck of the scapula, fracture of the glenoid cavity, and from simple sprains and contusions of the joint attended with more or less paralysis of the deltoid. At- tention to the general and special signs of dislocation as above given, together with the absence of crepitus and other signs of fracture, will generally make the diagnosis easy ; but where the patient is very muscular, or there is much swelling, or manipula- tion causes excessive pain, an anaesthetic should be given, and a thorough examination made. It should not be forgotten that crepitus may be simulated by effusion into the joint and sheaths of the surrounding tendons. True bony crepitus having been once felt, however, can hardly be mistaken for this. Treatment. — The difficulty in reducing a recent dislocation consists in i. Overcoming muscular contraction, and 2. Re-intro- ducing the head of the bone through the hole in the capsule. In long-standing cases there are additional impediments to reduc- tion, viz., 3. The formation of adhesions around the joint; 4. Alteration in the shape of the head of the bone, and 5. The ob- literation of the old cavity. Manipulation should first be tried, if necessary, under an anaesthetic, and if this fails, extension should be made with the knee or heel in the axilla, and finally with the pulleys. In some long-standing cases where the above methods have failed, reduction by open incision may be advisable, i. Manipulation. — Many methods have been devised, some of which are not unattended with danger, as the axillary artery has been torn or ruptured in their use. The following method is now gen- erally employed at St. Bartholomew's, and has been attended with excellent success. Place the patient in the horizontal position ; flex the elbow ; rotate the humerus outwards as far as possible without using excessive force, then carry the elbow across the chest, at the same time rotating the humerus inwards. Another method consists in slowly abducting the arm to the level of the shoulder or above. 2. Extension (Fig. 158). — Place the patient 18 4IO INJL'RIES OF REGIONS. on his back ; seat yourself on the edge of the couch ; draw the arm sliglitly from the side ; place your heel without your boot well in the axilla, and grasping the wrist, make steady extension Reduction by the heel in the axilla. (Cooper's Dislocations.) Fig. on the arm, whilst the heel fixes the scapula and presses the head of the bone outwards. The head of the bone will probably be felt after a few minutes to shp into its place with an audible snap. Should it not do so, secure a jack-towel with a clove- hitch (Fig. 159) to the arm, and increase the extending force by getting an assistant to pull on it with you at the same time. The di- rection of the force may be slightly varied from time to time, and the humerus gently rotated. Where extension with the heel in the axilla fails, slowly carry the arm to a right angle with the body and extend, or raise it above the head, and again extend in this position. If still misuccessful, an anaes- thetic should be given, and the bone, on again trying manipula- tion or extension, will probably slip back quite easily into place. 3. Extension with the pulleys. — In long-standing cases the use of the pulleys may be required. First break down any adhesions that may be present, by cautiously manipulating the arm ; then fix the scafiiila by a well-jjadded leather strap passed under the axilla and secured to a staple in the wall. Attach the pulleys to a leather band buckled round the arm, and make steady extension, man- 'J'hc clove- DISLOCATION OF THE SHOULDER. 411 ipulating the head of the bone the while. The extension and counter-extension should always be made in the same horizontal line. This may be first in the direction of the axis of the body, then across the body, with the arm at right angles to it (Fig. 160). Occasionally success may be obtained by suddenly relax- ing the extension after it has been applied for a few minutes, endeavoring at the same moment to manipulate the head into its Fig 160. Reduction with the pulleys. The patient, though here shown pitting, should as a rule be placed in the recumbent posture, as an anaesthetic is generally required. (Cooper's Dis- locations.) place. Although the direction of the force appears to vary in the different methods of extension, it is probable that in consequence of the mobility of the scapula, it is nearly always applied perpen- dicularly to the plane of the glenoid cavity. Afier-ireatmcut. — A pad should be placed in the axilla and the arm carefully bandaged to the side with the fore-arm across the chest, and the hand on the opposite shoulder. Passive move- ments of the joint should be begun about the end of a week and practised once or twice daily ; but the arm should be bandaged to the chest in the intervals for upwards of three weeks, and sub- sequently used with great caution for several months to prevent re-dislocation. 412 . INJURIES OF REGIONS. Occasional ill-effects following a dislocation of the shoulder. — i. Inflammation or suppuration of the joint and ankylosis ; 2. Paraly- sis of the deltoid or other muscles ; 3. Axillary abscess ; 4. Non- union of the rent in the capsule and a consequent tendency to re-dislocation on very slight violence. How long after a dislocation of the shoulder has occurred does it admit of reduction ? Sir Astley Cooper fixed the limit at three months, but cases are reported in which it is said to have been accomplished two years after the accident. It should be re- membered, however, that as in unreduced dislocations a new cavity is gradually formed for the head of the bone whilst the old cavity is filled up, reduction sooner or later becomes a physical i;r,poisibility. Still, where the arm is very stiff, although reduc- tion may not be accomplished, the range of motion in the false joint may be considerably improved by the attempt. On the other hand, where the motion is fairly free, the injury inflicted in an attempt at reduction may counterbalance any advantage gained. Risks that may attend reduction of long-standing cases. — i. Rupture of the axillary artery or vein ; 2. Injury of the brachial plexus of nerves ; 3. Fracture of the neck of the humerus ; 4. Fracture of the ribs; 5. Tearing open of the axilla; and 6. Evul- sion of the arm. 4. Reduction by open incision. — This method has been recently employed for long standing cases where cautious attempts at reduction by manipulation and extension have failed. The ad- vantages claimed for it are: — i. That the reduction can be accomplished without subjecting the patient to the dangers men- tioned above, and 2. That it is applicable at periods later than those at which reduction by manipulation or by extension can be accomplished without undue risk. An incision is made down to the head of the bone between the pectoralis major and deltoid muscles, and the subscapularis muscle detached from its insertion into the lesser tuberosity. The long head of the biceps should be preserved, as in excision of the joint. If the bone cannot now be manipulated or prized by an elevator into position, the attach- ments of the external rotators (the suprasi)inatus, infraspinatus and teres minor) are in like manner detached from the greater tuberosity. The head will now probably return into its socket, unless the time that has elapsed has been sufiicient for it to have been partly absorbed and the glenoid cavity filled up. When, however, the head cannot be replaced, it may be excised. Passive movements ought to be begun as soon as the wound has healed. Treatment of compound dislocation of the shoulder. — When the wound is small, the head of the bone uninjured, and the soft parts DISLOCATION OF THE ELBOW. 413 are neither much lacerated nor bruised, an attempt should be made to reduce the dislocation. If successful, the case may then be treated as a wound of the joint. When the head of the bone is much injured, it may be excised ; whilst in severe and complicated cases, amputation at the shoulder-joint may become necessary. The treatment of dislocation with fracture is often attended with much difficulty. As a rule the fracture if possible should be set, the arm placed in splints, and an attempt then made to reduce the dislocation. Failing in this, the separated head may some- times be manipulated into its socket ; otherwise, splints should be applied, and when the fracture has united, another trial made to reduce the dislocation. , Dislocation of the elbow is most frequent in the young. Cause. — Direct violence, or a fall on, or wrench of, the forearm or hand. — Varieties. — A. Both bones (radius and ulna) : i, back- wards ; 2, inwards ; 3, outwards ; 4, forwards ; and 5, radius for- wards, and ulna backwards. B. Radius only : i, forwards ; 2, back- ^^'^- '^^'^• wards; and 3, outwards. C. Ulna ^«/j'.- I, backwards. Of these, the dislocations of both bones back- wards and of the radius forwards or backwards are the only com- mon forms ; the others are very rare, and will receive but a passing ... , , , , , , , Dislocation of the radius and ulna back- nOtlCe. ward;. (Cooper's Dislocations.) Signs. — In the common form of doth bones backwai-ds (Fig. 161), the radius and ulna are dis- placed directly backwards, so that the coronoid process of the ulna rests in the olecranon fossa, and the neck of the radius on the capitellum of the humerus. The coronoid process is often fractured at the same time. The bones are frequently displaced slightly outwards, or inwards, as well as backwards — modifi;cations which have been unnecessarily classed as distinct varieties. The forearm is partially flexed and shortened. The olecranon and head of the radius form an unnatural prominence posteriorly, and are felt at a considerable distance behind the external and internal condyles respectively. The lower end of the humerus forms a broad projection below the crease of the bend of the elbovi^. In the rarer forms oi both bones inwards ox outtvards \.\\t. prominence of the opposite condyle of the humerus on one or other side is a characteristic feature. In both bones forwards (exceedingly rare) the forearm is lengthened, the natural prominence of the olecranon is lost, and the condyles of the humerus are very prominent. In the ulna backwards and the radius forwards the arm is greatly increased in its antero-posterior diameter. 414 INJURIES OF REGIONS. In dislocation of the radius alone, whether forwards, backwards, or outwards, the head of the bone is felt to roll in its abnormal situation, in front of, behind, or external to, the external condyle on pronating and supinatinfT the hand. The first of these forms (Fig. 162) is the most common, and in it the forearm cannot be flexed beyond a right angle, in consequence of the head of the bone striking the humerus. /// dislocation of the ulna backwards the forearm is pronated and shortened on the ulnar side, and the olecranon projects back- wards, but the head of the ndius is felt in its normal situation. Diagnosis. — In moderately thin subjects, when seen soon after the accident, attention to the above signs will generally enable the Surgeon to make a diagnosis.; but in a few hours the parts become so obscured by swelling about the joint, that it may be impossible to make out the nature of the injury till it has subsided. In all cases of injury of the elbow the relation of the points of bone to each other should be carefully compared with those of the uninjured side, and the relative position of the olecranon to the condyles should be determined {%&t Fracture of the lower end of the Humerus). Treatment. — The reduction of the common form of dislocation of both hones baclnvards is generally easily accomplished in recent cases by pressing with the knee in the bend of the elbow on the upper part of the radius and ulna to disengage the coronoid pro- cess, whilst forcibly but slowly flexing the forearm. As soon as the coronoid process is freed from the olecranon fossa, the muscles generally draw the bones suddenly into position. Pressure upon the humerus by the knee, as recommended by some, should be avoided, as it locks the coronoid process more tightly in the ole- cranon fossa. If necessary, an ana2->thetic should be given. In long-standing cases adhesiors mu.-t be broken down by forcibly flexing and extending the forearm, and extension may then be made either by the knee, or by an assiotant pulling on the wrist, or if this is insufficient, bv the p'lUevs. Six weeks is the period usually given as the time beyond which it is inexpedient to try and reduce the dislocation. This r"h% however, admits of some lati- tude. Thus, an attempt at reduction, when the movement is fairly good, even after less time has elapsed, may be unwise ; while, on Dislocation of the radius lorwartls. DISLOCATION OF THE WRIST. 415 the other hand, it may sometimes be made with advantage, espe- cially where there is much rigidity, even at a later period. In dis- location of the radius alone, extension should be made from the hand (so as to act solely on the radius), whilst the elbow-joint is grasped, and the head of the radius pressed into position by the thumb in a backward or forward or inward direction, according to the variety of the dislocation. In the other dislocations slight modifications of these methods are required, and will be suggested by a knowledge of the anatomy of the joint, a.nd a correct diag- nosis of the nature of the displacement. Afte7'-7reatment. — The joint should be placed on an inside angular splint and the arm in a sling, and evaporating lotions or ice applied to prevent inflammation. Passive movements should be cautiously begun about ten days or a fortnight after the injury. Complications. — i, Fracture of {a) the coronoid process ; (l?) the olecranon; (r) the neck of the radius ; {d) the lower end of the humerus ; and {e) the condyles of the humerus ; 2, separation of the lower epiphysis of the humerus ; 3, wound of the joint ; 4, laceration of the main artery ; and 5, injury of the ulnar or other nerve. Treatment of compound dislocation of the elbow. — When the patient is young, the wound small, the laceration and bruising of the soft parts but sHght, and the bones are uninjured, the disloca- tion should be reduced, and the case treated as a wound of the joint. Otherwise excision of the joint, or, in severe cases, ampu- tation, must be practiced. Dislocation of the wrist is very rare. The carpus with the hand may be displaced either backwards or forwards. In the dis- location backwards, which is the more common variety, the carpus forms a projection on the dorsal surface of the wrist, whilst the ends of the radius and ulna project on the palmar surface. It resembles Colles' fracture, which was formerly confused with it. In the dislocation the styloid processes of the radius and ulna are on the normal level, and are nearer the knuckles than is natural, and there is no crepitus. Treatment. — Reduction is easily affected by making extension on the hand and pressing upon the displaced bones. The forearm and hand should then be secured to a splint, and passive movements begun early to prevent stiffness. Dislocation of the lower end of the radius from the ulna may be produced by a violent twist of the hand. When the twist is in the direction of pronation, the radius is displaced for- wards ; when of supination, backwards. The former is the more common. The hand accompanies the radius, and the styloid process of the ulna projects prominently in the opposite direction, and has been sometimes forced through the skin. Treatment. — 4i6 INJURIES OF REGIONS. Fig. 163. Whilst making extension from the hand, manipulate the bone into position and retain it there by a compress and splint. Dislocations of the carpal and imeiacarpal bones are very rare. Their diagnosis is usually obvious. The pJia/aiigts of the fingers may be dislocated backwards or forwards. Reduction is easily effected by extension and manipu- lation. Dislocation of the metacarpal hone of the thumb from the trapezium may occur in a backward or forward direction, and is easily reduced by extension or pressure. Dislocation of the first phalanx of the thumb from the meta- carpal bone is of more importance. The phalanx is nearly always displaced backwards ; the shortening of the thumb and the projections of the base of the phalanx and head of the metacarpal bone serve for its diagnosis. Reduc- tion is often very difficult ; this is usually ascribed to the head of the metacarpal bone being forced between the two insertions of the flexor brevis pollicis by which its neck is tigthly embraced. (Fig. 163.) Sir George Humphry, however, has shown that the hindrance to reduction depends upon the fact that the sesamoid bones and the ligaments connecting them are carried back with the phalanx, and being held there by the flexor brevis and intervening between the metacarpal bone and the phalanx, prevent the articular surfaces of the bones being brought into contact. Treatment. — Press the meta- carpal bone well into the palm of the hand to relax the flexor brevis polhcis, and bend back the first phalanx on the metacarpal bone until the extremity of the thumb points towards the wrist, thus forcing the base of the phalanx wedge-wise between the two insertions of the short flexor. Next flex the phalanx while an as- sistant, by placing his thumb behind its base, prevents its slipping back. The head of the metacarpal bone will now prol)ably slide into its place between the two insertions of the flexor brevis pollicis, which are forced apart by the wedge-like action of the base of the i)halanx. Reduction may sometimes be accomplished by extension, e. g., by the clove-hitch, or, if at hand, by the Indian puzzle-toy or the American forceps — a method, however, less scientific than that of manipulation, and one which seldom Dislocation of the thumb back- wards at the mttacarpo-phalan- geal joint. lAfter .Agnew.) FRACTURES OF THE CLAVICLE. 417 succeeds if the other fails. These means not proving successful, it is usually advised that the insertion of the flexor brevis pollicis should be subcutaneously divided. Sir George Humphry, how- ever, recommends an incision over the sesamoid bones and the introduction of a hook to hitch the sesamoid bones over the head of the metacarpal. In this way, he says, the reduction is imme- diately effected. As a last resource, the joint may be cut down upon, the bands resisting reduction divided and the bone replaced ; or the joint may be excised, or perhaps better, left alone, as very fair movement will, as a rule, in time be gained. Fractures of the Upper Extremity, Fractures of the clavicle are divided into fractures of — i, the shaft; 2, the ac7'omial end,.anA 3, the sternal end. I. The Shaft may be fractured by direct violence, or, as is more commonly the case, by indirect violence, such as a fall upon the arm or shoulder ; more rarely by muscular action. Situatiojis. — When the result of indirect violence or muscular action, the bone is generally broken near its centre — its weakest part. When due to direct violence, the bone will break wherever the force is ap- plied. Nature of the displacement. — The inner fragment, although it appears raised in consequence of the depression of the outer, is not displaced, being held in position by the sterno-mastoid and the rhomboid ligament ; the outer fragment is drawn downwards, forwards and inwards by the weight of the arm and the contrac- tion of the pectoral muscles. The signs in an adult are usually very evident. The inner fragment projects prominently under the skin ; the shoulder droops forwards and down- ^"^- ^^4- wards ; the patient usually supports his elbow with the sound hand whilst he in- clines his head to the frac- tured side to relax the sternomastoid. In a fat "^ g^gj^^H ^'■^'^'"'■^ °^ ^^^ clavicle. (Holmes' child, however, especially when the fracture is of the greenstick variety (Fig. 164) which it often is in children, the signs are less evident ; indeed surgical aid is often not sought until the mother's attention is called to the part by the presence of a lump formed by the ensheathing callus. Union generally occurs in about three weeks in children and five in adults. Treatment. — The fracture is easily reduced by draw- ing back the shoulders, or by placing the patient in the recumbent posture ; but it is very difficult to maintain the fragments in ap- 4i8 INJURIES OF REGIONS. position. Hence the numerous bandages and apparatus that have been from time to time employed. Where it is important to avoid deformity, rest on the back for a fortnight is essential ; otherwise the patient may be allowed to get about with his arm bandaged to the side, and the parts kept as much as possible in apposition by bandaging or strapping. Of the many plans the following may be tried : I. Sayre's me/hod. — Take three pieces of adhesive strapping about three inches and a half wide, and long enough to surround the arm and afterwards the body. Stitch one piece, with the ad- hesive surface outside, loosely round the arm on the injured side Fig. 165. Fig. 167. Figs. 165, 166, 167. — Sayre's method of treating fractured clavicle. (After Agnew.) at the insertion of the deltoid muscle. Draw the arm forcibly backwards to put the clavicular portion of the pectoralis major on the stretch, and carry the strapping across the back and round the front of the thorax and sew the end to the part which crosses the back ( P'ig. 165), Fix one end of the second strip of ])laster to the sound shoulder ; carry it obliquely across the back beneath the elbow (which should be pushed forwards) of the injured side, a slit being made to receive the olecranon ; bring it upwards in front of the chest, and fasten it to its other end over the sound shoulder (Figs. 166 and 167). A third strip may be carried round the arm, forearm and thorax to keep the others in place. The first stri]) acts as a fulcrum ; whilst the second, by drawing the elbow forwards, forces the ujjper end of the humerus, with the THE SCAPULA. 419 clavicle, backwards, and at the same time keeps the shoulder raised. 2. Ellis^s metJiod consists briefly in the use of an axillary crutch supported by two straps, the one round the chest, the other passed over the sound shoulder. The chest strap also en- circles the arm and holds it firmly to the side. The forearm is further supported by a sling. 3. 77^1? axillary pad and ba7}dage. — Many surgeons simply place a wedge-shaped pad with the base upwards in the axilla, and then bandage the arm to the side with the elbow well raised. If the pad is used, care should be taken in bandaging lest the axillary vessels or nerves are compressed, and oedema, pain, or even gangrene of the arm be the consequence. II. Fraclure of the acro7?iial end of the clavicle may occur either at or external to the insertion of the coraco-clavicular hga- ments. In the former situation there is very little displacement, the fragments being held in position by the above-mentioned ligament!. Pain, crepitus, and possibly a sHght gap, will serve to distinguish it. When external to the ligaments, the outer frag- ment is drawn down nearly at a right angle to the rest of the bone, so that its acromial articulation looks inwards, forwards and slightly downwards. Ti-eatment. — An axillary pad and bandage, with a moulded leather shoulder-cap to protect the parts. III. Fracture of the sternal end is too rare to require descrip- tion in a book of this character. The scapula. — The fracture may extend through i, the body; 2, the neck; 3, the acromion ; 4, the coracoid process; and 5, the glenoid cavity. 1. Fracture of the body is nearly always caused by direct vio- lence. It may be star-shaped or transverse, or it may run vertically or obliquely through the spine ; but commonly it is limited to the infraspinous fossa, and frequently the angle is alone broken off. The displacement is not usually very marked, as the fragments are well covered with muscles. Signs. — On fixing the angle of the scapula with one hand, and raising the arm, crepitus and pain may be elicited. On running the fingers along the spine and down the posterior border, some irregularity may be detected when these parts are involved, and on grasping the bone the frag- ments may be felt to move on each other. Treatment. — Little can be done beyond confining the scapula by strapping and a bandage to the chest, and restraining the motions of the arm by bandaging it to the side. 2. Fracture of the neck. — By this is understood fracture through the surgical neck, /. egi//ar, in which both branches are ruptured. In the former the signs are constant, as the untorn branch of the Y ligament compels the bone to take a certain definite position. In the irregular the signs vary, as both branches of the Y being ruptured, the control which it exercises over the position of the bone is lost. Our attention here will only be directed to the regular dislocations. Of these 13igelow describes seven, the first four of which are commonly known as the classical dislocations of Sir Asiley Cooper. DISLOCATION OF THE HIP. — VARIETIES. 43^ cooper's CLASSIFICATION. BIGELOW's CLASSIFICATION. A. Regular. One or both branches of^ entire. Dislocation on to the dor- ) t-> i .,.. h = I- Dorsal sum ini j Dislocation into the sci- | ^ 2. Dorsal below the atic notch j tendon Dislocation into the ob- | ^ 3. Thyroid and down- \ turator foramen Dislocation on to pubes ] the 1^4. 5- 6. wards Pubic and spinous Anterior oblique sub- Both branches of Y entire. 1 Supraspinous j Outer \- branch of Everted dorsal Y ' ruptured. B. Irregular. Both branches ofi ruptured. 1. Dislocation on to the dorsum ilii {the dorsal of Bige low). — This is the most common form of dislocation of the hip. The head of the bone is thrown upwards and backwards on to the dorsum of the ilium, the articular surface of the head looking backwards, and the great trochanter forwards. The capsular ligament is generally ruptured at its lower and inner part, some- times posteriorly, and the lound ligament is usually torn. The Y ligament is uninjured, the external branch preventing eversion. The glutei muscles are raised from the ilium by the head of the bone, which is always situated above the tendon of the obturator internus. The other external rotators have been found variously lacerated or torn from their attachments. Signs (Fig. 175). — The limb is slightly flexed, adducted, rotated inwards, and short- ened, so that the lower end of the femur crosses the lower third of the opposite thigh, and the great toe rests on the instep of the opposite foot. The head of the bone, at least in thin subjects, can be felt in its abnormal situation on rotating the limb. The great trochanter is above a line drawn from the anterior superior iliac spine to the most prominent part of the tuberosity of the ischium {Nelaton's line) (Fig- i??) J s^id the distance from the top of the great trochanter to a line drawn horizontally round the pelvis on a level with the anterior superior iliac spines {Bryant's line) is less on the injured than on the sound side. 2. Dislocation into the sciatic notch {the dorsal beloiu the tendon 432 INJURIES OF REGIOKS. of Bige/otu). — The head of the bone escapes below the tendon of the obturator internus, and then ascends behind it on to the sur- face of the ihum just in front of the sciatic notch, or on the pyri- forniis as it emerges from the notch. The head looks backwards and the great trochanter for\vards, eversion being prevented by the outer branch of the Y ligament. The tendon of the obturator Fig. 175. Fic. 176. Dislocation on dorsum ilii. Dislocation into sciatic notch. (Cooper's Dislocations.) internus winds over the neck of the femur, and is therefore the great obstacle to reduction. The capsule is generally torn below, the round ligament ruptured, the gluteus maximus raised by the head of the bone, and one or more of the external rotators are usually torn. The Si^c^iis ( Kig. 176) are very similar to those of the former variety ; but the flexion, adduction, and rotation inwards are less pronounced. The lower end of the femur crosses the opposite knee, and the great toe rests on that of the opposite foot. Shortening with the limb extended is much less than in the former DISLOCATION OF THE HlP. — VARIETIES. 433 Fig. 177. A — B, Nelaton's line. variety; but with the limb flexed it is much greater. This is shown in the accompanying diagram (Fig. 178), and depends upon the fact that in the dislocation on to the dorsum ilii the head of the bone in extension lies above the acetabulum, and when flexed at a right angle to the body on the same level as the acetabulum ; whereas in the sciatic dislocation the head of the bone in extension is al- most on the same level as the acetabulum, but when flexed at a right angle to the body Hes considerably behind the acetabulum, 3. Dislocatio7i into the ob- turator foramen {the thyroid and doivnwards of Bigelow) . — The head is displaced down- wards on to the obturator ex- ternus, where it lies suspended by the Y ligament, and may remain either just below the acetabulum, or be carried sHghtly inwards towards the perineum, or outwards towards the tuberosity of the ischium. The head of the bone generally looks slightly inwards, and the trochanter outwards. The cap- sule and round liga- ment are ruptured, the former at its lower and inner part. The glutei, pyriformis, psoas and iliacus, ob- turator externus, pec- tineus, and the ad- ductor brevis are stretched or some- times torn. Signs (Fig. 179). — In the more common form, viz., that in which the head is displaced downwards and a little inwards, the limb is a.^'p^Lrcntly /engthened, 19 Sci.ntic dislocation of the left hip. n, shows slight shorten- ing in extended position of limb; 6, shows marked short- ening in fle.xed position. (After Dawson, ot Ohio.) 434 INJURIES OF REGIONS. due to the lowering of the pelvis on that side, but is really short- ened about half an inch or so. It is also abducted and slightly flexed, whilst the body is bent forwards to relax the psoas and iliacus, and as there is usually some external rotation, the toes point slightly outwards. The nearer the head of the bone ap- proaches the perineum the more plainly can it be felt, and the Fig. 179. Fig. 180. Uislocalion into obturator foramen. (Cooper's Dislocations.) Dislocation on the pubes. more eversion and abduction will there be ; conversely, the nearer it apj)roa(hes the tuberosity of the ischium, the greater its inver- sion and adduction ; whilst when it is disi)lacetl directly down- wards there will be neither eversion nor inver.^ion, adduction nor abduction, but marked flexion. 4. Dislocation on to tlie pubes {tlic pubic and subspinous of Bif:;e- iow). — 'J'he head of the l)one is thrown forwards and rests below Poupart's ligament, cither upon the ramus of the pubes {pubic) or DISLOCATION OF THE HIP. — VARIETIES. 435 upon the pectineal eminence just in front of the anterior inferior spine {subspinous). The head looks forwards and the trochanter backwards. The capsule is generally torn below, and the round ligament ruptured. The Y ligament is entire and produces the eversion of the limb characteristic of this variety. The psoas and iliacus, with the anterior crural nerve between them, are generally stretched tightly over the head of the bone. The femoral vessels are displaced to its inner side, ^^igiis (Fig. t8o). — The limb is slightly shortened, flexed, abducted, and rotated outwards ; and the head of the bone can be plainly felt in its new situation. There is flattening over the hip-joint. The anterior oblique, st/praspinous, and everted dorsal, the three remaining regular dislocations of Bigelow, are too rare to be described here. They can readily be produced, however, on the dead body. Thus the ordinary dorsal dislocation can be con- verted into the anterior oblique by carrying the leg across the symphysis, forcibly everting the thigh and bringing it down across the lower third of the opposite thigh, in which position it becomes firmly locked. If now the thigh is forced into the perpendicular position, the outer branch of the Y ligament will be ruptured and the supra-spinous variety produced. This variety in its turn can be converted into the everted dorsal by circumducting the ex- tended limb inwards and then e\erting it. Treatment. — Pv.eduction may be eftected by : i, manipulation ; 2, traction with the limb in the flexed position ; 3, traction with the limb in the extended position. Of these methods the first and the second are by far the most scientific, and when their principles are thoroughly understood and they are rightly applied, they are the most successful. Recent dislocations should always be re- duced by the first or second method, aided if need be by an anaesthetic ; and these methods will also often succeed in reducing cases of long standing after traction in the extended position, even with the pulleys, has failed. In long-standing cases, should the above-mentioned methods fail, reduction may under some circumstances be attempted by 4, open incision. I. Reduction by manipulation consists in relaxing the Y ligament, the chief obstacle to reduction, and then by means of various movements of rotation, circumduction and extension apphcable to each particular variety of dislocation, in making the head of the bone retrace its steps round the margin of the acetabulum, and finally re-enter the acetabulum through the hole in the capsule by which it escaped. To do this it is necessary to know in what direction the head of the bone looks in any particular position of the hmb — a point easily determined by remembering that the articular surface of the head looks very nearly in the same direc- 436 INJURIES OF REGIONS. tion as the internal condyle. It must be further remembered that by rotation is meant the rolling of the femur on its own axis ; that in outward rotation the anterior surface of the patella is rolled outwards, and in inward rotation inwards; that by circum- duction is meant the revolving of the femur round the axis of its head, and that in this movement the anterior surface of the patella always looks to the front. During the manipulation the patient should be placed upon his back on the floor, while the Surgeon with one hand should grasp the ankle, and with the other the thig'i or leg. and put the limb through the several movements required for the kind of dislocation. An assistant, if necessary, should fix the pelvis. For the dislocation on the dorsum ilii and into the sciatic notch the movements are practically the same (Fig. i8i). The limb should be flexed and slightly adducted to disengage the head from behind the acetabulum, and then ab- ducted, rotated outwards and brought down parallel to the sound limb. These movements are tersely described by Bigelow in the words 'lift up,' 'bend out,' 'roll out,' /. son's Metliod. — A strong steel pin is passed through the liga- mentum patellae outside the knee-joint ; the skin is then drawn down over the patella, and another pin passed through the ten- don of the quadriceps also outside the joint. The two pins and with them the fragments of the patella are then drawn together by a figure-of-eight suture on each side, so as to bring the frac- tured surfaces into apposition. An antisei)tic dressing is applied, and the pins allowed to remain /// situ for a month (see Fig. 199). Mayo Robson's method of holding fragments of patella in contact. THE IIBIA AND FIBULA. 455 Aspiration of the joint. Wiring of the fragments . — With the object of obtaining firm fibrous or bony union, some Surgeons, where there is much distension of the joint, draw off the blood or serum with the aspirator ; and others lay the joint freely open and wire the fragments of the patella together. The latter proceed- ing, it cannot bfe denied, has often secured bony union without any ill effects, but on the other hand, suppuration, stiff-joint, amputation, and even loss of life, have resulted. In the face of these facts, therefore, and considering that no such dangers at- tend the ordinary methods, and that by these methods a per- fectly useful joint can be obtained, even though the union is only fibrous, I have hitherto hesitated to undertake such an operation for a recent fracture of the patella. Recently Mr. Barker has tied the fragments together subcutaneously by passing a suture by the aid of a n^evus needle first behind the patella, and then in front of it between the patella and the skin. The blood is squeezed out of the joint, the fragments pressed together, and the sutures tied tightly, thus keeping the fragments in apposition. The tibia and fibula. — ^Both bones, or the tibia or fibula alone, may be fractured. Fracture of both bones, which is by far the most common variety, may be due to either direct or indirect violence. When the result of direct violence, the fracture occurs at the spot where the force is applied, and both bones are usually fractured more or less transversely, and in the same line ; but when the result of indirect violence, the tibia generally first gives way at its weakest spot, /. e., about the junction of the middle with the lower third, and then the fibula also at its weakest spot, i. e., in its ripper third, and the fractures are usually oblique. In the transverse fracture but_ little displacement occurs ; in the oblique, in which the Hne of fracture usually runs downwards, forwards, and a little inwards, the lower fragments are drawn upwards, backwards and outwards, behind the upper, by the muscles of the calf, while the sharp end of the upper fragment of the tibia projects forwards, threatening, and indeed often causing, perforation of the skin (Fig. 200). Fracture of the tibia alone is generally caused by direct violence, as a kick or a blow on the shin, occasionally by indirect violence, as a fall on the foot. Nature of the displacement. — The fracture is usually situated in the lower third of the bone, and is generally transverse, and attended by Httle displacement, the fragments being held in position by the fibula, which plays the part of a splint. Fractures of the upper and lower ends, involving the knee- and ankle-joints respectively, and separation of the upper and lower epiphysis, may also occur, but are rare. 456 INJURIES OF REGIONS. Fig. Fracture of the fibula alone is more common than fracture of the tibia alone. Cause. — Though sometimes produced by direct it is more often the result of indirect violence, such as a severe wrench or twist of the foot. The fracture is then generally situ- ated from two to three inches from the external malleolus, and the foot is at the same time very commonly dislocated either out- wards or inwards, according to the direction of the force. Nature of the displacement. — In the fracture with outward dislocation of the foot {Pottos fracture, as it is generally called), the upper end of the lower fragment is driven inwards towards the tibia, the external lateral ligament remains intact, but the in- ternal lateral ligament is ruptured, or the end of the internal malleolus is torn off. The foot, at the same time that it is dis- placed outwards, is also drawn backwards by the tendo Achillis. In the fracture with inward dislocation (which is rare), the articular surface of the external mal- leolus usually follows the astragalus, and the upper end of the lower fragment of the fibula in consequence projects out- wards. Signs. — In fracture of both bones the signs are usually unmistakable, especially when the fracture is oblique and in the lower third of the leg. When the tibia or fibula alone is fractured the diagnosis is often very difficult. In the tibia some irregularity may be felt oh running the finger along the shin, and crepitus may perhaps be elicited. In the fibula, fracture of the lower third may be detected by running the finger along the subcutaneous surface of the bone just above the external malleolus ; but if the case is not seen till swelling from effusion has set in, it may be quite impossible to say whether we are dealing with a fracture or a sprain. If in doubt the case should be treated as a fracture. In the upper two-thirds, where the bone is covered with muscles, and cannot be felt, the follow- ing tests for fracture may lie applied : i. Move the foot laterally, and crepitus will probably be elicited if there is a fracture. 2. Press the tibia and fibula together just above the ankle by grasp- ing them with the hand. In fracture, pain will be felt at the frac- tured spot, not at the situation where grasped. 3. Grasp the tibia and fibula with the hands just below the knee and above the Fracture of the lower third of the tibia. (After (Jray.) FRACTURE OF THE FIBULA. 457 Fig. 20I. ankle. If there is a fracture the natural springiness of the fibula will be lost, and crepitus may perhaps be detected. In Pott's fractu7'e (Fig. 201), the foot is twisted outwards, so that whilst the inner edge is towards the ground the sole is directed out- wards. There is a well-marked depression over the seat of frac- ture, the internal malleolus projects prominently under the skin, and crepitus can be easily obtained. There is also marked back- ward displacement of the foot. Treatment. — In uncomplicated fractures of the tibia or fibula alone, the leg may be placed at once in plaster-of-Paris splints, and the patient, after a {^^^ days' rest in bed, allowed to get about on crutches. Where there is much swelling, the leg had better be placed for a few days on a back- splint to allow the swelling to subside before the plaster- of-Paris is applied. In simple fracture of both bones, where the line of fracture is transverse and there is but little swelling or displacement, the same treatment may often be adopted with advantage. But greater care and watchfulness will be necessary to prevent any untoward acci- dent. Indeed, whenever this method of treating fractures is used, the precautions mentioned at page 174 should be taken. When there is any displacement, however, the fracture must be reduced by making traction upon the foot whilst the thigh is steadied by an assistant, special care being taken to correct the eversion, so frequently pres- ent, of the lower fragment. You will know when this has been done by the inner side of the patella, the internal malleolus, and the inner side of the great toe being in the same line. Further, you should not, as a rule, rest satisfied as long as any irregularity can be felt on drawing your finger down the crest of the tibia, or as long as any marked difference is apparent on comparing the frac- tured with the sound leg. If any difficulty is experienced, give chloroform, and if necessary, cut the tendo Achillis. Having re- duced the fracture, secure the foot and leg on a splint. What- ever form of the various splints for the purpose is adopted, take care : — i, that the foot is at right angles to the leg; 2, that the ball of the toes and the heel touch the foot-piece of the splint ; 3, that the foot is square with the foot-piece ; and 4, that the back of the heel is kept from contact with the splint by a small pad placed under the tendo Achillis just above the heel. The iron 20 Pott's fracture. (St. Bar- tholomew's Hospital Mu- seum.) 458 INJURIES OF REGIONS. splint and cradle, shown in Fig. 202, is almost invariably em- ployed by the whole of the surgical staff at St. Bartholomew's Hospital for ordinary fractures of the tibia and fibula, and with the most satisfactory results. In applying the splint, which should reach as high as the junction of the middle with the lower third of the thigh, and should be well padded and shaped to the limb, the foot is first secured to the foot-piece by strapping and a band- FiG. 202. Fracture apparatus for the bones of leg. age. The Surgeon having then assured himself that the fracture is in good position, secures the splint by a broad strip of strap- ping, and a figure-of-eight bandage over the knee. The splint is next swung in the cradle, as shown in the figure, and side splints Fig. 203. C'line's splints (or I'ott's fr.-ictiirc. The outside splint is known by the foot-piece. are then applied and fixed by webbing straps. In the case of fracture of both bones, the apparatus is generally kept on for a month ; in the case of the fibula or tibia alone, for two or three weeks. The leg is then placed in a plaster of- Paris, a gum and chalk, or a silicate of .soda bandage. In Pott's fracture, the above apparatus is also generally used, and here again I speak of POTT S FRACTURE. 459 Roughton's splint. it in the highest praise. Where, however, there is much difficulty in keeping the bones in good position, the leg is sometimes laid on its outer side, with the knee semi-flexed to relax the gas- trocnemius, and secured in Cline's splints (Fig. 203), the tendo Achillis being divided, if found necessary. The backward dis- placement of the heel, Fig. 204. however, is best corrected by using Roughton's mod- ification of the splint (Fig. 204). It consists of an outside splint with a foot- piece. The heel is drawn forward and secured in position by a " heel band- age," the limb being fixed to the splint by two other bandages, one placed just above the ankle and the other just below the knee (Fig, 205). At times Dupuytren's splint (Fig. 206) may be better adapted to a par- ticular case. The splint con- FiG. 205. sists of a straight lath notched at its lower end. It is placed on the inner side of the limb, and should reach from the tuberosity of the tibia to three or four inches below the foot. A wedge-shaped pad, with its base below, and not extending beyond the internal malleolus, should line the splint. The splint is bandaged on from above downwards, and the leg having been thus secured, the foot is brought over to the splint by making figure-of-eight turns over the ankle and foot and through the notches at the lower end of the splint. The bandage should not pass over the external •*&.! Roughton's splint applied. The arrows show the direction in which the bandages pull. Fig. 206. Dupuytren'": splint for Pott's fracture. malleolus or the seat of fracture. The great objection to the use of this splint is, that having no foot-piece, the foot is not kept at a right angle to the leg. When no special apparatus is at hand the fracture, whether of both bones of the leg or of one bone 460 INJURIES OF REGIONS. only, may be put up in what is known in Edinburgh as the box- splint (Figs. 207, 208). All that is required is two ordinary side splints and some towels, cotton wool, and a few bandages. The spHnts showld be rolled in the two ends of a long towel (Fig. 207) so as to form a trough for the fracture, the width of the trough being determined by first placing the sound leg in it. The fracture having been set, the leg is placed on the towel and the splints forming the sides of the trough or box are raised and se- cured in position by slip-knot bandages (Fig. 208). Pads formed of folded towels should be placed over the tibia or where re- quired, and the foot fixed at a right angle to the leg by a figure- of-eight bandage (Fig. 208). Backward displacement of the heel may be controlled by a ring-pad. The tarsus. — Fractures of the bones of the tarsus are for the Fig. 207. The Pox-splint for fracture of the Ijones of the leg. In the ujjpcr fig\irc the position of a towel used as a pad is shown. In the lower figure ihc :ii)i)ai:itiis is shown completed. (After Caud and Cathcart.) most part the result of great violence, and are rare. The only one calling for y^assing notice is fi-actiirc of ihc os calcis, which may occur from a fall on the heel, passage of a wheel over the foot, or violent contraction of the calf-muscles. Crej)itus, and, when the line of fracture is behind the interosseous ligament, some drawing up of the posterior fragment by the tendo Achillis, are the chief signs, iiut where there is much swelling and bruis- ing of the soft parts, the fracture, as is the case in fractures of the THE METATARSAL BONES AND PHALANGES. 46 1 astragalus and of the other tarsal bones, may be very difficult to diagnose. Rest, with the foot and leg on a splint, in such a posi- tion as to relax the calf muscles where there is much displace- ment, and an ice-bag to subdue inflammation, are the points to be attended to with regard to treatment. When the case is seen early, and there is but little swelling, a plaster-of-Paris splint or bandage may be advantageously used. The metatarsal bones and phalanges of the toes may be frac- tured by direct violence. No special description, however, of these fractures is necessary. 462 DISEASES OF REGIONS. SECTION VI. Diseases of Regions. diseases of the scalp and skull, Erysipelas of the scalp is common, and may occur idiopath- ically, or as the result of a wound. In the so-called idiopathic cases, however, it is probable that there is generally some scratch or abrasion through which the specific micrococcus gains admis- sion. The inflammation spreads with great rapidity, but is accom- panied by very little redness and swelling, on account of the tenseness of the parts. It is apt to be attended with headache, drowsiness, or deliriiim, consequent upon the hypersemia extend- ing to the pia mater. See Erysipelas, p. 144. Cellulitis of the scalp is usually due to a wound, and is described under Injuries of the Scalp. {See also Celluhtis.) Abscess may occur above the aponeurosis, between the aponeu- rosis and the pericranium, or beneath the pericranium. It is gen- erally the result of an injury, but may be due to the breaking down of a gumma, diseases of the bones, etc. It is further re- ferred to under Injuries of the Head (p. 327). Rodent ulcer, and Epithelioma of the scalp, require no special mention here. Sebaceous cysts are very common on the scalp, where they are at times hereditary. They are frequently multiple, and as they increase in size, the hair covering them falls off, and they appear as bare, rounded tumors. The signs, secondary changes, diagnosis, and treatment of these cysts have been given at p. 99. All that need here be repeated is that the mass of granulations which sometimes protrudes from the walls of these cysts {fi/ni^atiii(^ ulcer of the sea /p) closely resembles ei)ithelioma, from which, how- ever, it may generally be distinguished by the absence of indura- tion and glandular enlargement, and by the history of a sebaceous cyst having been j)reviously present. Congenital and dermoid cysts are described at p. 102. N^vi are also common on the scalp. When large and situated over the anterior fontanelle they should be dealt with cautiously, lest the membranes of the brain be injured and meningitis result. Caries and necrosis of the bones of the cranium are not un- common. 'J'hey are generally the result of syphilitic periostitis or MENINGOCELE AND ENCEPHALOCELE. 463 injury, or very rarely of tubercle or fevers. The external table is the most often affected, but whether the external or the internal table is involved, the disease seldom extends beyond the diploe, as the two tables have a distinct blood-supply. At times, however, complete perforation of the skull occurs. Caries and necrosis in this situation are apt to be followed by septic or infective inflam- mation of the diploe and its consequences ; by suppuration between the bone and dura mater ; by meningitis and abscess of the brain ; or by thickening of the dura mater, resulting in persistent head- ache or even epilepsy. When the skull is completely perforated, the hole is not filled up by bone ; and when necrosis occurs the sequestrum is not invaginated. Treatmerti. — Beyond keeping the parts aseptic, providing free exit for the discharges, and removing loose sequestra, little, as a rule, is required. Should pus collect between the bone and dura mater, it must be let out by the tre- phine ; and a portion of necrosed inner table may also require the trephine for its removal. Appropriate constitutional remedies for syphilis or tubercle will of course also be necessary. ExoTOSES of the skull are described under Diseases of Eone, p. 230. Meningocele and Encephalocele are rare congenital tumors, formed by a protusion of the membranes of the brain through an unossified part of the skull. They are believed to be dependent upon hydrocephalus, the excess of fluid in the sub-arachnoid space or in the ventricles of the brain leading respectively to a protrusion of the membranes alone {meningocele), or of the brain also {en- cephalocele). In the latter instance, the dilated ventricle may ex- tend into the protruding portion of the brain, a condition further distinguished as hydrencephalocele. The protrusion is most common in the occipital region, just behind the foramen magnum, be- tween the four centres from which this part of the occipital bone is ossified ; next, at the root of the nose, between the frontal and nasal bones ; but it may occur in any situation in the course of the sutures, and even project into the nasal fossae or pharynx. Symptoms. — In the occipital region these tumors are generally pedunculated and of large size — sometimes nearly as large as the child's head ; at the root of the nose they are usually small and sessile. The skin covering them is generally normal. They swell up when the child cries, and can be completely or partially re- duced on pressure, the reduction sometimes producing convul- sions or other brain symptoms. When they contain fluid only {meningocele) they are soft, fluctuating, translucent, and com- pletely reducible on pressure ; they rarely pulsate, and are gen- erally pedunculated. When they contain brain- matter {encepha- locele) they are doughy, non-fluctuating, opaque, and only par- 464 DISEASES OF REGIONS. tially reducible ; they pulsate, and are usually sessile. They may be mistaken for other tumors of the scalp, but especially for con- genital dermoid cysts and degenerate n^vi. However, their in- tmiate connection with the bone, their situation in the course of the sutures, and their partial or complete reducibility, together with the facts that they swell up on expiratory efforts, and occasion- ally pulsate synchronously with the brain, will usually serve for their diagnosis. Further, the hole in the skull may at times be detected and brain symptoms be produced by pressure. Treat- ment. — As a rule they should be left alone, or merely supported by a pad or bandage. A meningocele, when pedunculated, and apparently communicating with the interior of the cranium by a small aperture only, may be injecled with Morton's fluid, or under exceptional circumstances excised. Fungous Tumors, generally of a sarcomatous nature, and springing either from the tissues of the scalp or pericranium, or from the diploe or dura mater and then penetrating the bone, are occasionally met with, and may be mistaken for inflammatory affections of the pericranium or bone, or for syphilitic gummata. Their rapid growth, resistance to syphilitic remedies, the escape of blood only on puncture, and the concomitant loss of weight and strength of the patient, will usually serve to distinguish them ; but an exploratory incision may in some cases be necessary to clear up the diagnosis. Secondary tumors which pulsate and have the structure of thyroid-gland tissue, are also very occasionally met with in cases of malignant goitre. Treatinetil. — Where there is no evidence of dissemination, and the tumor is small and fairly circumscribed, it may be removed. When growing from the scalp this can usually be done without much difficulty ; but when the growth arises from the bone or dura mater a much more serious operation will of course be required, since a considerable portion of the skull will have to be cut away, and the dura mater probably opened. It need hardly be said that the strictest anti- septic precautions must be observed. DISEASES OF THE BRAIN THAT MAY CALL FOR SURGICAL INTERFERENCE. Abscess in the brain is generally the result of a head-injury or of middle-ear disease, and when its situation can be localized with a fair amount of probability imperatively calls for surgical interference. See Intracranial Su]jpuration and Complications of Middlc-I'^ar Disease. The 'i umors and new growths in the brain suitable for opera- tion are gliomata and psammomata, localized tubercular lesions, THE TUMORS. 465 syphilitic scars which drugs cannot absorb, scar-tissue and cystic formations following injury, and parasitic cysts. Sarcomatous and carcinomatous growths are usually too extensive for removal, or are multiple from the first. Moreover since they have no capsule they are not sufficiently distinguishable from the surrounding brain substance to ensure their complete excision and their non-return in the scar. The chief signs of a cerebral tumor are vomiting, persistent headache, optic neuritis, localized spasms or paralysis, and epileptiform convulsions, the convulsive seizures usually start- ing in the part connected with the cortical area involved in the growth {Jacksonian Epilepsy). Among the symptoms that may enable the Surgeon to localize the growth are the following (Figs. 209 and 210) : — i. If at the beginning of the epileptiform fit Fig. 209. The convolutions of the outer surface of the left cerebral hemisphere with the cortical centres marked. F,, f„, F3, First, second, and third frontal convolutions; t,, t.,, t^, First, second, and third temporosphcnoidal convolution^; A. Angul.nr convolution ; o. Occipital lobe; F s. Sylvian fissure; p o F. Pa rieto-occipital fissure; p F. Intra-parietal fissure. there is — {a) pain, peculiar sensation, flexion, or hyper-extension of the great toe, a lesion of the leg-area on the opposite side of the cortex about the upper end of the fissure of Rolando close to the middle line is indicated ; {b) movements of the shoulder, a lesion near the upper part and rather in front of the fissure ; {/) flexion of the thumb, a lesion about the genu of the fissure ; (^) turning of the head and eyes to the opposite side, a lesion about 466 DISEASES OF REGIONS. the hinder portion of the superior and middle frontal convolu- tions ; (e) movements of the mouth and tongue, a lesion about the lower end of the fissure of Rolando. An epileptiform move- ment starting in one of these parts may be followed by loss of power in the part for some time after the fit. 2. Aphasia indi- cates a lesion of Broca's convolution. 3. Loss of half the fields of vision in both eyes points to a lesion of the angular gyrus of the side opposite to the lost fields of vision. 4. Loss of hearing suggests a lesion of the two upper temporosphenoidal lobes. 5. The aid to localization that may be derived from the involvement Fig. 210. The convolutions of the median surface of the left cerebral hemisphere with the cortical centres marked. F,, First frontal convolution: c in i". Calloso-marginal fissure; r, f. Gyrus forni- catus; Q. Quadrate lobule; c. Cuneate lobule; p o i", Parieto-occipilal fissure; c f. Cal- carine fissure; v. Uncinate lobule; v. Paracentral lobule. of the cranial nerves has already been mentioned under Injuries of the Head (p. 342). Where, from a consideration of the above symptoms, a tumor or new growth is believed to be fairly circumscribed and in an accessible situation, the skull should be trephined, a sufficient portion of the bone removed to fully expose the growth, by a Hey's saw, Hoffmann's or Keen's forceps, or the surgical engine, and the growth cut away by making perpendicular incisions into the brain around it and raising it by means of a sharp spoon. The removal of a portion of the cortex will be followed by loss of function of the area removed, but this to a great extent will be regained by the aid of the surrounding areas, especially as regards the coarser movements. "^I'he finer movements of the fingers and thumb will not be completely regained ; hence in this region the removal of cortex should be as limited as is consistent with suc- cess. Parasitic cysts should be drained. See Trephining, p. 347. CRANIECTOMY. 467 Focal epilepsy, general paralysis, cephalalgia. In focal epi- lepsy, that is epilepsy without obvious gross lesion, when the fits become very frequent, for example more than one an hour, and the mental processes are becoming further impaired, the focus in the cortex representing the initial movements may be exposed, the exact spot for the initial movements found by exciting the brain with the Faradic current, and this area of the cortex ex- cised. After such an operation a diminution in the number of fits as well as an improvement in the health of the patient may be expected. In general paralysis trephining in a few cases has been of some benefit in the early stages of the disease. Thus the hal- lucinations have disappeared and the patient has so far improved as to be fit to be at liberty. In severe cephalalgia incapacitating the patient for work or preventing sleep, trephining may give re- lief. In such cases an exostosis, a spiculum of bone, an enlarged Pacchionian body, or a fibrous tumor or cyst of the dura mater has been found, and its removal has been foUovved by complete recovery. In other cases where a tumor, etc., of the brain which did not permit of removal has been discovered, the relief of pres- sure has freed 'the patient from the excessive pain, or threatened blindness. Hydrocephalus, especially {a') when accompanied by fits, (b^ when progressive atrophy of the optic nerve threatens, or {c) when dementia or coma supervenes, may be treated by tapping the ventricles at intervals and applying sHght pressure to the skull, or if this fails, by continuous drainage of the ventricles. Microcephaly combined with idiocy, due it is thought to too early synostosis of the cranial sutures, especially the sagittal and coronal, may be benefited by craniectomy, /. e., the removal of a strip of bone on either side of the middle line of the skull. The aim of the operation is to allow the brain, the development of which has been prevented by the early synostosis, to expand. In some of the cases reported the mind of the child had continued to develop since the operation. Craniectomy. — Having prepared the scalp as described under trephining (p. 347), make a semicircular incision over the side of the head, extending from a little behind the external angular pro- cess of the frontal bone to a little in front of the middle of the lambdoid suture ; turn down the large semicircular flap thus marked out, and apply a half-inch trephine over the parietal bone two inches or so external to the sagittal suture. Gently separate the dura mater and cut away with Hoffmann's or Keen's forceps a narrow strip of bone some five or six inches long from the pari- etal and frontal bones, parallel to the sagittal and interfrontal sutures. Care should be taken during the operation to make as 468 DISEASES OF REGIONS. little pressure as possible on the brain. At the end of the opera- tion the flap should be replaced and accurately secured by sutures. The operation should be repeated on the opposite side of the head when the first wound has healed. I have performed this operation on three patients, but sufficient time has not elapsed to say what improvement in their mental condition will result. The strictest antiseptic precautions in this as in all operations on the skull and brain should of course be taken. See Trephin- ing, P- 347- DISEASES OF THE EAR. By A. E. CuMBERBATCH, F. R. C. S., Aural Surgeon to St. Bartholomew's Hospital. Physical examination of the ear. — In making an examina- tion of a patient, let him be seated between the Surgeon and the source of light, with the affected ear towards the examiner. Throw the light on the ear with the mirror and notice any ab- normal condition of the auricle or the external meatus. Next grasp the auricle between the middle and index fingers, the speculum (Fig. 211) between the index finger and thumb, and pulling the auricle upwards and backwards insert the speculum Fig. 211. Fig. 212. Aural specula. Aural toothed forceps. with a gentle rotatory movement. Any epithelium or wax that may obstruct the view should be removed by means of forceps (Fig. 212) or the syringe. If the canal be unobstructed, the membrana tympani can be seen stretching across its deeper part as a delicate bluish-grey or yellowish-grey semi-transparent and highly polished film. Near the upper and anterior margin is a whitish prominence — the processus brcvis, and running down- wards and boackvvards from this, to a point just below the centre of the membrane, is the handle of the malleus. From the tip of the handle a cone of light extends downwards and forwards, with its base to the perij^hcry. I''rom the ])rocessus brevis two indis- PHYSICAL EXAMINATION OF THE EAR. 469 tinct lines extend backwards and forwards — the anterior and posterior folds. If the membrane be very thin or its posterior segment much retracted, the long process of the incus can be seen, posterior to and parallel with the handle of the malleus. The portion of membrane above the anterior and posterior folds is called SchrapnelPs memb?-ane, and consists only of the dermoid and mucous layers. Whilst noting these points, carefully search the membrane for perforations, opacities, or small polypi. After thus inspecting the membrane, its mobiHty should be ascertained by means of i, the pneumatic speculum, or 2, by forcing air into the tympanum through the Eustachian tube, either by {a) Valsalva's method, (l>) by Pohtzer's method, or {c) by the catheter. {a) Valsalva's method consists in making forcible expiration with the nose and mouth closed. ((^) Politzer's method. Direct the padent to take a mouthful of water ; insert the end of the india-rubber tube into one nostril, carefully close the unoccupied portions of this Fig. 213. and the other nostril with the index finger and thumb ; tell the patient to swallow, and sharply compress the bag (Fig. 213). In small children the tympanum can be inflated without their PoUtzer's bag. drinking water. Some pa- tients find a difficulty in swallov/ing easily when told to do so ; such persons should be made to say some guttural word, such as " Huck." {c) To pass the Eustachian catheter {Y\g. 214), hold the in- strument lightly between the forefinger and thumb and pass ^"^- ^^'^• it quickly along the floor of ^^^g»— • - ^^^ the nose, keeping the point of the instrument downwards till it reaches the back of the ' Eustachian catheter. pharynx ; next draw it forward about three-quarters of an inch, gently rotating outwards at the same time, till the point is felt to ride over the posterior lip of the Eustachian orifice, and further rotating it till the ring of the catheter is in a line with the outer canthus of the eye, push the instrument slowly onwards, when the point will be in the Eustachian orifice. Another method for reaching the orifice of the tube is to draw the instrument forward over the back of the 470 DISEASES OF REGIONS. soft palate till the point begins to ride over the posterior border of the hard palate, then turn it upwards and outwards as before. These are the best two methods. If the mucous membrane of the nose be very irritable, first paint the inferior meatus with a 4 per cent, solution of cocaine. Occasionally, owing to post-nasal thickening, deformity of the septum or enlargement of the in- ferior turbinal, the catheter either cannot be passed, or else when passed cannot be turned. In such cases give the catheter a greater curve, and attempt to reach the tube through the other nostril. When air enters the tympanum freely, it is heard dis- tinctly to impinge on the tympanic membrane. If the Eustachian tube be narrowed, the air is heard but feebly, or not at all, to impinge on the membrane, li Jlui'd he present, either- in the tube or in- the tympanum, a bubbling or gurgling sound is heard. If the tympanic membrane be pej-forated, the air is heard to whistle through the perforation. To hear these sounds in the tympanum it is necessary while inflating to use the diagfiosttc tube, which is nothing more than a piece of india-rubber tubing 18 inches long, one end of which is inserted into the patient's, and the other into the Surgeon's, ear. Having thus examined the condition of the external and mid- dle ear, the next step is to ascertain, if possible, the condition of the auditory nerv^e. If a vibrating tuning-fork be ai)plied to the vertex of the head in the middle line the sound is heard equally in both ears. In this case the sound is conducted directly to the labyrinth by the cranial bones. If now one meatus be closed by the finger, the sound is heard with greater intensity in that ear. The explanation offered of this phenomenon is that many of the waves of sound, prevented from escaping through the tympanum and meatus, are thrown back and intensified. If, then, a patient who is deaf on one side, hears the tuning-fork better with the affected ear, it may be assumed that the lesion is in the sound- conducting apparatus ; while if he hears it better with the sound ear, some affection of the labyrinth or auditory nerve may be suspected. Another way of testing the condition of the labyrinth is to place the vibrating fork on the mastoid process of the af- fected ear, and when the patient can hear it no longer for the Surgeon to transfer it to his own mastoid, and note if he can still hear it himself. There are certain rare exceptions to the truth of what is here stated, but it is impossible to discuss the subject further in so limited a space. To complete the examination of a patient, test his hearing by means of 'the watch and voice, and finally ex- amine the nares and pharynx in cases where there is reason for suspecting that an unhealthy condition of these parts may be the exciting cause of the ear- mischief. DISEASES OF THE MEATUS. 47 1 I. Diseases of the external ear. The auricle is liable to attack from various diseases, but it will only be necessary here to notice two : Eczema and Hsematoma. Eczema may be acute or chronic ; primary, or secondary to eczema of the head. In the acute form there is great redness and swelling of the auricle ; it is hot, tense, and tender, and later a crop of vesicles appear which exude a serous fluid soon drying into crusts ; these, when they fall off, leave a raw surface. Acute eczema rarely invades the meatus. The chronic variety may at- tack the whole auricle ; more frequently it is limited to some part of it. There is little or no redness, the surface is dry and scurfy, and fissured in places, and the disease generally spreads into the meatus, and sometimes even to the drum-membrane. In such cases there is more or less deafness, accompanied, it may be, by tinnitus, and a stufly feeling in the ear. Treatment. — In the acute stage apply lead and opium lotion, or powdered zinc and starch in equal parts ; later, useful applications are linimentum calcis, or ung. hydrarg. subchlor. (gj. ad 53.). If the parts continue red and swollen, paint them with argenti nitratis (gss. ad aq. f5J.), and then apply powdered boracic acid, or ung. hydrarg. oxidi. rub. (gr. ij. ad 5J.). Applications to the meatus must be applied with a small brush ; the parts should be washed with oatmeal instead of soap. Constitutional treatment must not be neglected. HyEMATOMA AURis may occur spontaneously or as the result of an injury, and is not uncommon among the insane. It consists of an effusion of blood between the cartilage and perichondrium on the anterior surface of the auricle. It occurs as a hard and rarely fluctuating swelling, varying greatly in size. The skin over it is of a more or less livid hue, but occasionally is hardly discolored. There is a feeling of warmth or tingling, but rarely of pain. After a time it gradually becomes smaller and may en- tirely disappear. Sometimes it suppurates. In the end the auri- cle is left more or less deformed. Treatment. — At first the apphcation of ice or cooling lotions ; some recommend tapping it and injecting iodine ; others laying it open and dressing with a weak solution of carbohc or boracic acid. Of course, if it sup- purates, it must be opened freely. II. Diseases of the meatus : — Diffuse inflammation is caused by injury, irritants (such as scratching the meatus with a pin), or sea-bathing. There is redness and swelling of the skin fining the meatus, a sense of fulness, and throbbing and occasional tinnitus, followed by serous or semi-purulent secretion. After a time the epithelial fining becomes v/hitish and sodden, and, on syringing, comes away in flakes, or even as a cast of the meatus, leaving the surface beneath red, and frequently obliterating the demarcation 472 DISEASES OF REGIONS. between the meatus and tympanic membrane. Rarely the tym- panic membrane may be perforated. There is pain, increased by movements of the jaw or pressure on the auricle, and some- times fever. Treatment — In the early stages cold compresses, and a leech or two to the tragus ; and antiphlogistics. As soon as secretion is established, instil a warm solution of boracic acid, and later equal parts of alcohol and water, or blow in powdered boracic acid. If the discharge proves obstinate, the surface may be painted with a solution of nitrate of silver (,5ss. ad foJ-)> or liquor plumbi subacetatis. Furuncles. Small boils frequently occur in the meatus in gouty, anaemic, and diabetic patients ; also in those whose nervous system has been greatly taxed. The attack begins with pain, often of the greatest intensity, radiating over the side of the head and increased by movements of the jaw, or the slightest pressure on the auricle. There may be deafness as the result of closure of the meatus, not otherwise. Examination shows little or no redness, but one or more swellings. Fig. 215. often closing the meatus. These are exquisitely tender when touched. As soon as the abscess bursts the pain subsides, but very often one abscess after another forms, till the patient's life be- comes a burden to him through pain and sleepless- Aurai forceps. ^gss. Treatment. — Apply hot fomentations, a leech or two to the tragus, and instil a concentrated solution of boracic acid in alcohol. Often a plug of cotton-wool soaked in glycerine and laudanum, and gently inserted into the meatus by the aural forceps shown at Fig. 215, or Oruber's medicated gelatin bougies, give relief. When the abscess is fully formed incise it, but not before, as early incision is excessively painful and gives but tem- porary relief. The general health should be attended to, and full doses of opium given to procure sleep. Von Troltsch recom- mends arsenic to prevent the recurrence of furuncles. Impaction of cekumkn may be caused by narrowing of the meatus, cleaning the ears with the end of a towel or ear- pick, or the presence of a foreign body, such as a piece of cotton-wool in- serted into the meatus and forgotten. The chief syt>ipto//i is partial or complete deafness, generally coming on suddenly. 'J'here may be tinnitus or even giddiness, often persistent cough, rarely pain. Sometimes the impaction of cerumen is really due AURAL EXOSTOSES. 473 to a peculiar laminated desquamation of the skin of the meatus, which becomes mixed with wax, and thus forms a plug. Treat- 7nent. — If the wax be not very hard, it can be at once removed by syringing with warm water, the auricle being pulled backwards and upwards, and the nozzle of the syringe directed along the upper and posterior wall. If any difficulty be experienced in re- moving the wax owing to its hardness, soften it first by dropping into the ear for a few nights a warm solution of bicarbonate of soda (gr. x. ad f^j.). After removal gently dry the meatus with a cone of absorbent wool, and let the patient keep a piece in the meatus for a few hours. Otomycosis is a chronic inflammation of the external auditory meatus, due to the presence of a vegetable fungus. The symptoms are a sense of fulness, tinnitus and occasional vertigo, more or less itching, and occasionally pain. On examination there is seen a slight serous discharge, and the meatus contains yellowish or blackish flakes, on removal of which the skin beneath is found to be reddened and occasionally bleeding. Microscopical exami- nation of the flakes at once reveals the parasitic nature of the disease. The Treatment consists in frequently syringing with a warm solution of perchloride of mercury (i in looo), or chlorinated lime (gr. ij. ad f.^j.), or hyposulphite of soda (gr. iv. ad f3J.), and, when the meatus is thoroughly freed from the flakes, instill- ing alcohol. Aural exostoses may roughly be divided into the spongy and the ivory. {a) The Spongy are single and generally pedunculated, are most comimonly found at the junction of the cartilaginous and bony meatus, are rapid in growth, follow suppuration of the mid- dle ear, and are frequently the result of ossification of granula- tions. Treatment. — They can generally be removed by seizing them with a pair of forceps and breaking them off". (^) The Ivory exostoses or rather hyperostoses may be single, but are more often niultiple. They vary from ridge-like eleva- tions to rounded tumors with broad bases ; they are found near the orifice of the meatus, more or less blocking up the canal, and grow slowly. Syphilis, gout, irritation of the meatus, and sea- bathing are said to be the exciting causes. Treatment. — They should not be interfered with unless they cause deafness by com- pletely closing the meatus, except in those rare cases where they are associated with discharge. In such cases, as they greatly lessen the lumen of the canal, they should be removed to avoid the risk of pent-up matter. When their removal is necessary, this should be done by means of a chisel and hammer, or the dental drill. ■ 20* 474 DISEASES OF REGIONS. III. Diseases of the middle ear : — Acute catarrh may be started by any condition which produces acute naso-pharyngeal catarrh, such as a severe cold, the exanthemata, etc. It may also be caused by sea-bathing, or by the use of the nasal douche. Sy?upto»is. — The attack begins by a feeling of fulness in the head, followed by pain, which varies in character from a dull aching to a severe throbbing or stabbing ; there is more or less deafness, and sometimes tinnitus, and even giddiness, and in severe cases febrile disturbance. On examination, the membrane shows at first but little change beyond a slight loss of lustre, and the presence of a fine streak of red along the posterior edge of the malleus-handle. In severe cases, the posterior segment of the membrane and the adjacent meatus are red, and this redness may spread over the entire membrane till the outline of the malleus-handle is lost. Vesicles and even small abscesses may form on its surface. Later the epidermis is loosened in white flakes, and finally the membrane distinctly bulges, when the effusion of fluid is great. The Eu- stachian tube is closed by swelling of its lining membrane. After some days, varying with the severity of the inflammation, resolu- tion begins, or the fluid (mucus or pus) bursts through the mem- brane, and is discharged into the meatus. 2'reatnient. — The patient should be confined to the house, or even to his bed, ac- cording to the severity of the attack. An aperient should be at once given, and an astringent gargle. If the pain is severe, a leech or two should be applied to the tragus. Cold compresses should as a rule be avoided, but hot fomentations are grateful to the patient and generally useful. The ear may also be gently syringed with warm water. If there be distinct bulging the mem- brane should be incised, especially if the pain persists. If there be any tenderness over the mastoid, this should also be leeched. After the severity of the symptoms has subsided, the tympanum should be inflated daily by means of the air-douche, and if the discharge continues, the ear syringed with a warm solution of boracic acid (1-40), night and morning, and a lotion of sulphate of zinc (gr. v. ad f5J.), or equal parts of rectified spirit and water instilled ; or after syringing with warm water and drying the meatus with absorbent wool, powdered boracic acid may be blown in. If the catarrh is non-purulent the membrane is rarely per- forated ; and even if perforation occurs, the aperture speedily heals after the escape of the fluid. Inflation by means of Politzer's bag should be continued with decreasing frequency till the hearing is restored. Chronic purulent catarrh (pojnilarly called Otorrhaa) fol- ] •. J the acute form of disease. After freeing the ear from dis- tl. . rje, the membrane appears thickened, yellowish from the CHRONIC PURULENT CATARRH. 475 presence of sodden epithelium, or if this has been removed, red- dish in hue. In some part of it a perforation can usually be de- tected, varying in size, the margins granular or clean cut. If large, the lining membrane of the tympanum can also be seen, varying in color from pale pink to dark red, according to the degree of inflammation present. When very small and situated anteriorly, the perforation sometimes cannot be seen, but its existence can be proven by inflating the tympanum and listening with the diag- nostic tube. The amount of deafness present in chronic purulent catarrh varies greatly. There is rarely tinnitus, but giddiness is far from uncommon. It is in this form of disease that patients are specially liable to the complications which will be considered later. Treatment. — After attention to the general health, the most important part of the treatment is great cleanliness. If a quantity of half-dried secretion mixed with epithelial debris be found in the meatus, this should first be removed by the instilla- tion of warm bicarbonate of soda (gr. x. ad f5J.) for several nights, and then thoroughly syringing the ear. Next let the ear be syringed with warm boracic acid night and morning, and after drying the meatus blow in powdered boracic acid. If this treat- ment be unsuccessful, then try an alcoholic solution of boracic acid ; or if this causes pain, the solution may at first be diluted with an equal quantity of water. Or sulphate of zinc (gr. x. ad f5J.), or acetate of lead (gr. iij. ad f^j.) may be tried. If the perforation be large and the mucous membrane of the Fig. 216. Forceps for inserting artificial drum. tympanum much swollen, it should be touched with solid nitrate of silver, or a saturated solution of chromic acid. Often when the discharge has ceased, the membrane remains perforated, and there is considerable deafness. In such cases the hearing may be greatly improved by means of an artificial membrane. Without here discussing how the artificial membrane acts, it is sufficient to say there are two kinds, known as Yearsley's and Toynbee's. i. F^arj-Z?r'.y consists of a piece of moistened cotton- wool, rolled into an elongated pUig, and appUed with a pair of forceps specially designed for the purpose (Fig. 216). 2. Toynbee's consists (Fig. 217) of a disk of soft india-rubber with a piece of silver wire attached to the centre. The former has the advantage of being less irritating to the ear, and can be moistened with 476 DISEASES OF REGIONS. Fig. 217. Toynbee's artificial drum. Fig. 218. medicated fluids, should any discharge still persist, but it has the disadvantage of being more difficult to apply. Toynbee's is easily applied, but it is more irritating to the ear. There are various modifications of Toynbee's, the best being Gruber's. It is impossible to tell in any given case whether the artificial drum will succeed ; this can only be ascertained by trial. When suc- cessful the artificial drum should only be worn at first for a few hours. The length of time should gradually be increased as the ear becomes accustomed to its pres- ence. It should always be re- moved at night. Various complications may arise in the course of chronic purulent catarrh. These are i, polypi; 2, mastoid disease ; 3, caries and necrosis ; 4, meningitis and intra- cranial suppuration ; and 5, phlebitis and septicaemia. (i) Polypi may grow from the tympanic membrane, the meatus, or the tympanic cavity. Those growing from the meatus are not true polypi ; but for brevity they will all be classed under the name of polypi. They vary much in size, being sometimes not larger than a mustard seed, at other times large enough to project be- yond the external orifice of the meatus. They are usually bright red in color, but may be pale pink, and when very large greyish yellow. They bleed more or less readily when touched. The diagnosis is easily made, but care must be taken not to mistake a swollen and vas- cular membrane for a polypus. In case of doubt the mobility of the latter, when touched with a probe, will settle the point. Treatment. — Polypi growing from the tympanic membrane should be destroyed with a saturated solution of chromic acid or per- chloride of iron applied by means of a piece of cotton-wool twisted round a fine pair of forceps (Fig. 215). When the growth springs from the meatus, and is not too far in, it can easily be pinched off with a pair of aural forceps ; when deeper in, it can be scraped off with a small sharp spoon. 'I'hose of larger size, especially when arising in the tympanic cavity, should ta removed by the snare (l''ig. 218). If the growth be of large size, of long duration, and firm in structure, it is most easily re- moved by seizing it with a pair of dressing-forceps, and slowly ^olypus snare. CARIES AND NECROSIS. 477 twisting it round on its own axis. Care must be taken to fix the patient's head in order to avoid sudden movement on his part. However removed, the root of the polypus must be touched with a saturated sokition of chromic acid or perchloride of iron till it is quite destroyed. During the time occupied in destroying the root, the ear must be syringed twice a day with warm water, and alcohol dropped into the meatus and retained there some minutes. (2) Mastoid disease. — Not unfrequently inflammation of the tympanum spreads to the mastoid cells, especially to the large irregular cell {mastoid aninim) situated just behind and slightly above the external auditory meatus. The symptoms are deep- seated pain, tenderness on pressure, and when the periosteum is involved, redness and swelling ; and the ear projects more or less unduly from the side of the head. In many cases after a while, there is fluctuation, and on opening the abscess, the bone beneath is felt to be bare. Sometimes there is a fistulous opening com- municating with the mastoid cells. If the abscess is not opened, the matter may burrow downwards beneath the sterno-mastoid, or backwards beneath the muscles attached to the occiput. In severe cases there may be signs of cerebral irritation. Some- times the signs are very obscure, there being little indication of the mischief beyond deep-seated pain, tenderness on making firm pressure, and some fever. It is in such cases that the inflamma- tion is apt to spread to the cranial cavity. Occasionally the in- flammatory products ossify, and convert the mastoid cells into solid bone. Tj-eatment. — In the early stages apply hot fomenta- tions and leeches, and as soon as fluctuation can be detected, make a free incision into the swelling, and encourage the dis- charge from the tympanum by frequent syringing with warm water. In obscure cases, if the pain persists, and the temperature keeps above the normal, trephine the mastoid cells or open the cells and antrum by means of a mallet and chisel. There is little danger in trephining the mastoid cells, if care be taken to avoid wounding the lateral sinus. (3) Caries and necrosis. — The parts of the temporal bone most frequently attacked are the mastoid process, the posterior wall of the meatus, and the roof of the tympanic cavity. It is generally easy to make a diagnosis, but when the deeper parts are affected it may not be possible to do so with certainty. The points that will help the surgeon are, facial palsy, the persistence of offensive discharge in spite of cleanhness, and granulations re- sisting all attempts at destruction. Even then it may be neces- sary to put the patient under an anaesthetic, and carefully examine with a probe. Treatment. — If the diseased bone can be reached without further injuring the hearing, it should be freely scraped or removed. 478 DISEASES OF REGIONS. (4) Meningitis akb intracranial suppuration. — Although meningitis may supervene in the course of acute purulent catarrh of the middle ear, it is generally in the course of the chronic disease that it arises. Intracranial suppuration may occur be- tween the dura mater and the bone — subdural abscess — or in the cerebrum or cerebellum. Subdural abscess is generally found on the roof of the tympanum or on the posterior surface of the petrous bone ; cerebral abscess in the hinder part of the middle temporo-sphenoidal lobe ; cerebellar abscess in the anterior part of the lateral lobe. If in the course of chronic suppuration, headache, rigors, and a rise of temperature supervene, we may strongly suspect intracranial mischief; and if in addition there is photophobia, sluggish pupils and optic neuritis, the diagnosis is all but certain. Treatment — If the symptoms point to the prob- ability of intracranial abscess, the skull should be trephined, and an attempt made to reach the pus. The position of the trephine openings to reach matter are the following: — {a) to reach the mastoid antrum the centre of the trephine opening should be Vq, inch behind, and 3^ inch above the centre of the external auditory meatus ; {b) to expose the anterior surface of the petrous bone, and roof of the tympanum, the centre of the opening should be y% inch above the middle of the meatus ; (r) to expose the lateral sinus, the opening should be i^ inch behind, and Y^ inch above the middle of the meatus ; {^d) to reach a temporo-sphenoidal abscess, trephine x^ inch behind, and i^ inch above the meatus ; {e) to reach a cerebellar abscess, trephine i ^^ inch behind, and i^ inch below the middle of the meatus. Use a half-inch trephine, and afterwards enlarge the opening when necessary with chisel, gouge, forceps, etc. (5) Phf-ebitis and SEFric/EMiA. — Phlebitis of the lateral sinus may supervene in the course of suppuration of the middle ear, especially when there is caries of some part of the tympanic walls. When followed by septic poisoning, the symptoms are headadie, vomiting, and rigors, with great rise in temperature, sweating and tenderness over the mastoid, and in the course of the internal jugular vein. 'J'here is also frequently pain on making firm pres- sure at the posterior border of the mastoid processes, and, oc- casionally, local (jederna, and sometimes optic neuritis. Treatment. — 'I'rephine the mastoid, and if the sinus be found ])lugged, ligature the internal jugular vein in two places, and di- vide it between the ligatures. Now lay open the lateral sinus, and, removing the clot, thoroughly wash out the sinus with a weak solution of perchloride of mercury. If in doubt as to whether the lateral sinus is plugged or not, a fine trocar and cannula may first be inserted into it. CHRONIC NON-PURULENT CATARRH. 479 Chronic non-purulent catarrh. — By far the largest propor- tion of cases of deafness met with are due to chronic catarrh. So many pathological conditions are included under this heading, that it is impossible to do more than give a very general outUne of the symptoms. The affection may result from an acute attack, but more generally is a chronic affection from the very first. Heredity, syphilis, gout, rheumatism, and gestation, are predis- posing, and perhaps in some cases, exciting causes. Large doses of quinine, long continued, may also be an exciting cause. The disease at first progresses so insidiously, as often to remain un- suspected for some time. In many cases, tinnitus is the first and perhaps for a time the only symptom. More often, however, the earhest symptom is slight dfficulty of hearing general conversa- tion ; later there is tinnitus, at first intermittent, afterwards per- sistent. Gradually the deafness increases till it becomes marked. This deafness varies greatly with the state of the weather and the patient's general health. There is rarely pain, and when present, it is transient, and never severe. There is often a sense of tight- ness in the head, and a feeling as if the ears were stopped with cotton- wool. Sometimes there is giddiness, and some patients hear perfectly in a vibrating noise, as for instance, in a railway carriage. On inspection, the meatus is dry and shining ; and oc- casionally it contains impacted cerumen, the removal of which, however, causes no improvement in hearing. The membrane varies greatly in appearance. At times it is normal, oftener more or less opaque ; rarely is there any sign of congestion. The an- terior segment may be retracted, the handle of the malleus being sharply defined, or the entire membrane may be cupped, and the handle drawn inwards and backwards. Opacities, calcareous de- posits, and thinned spots are often seen. The cone of light may be altered in direction, may be broken into points, or may disap- pear. Rhinoscopic examination may show the naso -pharyngeal raucous membrane swollen, congested and granular, or pale and dry. Adenoid vegetations may be present. The Eustachian orifice may be obliterated by cicatricial bands, or variously dis- torted. Inflation may prove the canal patent, or more or less obstructed. If the labyrinth be not seriously involved, the tuning- fork is heard louder in the affected ear. Treatment. — The nasal cavity and pharynx should be examined and as far as possible re- stored to a healthy condition (see diseases of nose and pharynx). The patency of the Eustachian tube must be restored, if possible, by means of the air-douche, catheter, or electric bougie. The nostrils should be syringed through v/ith warm saline solutions, and astringent gargles when necessary should be given, or the throat painted with nitrate of silver, chloride of zinc or glycerine 480 DISEASES OF REGIONS. of tannin. If these means fail, the chloride of ammonium inhaler may be tried, or medicated fluids may be injected into the tym- panum, such as bicarbonate of potash, iolide of potassium, vapor of iodine, or pilocarpine, although I cannot say I have observed much benefit from their use. Some Surgeons recommend, in obstinate cases, peforating the membrane, and dividing the tensor tympani, the posterior fold, or the anterior ligament of the malleus. IV. Diseases of the internal ear. — Our knowledge of diseases of the internal ear is still so iipperfect, and our means of treatment so inadequate, that this part of the subject need not be discussed at any great length. Diseases of the internal ear, although often primary, are more frequently secondary to diseases of the middle ear. Jlie causes are: — 1. General diseases of the system, especially the zymotic diseases, such as scarlet-fever, measles, mumps, typhus, diphtheria, etc. ; also anaemia, lactation, and especially syphilis. 2. Extension from the middle ear, either directly or indirectly by causing reflex vaso-motor changes in the labyrinth. 3. Intracranial mischief, such as aneurysm of the basilar artery, meningitis, abscess or tumors. 4. Sudden loud noises, such as heavy artillery firing. 5. Great emotion; and 6. Continued use of large doses of quinine. The chief points of diag- nostic value are : — i. The vibrating tuning-fork placed on the middle line of the head is heard less distinctly with the deaf ear, or if both ears be affected, it is not heard at all or very indis- tinctly. 2. The tuning-fork when it has ceased to be heard through the cranial bones, can still be heard when placed opposite the meatus. 3. The tuning-fork when it has ceased to be heard by the patient, can still be heard by the Surgeon. 4. The patient hears the tick of the watch proportionately better than speech. 5. There is generally nausea or vomiting, giddiness, and always tinnitus. None of these signs and symptoms when taken sepa- rately are of much value, but when taken together, they are strong presumptive evidence of mischief in the internal ear. Meniere's disease is a sudden hsemorrhagic effusion into the labyrinth. The symptoms are very marked. The patient, whose hearing was more or less perfect before the attack, is suddenly seized with intense tinnitus and giddiness, often so great as to cause him to fall. The giddiness is followed by nausea or actual vomiting, faintness, and cold sweats. (Jn recovering somewhat, he finds he is deaf with one ear. The giddiness sooner or later passes off, but the tinnitus and deafness persist. If the deafness is absolute, the tinnitus may eventually disappear. Treatment. — Quinine, bromide of potassium, subcutaneous injections of pilo- carpine, and electricity are recommended ; but all treatment directed towards restoring the hearing is generally useless. TINNITUS AURIUM. 48 1 Auditory vertigo is characterized "by a sensation of motion, referred by the patient either to himself, or to surrounding objects, which seem to revolve in certain defined planes" (McBride). The attacks are generally paroxysmal, but often there is more or less constant giddiness, with occasional exacerbations. As may be seen above, auditory vertigo is a prominent symptom in Meniere's disease, but many causes may give rise to the symptom, such as (a) increased pressure on the secondary membranes of the tym- panum induced by accumulations of wax in the meatus, forcible syringing, or retraction of the membrana tympani due to obstruc- tion of the Eustachian tube; {^) fluid accumulations in the tympanic cavity ; (c) vascular and nervous changes, or effusion and secondary formations in the labyrinth itself; {d) intra- cranial lesions ; (e) dyspepsia, and (/) such drugs as quinine and salicin. Treatment. — The treatment consists in finding the cause, if possible, and attempting to remove it. When this is impos- sible, large doses of bromide of potassium, alone or combined with hydrobromic acid, will be found most efficacious. Next, quinine in large doses, but this must be carefully watched ; and lastly, the use of the continuous current of electricity. Tinnitus aurium arises under most varied conditions. The sounds complained of are very numerous, but may be divided into ringing, rushing, bubbling, and pulsating sounds. Any abnormal condition of the auditory apparatus will produce it, such as — i, accumulations of wax pressing on the drum-membrane ; 2, in- creased intra- labyrinthine tension, from undue pressure on the fenestrse (either by fluid in the tympanum, or retraction of the membrana tyaipani through obstruction of the Eustachian tube) ; or lastly, hypersemia of, or pathological change in, the labyrinth. But in addition to these local causes tinnitus may be produced by causes acting at a distance, such as aucemia, chlorosis, pulsating exophthalmos, aneurysm of the vertebral artery, cerebral disease, large doses of quinine, or salicin. Treatment. — In every case it is important, if possible, to ascertain whether the cause is to be found in some derangement of the auditory apparatus, or else- where. If the cause be local, it is generally possible to reheve or cure the tinnitus by curing the local affection. If the tinnitus depends on general anaemia, some form of iron, with a generous diet and the addition of stimulants may be sufficient to effect a cure. If there be hyperassthesia of the nervous system, the bromides are indicated, with the addition of hydrobromic acid, if the singing is of a pulsating character. Tinnitus frequently occurs in patients of a rheumatic diathesis, and in such, anti- rheumatic treatment is, of course, indicated. Other remedies failing, the Surgeon, empirically, may try chloride of ammonium, nitrite ot soda, and lastly, the continuous current of electricity. 21 482 DISEL-^SES OF REGIONS. DISEASES OF THE EVE. By Walter H. Jessop, M. B., F. R. C. S., Ophthalmic Surgeon to St. Bartholomew's Hospital. Physical examination of the eye. — For the complete and thorough examination of the eye it is necessary that it should be examined : — (i) by the unaided eye or by focal illumination ; (2) by the ophthalmoscope; (3) for acuteness of vision, fields of vision, color-sense, and tension. In all cases where practicable each observation on the one eye should be repeated on the other for comparison. (i ) Seating the patient in front of a window, or in a dark room with the lamp to the left and about two feet in front of him, direct and concentrate the light on his eye by a biconvex lens of about 2^ inches focal length {focal illiiviination^ . First look at the lids, and tell him to open and shut them ; then, with the hds open, to execute the various complete in, out, down and up movements of the eye to test the extrinsic ocular muscles. Along the edges of the lids look for the puncta which ought to be applied close to the ocular conjunctiva. Press near the inner canthus over the lachrymal sac to see if any discharge passes through the puncta. Evert the upper lid to examine its conjunctival surface by direct- ing the patient to look down to the ground, laying a probe hori- zontally on the external surface of the lid and then taking hold of the lashes turn the lid over the probe. Pull down the lower lid to examine its conjunctival surface. The ocular conjunctiva should be transparent-looking and a few small vessels should be seen through it perforating the white or bluish sclerotic. Just external to the inner canthus is a small greyish-red projection, the caruncle, and extending from it a pinkish fold, \\\q. plica semilunaris. The vessels seen in inflammations of the eye may be divided into the following: — i. '\\\t poskrioi conjunctival. These are generally brick- red in color, tortuous, movable with the con- junctiva, and disappear on pressure. 2. The suh-coiijunctival 'Mt branches or radicles of the anterior ciliary vessels and arc divided into the per/oraliui^ and the episcleral. The perforating::; arteries stop about ,|„ inch from the corneal margin, and are well seen in glaucoma ; the episcleral arteries form a ])ink zone of straight parallel vessels {circumcorfieal zone) not disappearing on pressure, and are well marked in iritis and keratitis ; the episcleral veins are dark, dusky-looking, often in limited i)atches, and are found in cyclitis, scleritis, glaucoma, etc. 3. The anterior conjunctival vessels are superficial branches of the anterior ciliary. They are bright red in color, found near the corneal margin, and indicate superficial corneal mischief. PHYSICAL EXAMINATION OF THE. 483 Next examine the cornea, the depth and contents of the an- terior chamber, and the iris as to its color, polish and pupillary aperture. The normal pupil is from 3.5 to 5 mm. in diameter, circular, regular, shghtly to the nasal side of the centre of the cornea, and equal to and varying with its fellow under dififerent degrees of illumination. The pupil should contract : — on light being thrown into the same eye {direct light reflex), on light being thrown into the opposite eye {consensual light reflex), and on accommodation or on the convergent movements of the eye associated with ac- commodation {accoinmodatioji reflex). It should dilate on one or both eyes being shaded, and also on stimulation of a sensory nerve {sensory reflex). Atropine, and homatropine, produce a dilated pupil {mydriasis) inactive to any of the reflexes ; cocaine causes mydriasis, but the pupil still acts to the contraction re- flexes ; and eserine, pilocarpine, produce a contracted pupil {miosis) always dilating slightly on shading or on relaxation of accommodation. The pupil is influenced by the blood supply, and if there is congestion of the iris it is contracted {congestion miosis) . (2) Examinatio7i with the ophthalmoscope. — The ophthal- moscope in its simplest form consists of a silvered glass concave mirror of about 20 centimetres focal length, with a central aper- ture {sight hole) of 3 miUimetres diameter, fitted on a suitable handle. If required for estimating refraction, lenses are arranged to pass behind the sight hole. The methods of using it are di- vided into {a), direct ^.wA {b), indirect, and are much easier with a dilated pupil ; for this object homatropine or homatropine and cocaine should be used if possible, {a) To use the direct method the patient should be sitting with the light at first just above and behind the head, the observer being about four feet away. Throw the reflection of the light from the ophthalmoscope- mirror through the pupil, and observe through the sight hole the pupillary area as a red color {red reflex). On now slowly rotat- ing the mirror horizontally and vertically a shadow is seen if the refraction is abnormal (araetropic), and this shadow moves in the same direction as the mirror in myopia, and in the opposite di- rection in hypermetropia and in myopia of less than one dioptre. {Retinoscopy.) Approaching closer to the patient, examine the media, and observe if any objects other than retinal vessels and the optic disk are seen. If so, on telling the patient to move his eye in different directions, these objects, which are usually of a dark color, will float about if they are in the vitreous. The lamp should next be moved on a level with the patient's head and on the same side as the eye under examination. On now bringing 484 DISEASES OF REGIONS. the ophthalmoscope to about 2 inches from the patient's cornea, and at the same time relaxing your own accommodation and tell- ing him to look into the far distance and to move his eye about as you direct, inspect the details of the fundus. If the patient has an error of refraction it is necessary to correct it by a suitable lens behind the sight hole. Now place a lens of nine dioptres behind the sight hole to investigate the vitreous and the posterior part of the lens, and one of twenty dioptres to see the cornea, anterior chamber, iris and anterior part of the lens. {d) The /;/c//;rr/ method is perhaps easier to a beginner, and gives an extensive and rapid view of the fundus, but is not so ac- curate as to minute details. At a distance of 18 inches look through the sight hole, your right eye at the patient's right eye, and vice versa, telling him to look into the far distance (to relax his accommodation) in the same direction as the fingers holding the ophthalmoscope if the disk is to be examined, or at the sight hole if the yellow spot region is to be investigated. Atter obtain- ing the red reflex, hold a lens of about 2^ inches focal length be- tween you and the patient and at about 2}4 inches from the patient's eye ; an inverted view of the fundus will be thus obtained. The following are the chief details to be observed in the normal fundus. The optic disk is grayish-pink, lighter than the rest of the fundus, and nearly circular in shape ; its centre is sometimes stippled {lamina cribj-osa), and often depressed {physiological cup) with the retinal vessels dipping into it. The periphery of the disk is usually lighter in color {scleral ring) and often bor- dered in part by pigment. Occasionally an opaque white striated patch, radiating from the edge of the disk, is seen with its margin gradually thinning out {opaque nerve fibres'). The rest of the fundus is bright red, with the retinal vessels on it ; sometimes the choroidal vessels may be seen plainly as a network and of a lighter color than the retinal vessels. At the yellow spot the choroidal red is generally deeper in color and there are no blood- vessels. 'I'he retinal arteries are as a rule smaller and lighter in color than the veins ; both usually divide at a short distance from the disk into superior and inferior temporal and nasal branches. The retinal veins can often be seen to pulsate even in health, and by pressing on the eyeball with the finger the arteries can gen- erally be made to pulsate. (3) Acuteness of vision. — Snellen's test-types are those usually employed for testing vision, and are constructed so as to be seen under the smallest visual angle (5 minutes). Place the patient at 6 metres from the distant type, and if his distant vision is normal, he ought to read the smallest letters, numbered 6 on the types. His vision is then called ;;, or 1. If he only reads the MEIBOMIAN CYST. 485 top letter it is ,/\,, or tV, and so on. If the patient is under 45 give him the reading types arranged on the same plan, and find out the smallest he can read, and at what distance, thus finding his near point and accommodation. If he is too blind to see the type hold your fingers before his eye, and measure the greatest distance at which he can count them. If he is unable to see the fingers, shade his eye, and throwing light into it, see if he has perception of light. If a patient has only perception of light, the observer should, by means of the ophthalmoscope-mirror in a dark room, throw light on to the different parts of his fundus to see if all are equally light-percipient {^projection) . The fields of vision may now be mapped out roughly by the fingers, or by the perimeter, for white and colors. Any spots of the field in which the object used is not seen are called scotomata. The colo7' vision is usually estimated by colored wools. Intra ocular tension may be estimated by instruments called tonometers, or by the fingers ; the latter is the usual way, and is effected by directing the patient to look down on the ground, and then palpating the eyeball through the upper lid with both index fingers. Certain degrees of tension have been recognized, the firm, tense, semifluctuating feeling of the normal eye being taken as the mean i^Tn') ; these are denoted according to the degree of increased tension + I, -|- 2, +3, or of diminished tension — i, — 2, — 3- I. Diseases of the eyelids and lachrymal apparatus. Ciliary Blepharitis ( Tinea Tarsi) is the most common in- flammatory affection of the lids ; it is usually chronic, and occurs especially in ill-fed, dirty, hypermetropic, or strumous children. The symptoms are redness of the ciliary border of the lids, and either an eczematous condition of the border, or more commonly inflammation and vesication of the hair follicles, with stunted and misplaced eye-lashes, followed in bad cases by scarring of the edge of the hd, and slight eversion. The best treatment is an alkaline lotion, as sodium bicarbonate, and a weak mercurial oint- ment applied along the edges of the lids night and morning ; in severe cases removal of the lashes and painting the borders of the lids with silver nitrate solution is advisable. The eyelashes may be the seat of the pediculus pubis, giving rise to a condition which may simulate ciliary blepharitis if there has been much irritation. Meibomian Cyst {chalazion) is the most common form of tarsal tumor, and is due to chronic inflammation of the fundus of a Meibomian gland. It occurs as a small, hard, painless swell- ing, with the skin of the lid freely movable over it. On the con- 486 DISEASES OF REGIONS. junctival surface of the lid there is usually a bluish-grey dis- colored spot, due to thinning of the tissues. A cnicial incision should be made through this spot, and the semi-fluid contents evacuated by pressure or by a small spoon. These cysts have no wall, are generally multiple, most common in young adults, and are very prone to suppurate. Site {hordeolum) is a localized inflammation of the cellular tissue of the lid, usually about an eyelash, but sometimes in con- nection with the duct of a Meibomian gland. It gives rise to throbbing pain, and swelling and oedema of the lid ; it is usually succeeded by others, and is due to some derangement of the gen- eral health or error of refraction. It quickly disappears on evac- uating the pus if present, or on pulling out the faulty lash. Symblepharon, or adherence of the palpebral conjunctiva to the ocular conjunctiva or cornea, may occur owing to inflamma- tion following burns, wounds, and ulcerations. Congenital Malformations of the lids are, ptosis (drooping of the upper lid), epicanthus (a fold of skin stretching across the inner canthus and concealing the caruncle), and coloboina (a deficiency of part of the lid). The Muscular Syslem of the Lids may be affected by sj^asm of the orbicularis palpebrarum {blepharospasm), paralysis of the orbicularis giving rise to inability to close the eye, and paralysis of the levator palpebrse producing ptosis. Inversion of the Eyelid {entropion) is produced by some affection of the conjunctiva or tarsus, or by spasm of the palpebral portion of the orbicularis muscle. The most frecjuent result of entropion is trichiasis (turning in of the lashes) giving rise to pannus, ulceration of the cornea, etc. Evfrsion of 'jhe Eyelid {ectropion) is due to atrophy of the palpebral portion of the orbicularis muscle, to swelling of the con- junctiva, or to cicatricial contraction. Numerous operations have been planned for ectropion and entropion and the consequent faulty position of the lashes. The Lachrymal Apparatus consists of the lachrymal gland and its ducts situated at the upper and external angle of the orbit, and the drainage system, which includes the puncta, canaliculi, lachrymal sac and nasal duct. The lachrymal gland may be the seat of acute or chronic inflammation, and may also be affected by hypertrophy, or sarcoma. The chief lachrymal troubles, how- ever, are associated with the drainage system, and the most marked symptom is that of watery eye {epiphora). The puncta may be everted or inverted by changes in the lid, or stenosed from inflammation, etc. The canaliculi may be narrowed by in- flammatory changes or cicatrization after injury, or obstructed by PURULENT CONJUNCIIVITIS. 487 cilia, concretions, etc. The entrance of the canaliculi into the sac is a very common place for stenosis. The lachrymal sac may be affected by inflammation spreading from the conjunctival or nasal mucous membrane. This may be accompanied by stricture of the nasal duct, and sometimes gives rise to a collection of mucus in the sac {jnucocele), and presents as a fluctuating swell- ing near the inner canthus. On pressing over the swelling the fluid can usually be forced out through the puncta. A lachrymal abscess often follows a mucocele ; the symptoms are then tense swelling and redness of the integument in the neighborhood of the lachrymal sac. The treatment for stenosis of the puncta or canalicuH is to employ probes or electrolysis, and if these methods fail, to slit up the lower canaliculus by a Weber's knife, removing a piece of the conjunctiva from the inner side of the incision with scissors. For stenosis of the nasal duct probes should be used to dilate it, and in many cases the use of styles for some time is ad- visable. In acute inflammation of the sac an incision should be made from the outside through the swelling, or the lower canali- culus should be slit up, and the pus, if found, evacuated that way ; the sac should afterwards be syringed with antiseptic or astringent solutions. II. Diseases of the Conjunctiva. Conjunctivitis (^Ophthalmia) , or inflammation of the con- junctiva, is characterized by a feeling of grittiness, heat, and heaviness of the lids, which tend to stick together, especially at night, injection of, and small haemorrhages from, the posterior conjunctival vessels, and generally discharge from the eye. 1. Catarrhal {mitco-pi/mlent) Conjunctivitis may be acute or chronic ; it presents the usual symptoms of conjunctivitis (see above), and is often accompanied by more or less muco-purulent discharge. It occurs in epidemics, and if there is much dis- charge, is contagious. There is often marked enlargement of the conjunctival follicles, especially of the lower lid {follicular con- junctivitis). Occasionally the discharge is more plastic in nature, adhering to the lids {pseudo-membraneous conjunctivitis). It is best treated by slight astringents or antiseptic lotions, and by ointments placed along the edges of the lids to prevent their sticking together. In chronic cases the refraction should always be tested, as refraction- errors, especially hypermetropia, may pro- duce this condition. 2. Purulent Conjunctivitis is an acute affection characterized by the severity and rapidity of its onset. It is microbic in origin, and the specific organism is frequently the gonococcus. It may be conveniently divided into two classes : 488 DISEASES OF REGIONS. I. Adult Puj-ulent Conjunctivitis {^Gonorrhceal Ophthabnia), the more serious affection, is due to actual contagion with the vims, and usually first affects only one eye. The period of incu- bation may be only a few hours. The lids at first are red and cedematous ; the conjunctiva is much swollen and infiltrated with serum {cJiemosis), and the discharge is serous in nature. After two or three days the serous discharge changes to a very copious discharge of thick pus. The great danger, if the condition is not soon reUeved by energetic treatment, is infiltration of the cornea, giving rise to a perforating ulcer and subsequent loss of the eye for useful vision. II. Infantile Purulent Conjunctivitis {Ophthalmia neonatorum') occurs in new-born children, generally on the third day after birth. It. affects as a rule both eyes, and is due to inoculation from the vaginal discharges of the mother ; to avoid this risk every child's eyes should be thoroughly washed immediately after birth with an antiseptic solution. The symptoms are similar but not so severe as in the adult, and the cornea is not so likely to become involved. The chief complications are corneal ulcers, leukoma adherens, anterior polar cataract, and panophthalmitis followed by shrinking of the globe. The treatment must be directed chiefly to washing away the dis- charge. For this purpose the eye should be thoroughly syringed or washed every hour, day and night, with a lotion of corrosive sublimate (i to 6,000). At the same time the lid should be everted if possible and painted with silver nitrate solution (grs. X, to 5J.) once a day, and, if practicable, ice-pads applied to the lids. This treatment should be continued as long as the discharge continues purulent. Ulceration of the cornea should be treated energetically by the actual cautery or sohd nitrate of silver. If only one eye is affected, the rule in the adult, the opposite eye should be covered if possible by a watch-glass shade to prevent noculation. 3. Memhrani'.ous {(liphtheritic) cONjuNcrivrns is the most serious and virulent form of ophthalmia, and an eye may be de- stroyed by it in twenty-four hours. It is marked by great pain and excessive brawniness and stiffness of the lids, owing to the plastic infiltration of the mucous and submucous surfaces. The palpebral conjunctiva is covered by a smooth grey membrane, and if this is stripped off, the surface still remains grey. The mem- brane lasts from 6 to lo days, and is then followed by purulent conjunctivitis. Treatment. — At first antiseptic lotions and warm fomentations, and then the usual treatment for ])urulent conjunc- tivitis. In two cases lately under my care the membrane rapidly disappeared, without being followed by purulent conjunctivitis, after the subcutaneous injection of diphtheric anti-toxin. PTERYGIUM. 489 4. Granular conjunctivitis {Trachoma) derives its name from the presence on the palpebral conjunctiva, especially near the fornix of the upper lid, of greyish raised bodies about the size of a pin's head. It may be acute or chronic, and occurs at all ages except in very young children. It is especially common in those subjected to bad hygienic surroundings ; hence its frequency in insanitary schools, marshy districts, and overcrowded camps. The acute form is rare in England and is accompanied usually by a muco-purulent discharge which generally absorbs the granula- tions and so cures the disease. In the chronic form the symptoms are a heavy look of the lids, irritable eyes, and at times a muco- purulent discharge. The muco-purulent discharge depends more upon the condition of the conjunctiva than on the presence of the granulations. The disease is probably only contagious during the continuance of the discharge. The granulations often affect the submucous tissue, giving rise to scarring. Pathology. — There are two views as to the nature of the granules : i. That they are due to hypertrophy of the lymph-follicles of the conjunctiva ; and, 2, that they are new growths. The disease is beUeved by some to depend upon the presence of a specific micro-organism. It may be complicated by pannus, ulcers of the cornea, entropion, trichiasis, etc. Treatment. — In the acute form antiseptic lotions should be employed. In the chronic form, with muco-purulent discharge, paint the inside of the Hds once a day with silver nitrate solution (grs. x. to ,^j.), and order an astringent lotion, as zinz sulphate (grs. ii. to .?j.), to be dropped into the eye two or three times a day. If there is no discharge, touch the granula- tions lightly two or three times a week with a crystal of copper sulphate. During the discharge stage the patient should be isolated. 5. Phlyctenular conjunctivitis is characterized by the pres- ence on the ocular conjunctiva or on the anterior surface of the cornea of one or more papules or pustules surrounded by a limited vascular zone. It is extremely common in young children, es- pecially if strumous. Photophobia or Hd-spasm may be present. The t7-eatment is chiefly dietetic, with the local application of yellow mercuric oxide ointment. Pinguecula is a yellowish elevation, not containing fat, of thickened conjunctiva and subconjunctival tissue, near the inner or outer edge of the cornea. Pterygium is a triangular thickened piece of the ocular con- junctiva, with its apex at the margin of or on the cornea. It is especially found on people who have been in the tropics. If it invades the cornea it may be dissected off and the apex stitched back on the conjunctiva. 490 DISEASES OF REGIONS. Wounds of the conjunctiva heal well, and if extensive ought to be stitched up. III. Diseases of the coj-nea and sclerotic. Keratitis, or inflammation of the cornea, is characterized, as a rule, by pain, photophobia, lachrymation, impairment of vision, pink circumcorneal vascular zone, and want of natural trans- parency of the cornea. It may be divided by its position into i, superficial ; 2, interstitial ; and 3, posterior or punctate. 1. Superficial keratitis is usually produced by irritation due to roughness or insufficient protection of the lids. The condition is often vascular {pannus). A very painful form is accompanied by numerous small vesicles {herpes of the cornea). The treatment consists in the removal of the irritant, and in the application of sedative lotions of opium, belladonna, etc. In obstinate cases of pannus the operation of pcritomy (removal of a ring of con- junctiva round the corneal periphery so as to cut off the super- ficial blood supply to the cornea) may be performed. Corneal Ulcer a'-, a loss of substance due to limited inflammation of the corneal tissue. It is described here under superficial keratitis because it usually begins in the superficial or epithelial part of the cornea. Sometimes from the commencement it af- fects the corneal tissue proper, and is then generally produced by a limited collection of pus in the lamell?e of the cornea {abscess or onyx). A corneal ulcer may be {a) simple, or {I?) infective, and in either case may be central or peripheral, acute or chronic. {a) The simple ulcer may be due to an abrasion of the cornea, a phlyctenule, etc., and is best treated when acute by atropine drops, unless it be deep and peripheral, when eserine or pilocar- pine drops are to be preferred. When chronic, an ointment of yellow mercuric oxide (gr. ij. — xv. to vaseline ^j.) should be placed in the eye once or twice a day, and massage employed to the surface of the closed lid. {b) The infective ulcer tends to spread rajjidly at its edges and also in depth ; it is often accompanied by hypopyon (pus in the anterior chamber) and then is generally microbic in origin. The best treatment is the actual cautery or solid nitrate of silver ap- plied to the edges and base ; the evacuation of the pus in an adult by ta]jping the anterior chamber from below ; and the local application of belladonna or atropine. 2. Intersti'iiai, keratitis is usually associated with congenital syphilis, sometimes with struma, and occasionally with acquired syphilis. The whole cornea undergoes a subacute or chronic in- flammation, and at first looks steamy and then patchy and like FOREIGN BODIES. 49 I ground glass ; the patches usually become vascular {salmon patches^, but there is no tendency as a rule to superficial ulcer- ation or suppuration. After some months the eye begins to clear up under treatment, even in very bad and apparently hopeless cases. Though as a rule one eye is attacked first, the other after a few weeks or months generally becomes affected. The usual age is between five and sixteen. The attendant complications are iritis, secondary glaucoma, uveitis, and in very bad cases shrink- ing of the eyeball. After an attack there are to be found gen- erally nebulae in the cornea and always the remains, at the corneal periphery, of the vessels of inflammation. The treatment is usually the administration of small doses of mercury over a long period, or iron tonics, and locally atropine and yellow oxide of mercury ointment. 3. Keratitis punctata is probably never present without dis- ease of the uveal tract (page 492). It is characterized by the presence of dots of different sizes on the epithelium of Descemet's membrane. These are generally arranged in the lower half of the cornea in the shape of a conical bullet with the apex upwards. The dots may be proliferations of the posterior corneal epithelial cells, or granules, etc., deposited on the epithelium. The results of keratitis are often to be found in the corneal tissue as small branching lines (remains of vessels), greyish opacities {nebulce), and dense opaque white patches {leiikomata). The use of lead lotion in keratitis is especially prone to give rise to leukomata, and should therefore never be used in this disease. In cases of perforating ulcer, the iris may become adherent to the cornea, a condition known as anterior synechia, or if the corneal scar is white, as leukoma adherens. The other results which may occur are conical cornea, and bulging of the cornea and sclerotic {anterior staphyloma') . Conical cornea (keratoconus) is a bulging of the central por- tion of the cornea. It generally occurs in females, and is due to defective nutrition of the corneal tissue. It may follow an ulcer, especially if central. Operative procedures, as iridectomy, tre- phining the cornea, etc., rarely do any good, and the same may usually be said for concave and stenopeic glasses. Foreign bodies on the cornea should be removed as soon as possible. Anaesthesia of the cornea should first be obtained by dropping 4% cocaine solution three times into the eye at inter- vals of five minutes. The patient being placed on a chair facing the light, the operator stands behind the patient and with the fingers of the left hand separates the lids, at the same time press- ing on the eyeball to steady it. Then with a spud or needle held in the right hand the foreign body should be Ufted off or picked out of the cornea. 492 DISEASES OF REGIONS. ScLERiTis {episcleritis^ or inflammation of the scleral tissue, is accompanied by a circumscribed reddish-purple patch of vascular congestion about 2 to 3 mm. from the corneal margin, generally on the outer side. It lasts as a rule for some months, and often relapses ; the pain and tenderness vary much in intensity, and in severe cases keratitis and iritis may be present. It is more com- mon in women than men, and affects especially those of the rheu- matic and strumous diathesis, or patients with a syphihtic taint. The best modes of ireat»tent are warm fomentations of opium, leeches, massage, belladonna and atropine if iritis is suspected, and general constitutional remedies. Wounds of this region may be divided into id) corneal, {b^ scleral, and {c) sclero-corneal. (^) Corneal wounds, unless implicating the lens or iris, generally heal quickly, {b') Scleral liwunds more than y{ inch behind the sclero-corneal junction, if small and unaccompanied by the presence of a foreign body in the eye, may be stitched up, or the conjunctiva stitched over them, and then treated by ice-pads to allay inflammation, (r) Sclero- corneal wounds are the most dangerous, owing to the great risk of sympathetic inflammation, and demand great judgment in sav- ing the eye ; in most cases the eye ought to be excised, especially if the lens is injured. IV. Diseases of the uveal tract. The UVEAL traci' comprises the iris, ciliary body and choroid, and though disease may be limited to one part, there is always a tendency for it to spread through the whole tract. Iri'iis or iNFLAMMAiioN OF THE IRIS may be acute, subacute or chronic. The usual symptoms of a case of acute or subacute iritis are — pain and tenderness along the ophthalmic division of the fifth nerve, dimness of sight, lachrymation, injection of the episcleral vessels giving rise to a pink circumcorneal zone, and occasionally photophobia. The iris is dull and discolored, e. .<,'•., a blue iris becomes green, the pupil- is sluggish, contracted, generally irreg- ular owing to adhesions to the anterior capsule of the lens {pos- terior synechice), and acts badly or not at all to atropine. In chronic iritis there may be no symptoms except irregularity of pupil, dimness of vision, and at times pain. Iritis is especially likely to occur in- patients suffering from syphilis, rheumatism, or gout ; it may also have a traumatic origin, or be secondary to inflammations of the cornea, sclerotic, or the other parts of the uveal tract. The iritis associated with syphilis is often symmetri- cal, and generally accomj)anied by great effusion of lymph in the neighborhood of the pupil, but in the secondary stage of this dis- IRIDECTOMY. 493 ease the symptom may be absent. Iritis in rhaimatic patients is usually very painful, and differs as a rule from the syphilitic vari- ety in its great tendency to recur. It is especially liable to attack those of the rheumatic diathesis if suffering from prolonged gon- orrhoea! discharge. In gou/y subjects there may be a very insidi- ous form {quiet iritis). The local treatment is first directed to obtaining dilatation of the pupil by atropine or atropine and cocaine combined ; if there is much congestion of the conjunc- tival vessels and pain, it is well to apply one or two leeches or a small blister to the temporal region about one inch from the ex- ternal canthus. The general treatment is that applicable to the diathesis of the patient, but a mild course of mercury is by some always prescribed in acute iritis. The chief trauimatic affections of the iris are blood in the anterior chamber {hyphoenia) , mydriasis (due to paralysis of the sphincter pupillse), tremulous iris (generally due to dislocation of the lens), rupture of the ciliary border of the iris {coretlialysis), a rent in the pupillary border, and prolapse of the iris after a per- forating wound. The congenital abnormalities are difference in color in both irides, irregularity in shape and position of pupil, multiple pupils {polycoria), remains of pupillary membrane, deficiency of part of iris {coloboma), and absence of iris {iri(lej'emia) . In coloboma the defic- ^^'^■ iency is generally downwards and in- wards, and is often combined with a similar condition of the choroid. Iridectomy. — This operation may be ^I^^^^J^ performed {a) to improve the sight in cases of corneal opacity^ anterior polar Spring eye-specuium. cataract and lamellar cataract, {I?) as a remedial measure in glaucoma, relapsing iritis, and complete pos- terior synechia, and (<:) in cataract extraction. Operation. — Place the patient in the recumbent posture and induce general ansesthesia, preferably by chloroform, or local ansesthesia by means of cocaine (4 %), Standing behind the patient's head, introduce the spring speculum (Fig. 219) ; fix the conjunctiva near the cornea with fixation-forceps opposite the place selected for the coloboma. Pass the keratome by pressure perpendicularly through the cornea (Fig. 220), and then lowering its handle press the blade into the anterior chamber parallel to the iris, now lowering the handle still more till the point nearly touches the posterior surface of the cornea, and then slowly with- draw the keratome. Give the fixation forceps to an assistant to gently depress the eye ; pass through the wound the iridectomy 494 DISEASES OF REGIONS. Fig. 220. forceps closed with the points directed towards the posterior sur- face of the cornea, open the forceps, seize the pupillar}' border of the iris, slowly draw it out, and snip it off with the scissors either parallel to the wound, or at right angles to the wound across the cornea. Carefully return the edges of the coloboma with a curette (Fig. 221), and bandage up the eye. In iridectomy for glaucoma it is usual to have a large corneal incision (some operators preferring a Graefe's knife), and to remove the iris up to the ciliary border. Cyclitis, or inflammation of the ciliary body, rarely occurs without other parts of the uveal tract being involved. The symptoms are cir- cumcorneal zone of redness, pain and tenderness in the ciliary region, pain on accommodating, and often hypopyon and vitreous opacities. It is best treated by atropine and leeches. Ckoroiditis, except as part of a more general mflammation, is rarely accompanied by external signs or severe pain. Ophthalmoscopically there may be, if recent, soft yellow- ish-white exudation patches either at the yellow spot or elsewhere ; these patches on clearing up leave as a rule atrophy of the choroid, showing the sclerotic through, and the edges bordered by disturbances of pigment. 'J"he atrophic patches may be ringed, djffused, or punctate, and if due to haemorrhage from the choroidal vessels are generally large and deeply pigmented. I'he retinal vessels always pass over these patches of choroiditis. Vision is as a rule affected, but not always. The usual causes are syphilis (acquired and congeni- tal), myopia, tubercle and hasmor- Fir,. 221. rhages. In syphilitic cases mer- curial treatment should be con- tinued for a lengthened period. Curette. UvEi'iis, or general inflammation of the uveal tract, commonly starts in the ciliary body, and is characterized by the chief symptoms of iritis, cyclitis, and choroiditis. It may be divided into (i) purulent, and (2) plastic. I. I'URULENT uvKi'Jls { pa iiophthti/i/iitis) has usually a traumatic origin, but may occur in ijya:;mia and in old blind eyes. The Showing speculum in eye, fixation-for- ceps in position, and the keratome passed into the anterior chamber in the operation of iridectomy down- wards and inwards. PLASTIC UVEITIS. 495 symptoms are extreme pain, acute congestion and oedema of the lids and conjunctiva, and after a few days, if the media are trans- parent enough, a yellowish reflex, due, as a rule, to suppuration in the vitreous. The usual course is for the inflammation to affect the whole interior of the eye, and afterwards the extrinsic mus- cles and Tenon's capsule. The treatment is either immediate enucleation, or incisions into the eyeball to allow free vent to the pus. Meningitis has occasionally followed enucleation in these cases. 2. Plastic uveitis is characterized by a great tendency to de- position of lymph, and may be divided into Acute and Chronic. («) Acute plastic uveitis {Sympathetic Iiifiaiiimation or Sympa- thetic Ophthalmia^ is set up in one eye by morbid changes, usu- ally the result of a wound of the other eye. The injured eye is called the "exciting," and the other the "sympathizing eye." It occurs usually from six weeks to three months after injury. It is preceded, as a rule, by a condition known as " Sympathetic Irri- tation," characterized by lachrymation, photophobia, dimness of sight, oscillations of the pupil and frontal neuralgia. The symp- toms are impaired vision, circumcorneal zone, keratitis punctata, deep anterior chamber, iritis, papillo-retinitis, and opacities in the vitreous. These symptoms are followed by thickening and vascularization of the iris, occlusion of the pupil by lymph, shal- low anterior chamber, diminished tension, shrinking of the vitreous, detachment of the retina, etc. The prognosis is very unfavorable, as only in a few cases the changes stop short of actual loss of the eye for useful vision ; and it must always be re- membered that the sympathizing eye suffers as a rule more se- verely than the exciting. The nature of the disease is probably a microbic inflammation spreading from the exciting eye by the optic nerves and chiasina to the sympathizing eye. The treat- ment consists in confinement to a dark room, goggles, atropine, leeches and mercury. If the exciting eye is quite blind it should be excised, but if it has useful vision it should be saved. {i?) Chronic plastic uveitis occurs as a rule in strumous and syphilitic patients. The disease progresses Hke "Sympathetic Inflammation," but is more chronic ; it usually affects both eyes at intervals, and often passes on to complete blindness. In young children plastic uveitis may produce a condition called ''pseudo-glioma," which may be diagnosed as a rule from glioma by discoloration and adhesions of the iris, minus tension, etc. A less severe and more common form of chronic plastic uveitis may be called Anterior Uveitis {Serous Iritis) from its affecting the anterior part of the uveal tract. It is characterized by keratitis punctata, deep anterior chamber, often dilatation of the pupil, in- 496 DISEASES OF REGIONS. creased tension, and the usual symptoms of iritis and cyclitis, ac- companied frequently by a few peripheral choroidal changes, and small vitreous opacities. It is generally found in young adults, especially women, and is often associated with gout, rheumatism, and struma. The treatment is complete rest for the eyes, and atropine drops with careful watching of tension. The Uveal tract may be affected in any part by sarcoma (gen- erally melanotic), the usual primary ocular seat of sarcoma being the ciliary body or the choroid. V. Diseases of the crystalline lens. Cataract is the name applied to an opacity, complete or partial, of the lens, and is due to structural changes. Cataracts may be divided into ha?-d or soft, according to their consistency, and this usually depends on age, as below thirty-five they are all "soft." They are called /r/w^:;;!' when independent of any other ocular affection, and secondary when following some other disease, as glaucoma, intra-ocular tumor, etc. Though all cataracts at first are incomplete or partial, yet it is advisable to make a divi- sion into (i) complete (including those that in time tend to be- come complete), and (2) partial (those that do not, as a rule, tend to become complete). (i) Complete CATARACTS are usually senile or hard, and are called, according to their seat of origin, nuclear or cortical. Nuclear cataracts are characterized by an opacity at the nucleus of the lens ; they are often amber in color and usually hard, ex- cept sometimes in diabetes ; cortical cataracts, which are the more common, begin as flakes or streaks radiating from the axis of the lens. Congenital cataract may occur as a general opacity of the lens ; it is usually binocular, and, of course, soft. A com- plete cataract may degenerate and its cortex become fluid {Mor- gagjiiafi Cataract). (2). Partial cataracts include {a) lamellar, {I)) anterior polar, and {c) posterior polar. {a) Lamellar {zonular) cataract xv, either congenital or forms in early life ; it is generally associated with a history of infantile convulsions, and with a deficiency of the enamel of the teeth, 'i'he opacity is situated as a shell between the nucleus and cortex, which are l)oth clear. It is usually symmetrical. {b) Anterior polar {pyramidal) cataract is a small dense white centr il opacity on the anterior cajisule of the lens, usually due to jjerforation of the cornea in early life, and as a rule asso- ciated with corneal nebula. (^) Posterior polar cata^'act is situated at the posterior pole of PLASTIC UVEITIS. 497 the lens. The opacity is generally in radiating spokes, and is often accompanied by disease of the vitreous or choroid. Diagnosis. — When a cataract is complete it looks white, amber, or gray, and may be best seen by dilating the pupil, and examin- ing by focal light. When incomplete and cortical the strige may be seen by oblique illumination if the pupil is dilated, or by throwing light into the eye by the ophthalmoscopic mirror (pre- ferably a plane mirror), when the striae will appear as black lines. The siibjeclive symptoms in incipient cataract are failing vision, black fixed spots or lines before the eyes, ability to see better in the dark due to dilatation of the pupil, myopia, and sometimes monocular diplopia or polyopia. Treatment. — In incipient senile cataract, especially of the nuclear variety, weak atropine (gr. ^ to gr. j. to .^j.) drops will often temporarily improve the sight, and may be ordered with caution. The operations for removal of the lens are of two kinds, namely {a) extraction, and (^) discission; extraction is always prefera- ble in hard cataracts, and sometimes in soft, especially in adults. It is, of course, necessary before proceeding to operation that the condition of the eye be satisfactory as far as the lids, conjunctiva and lachrymal apparatus are concerned, and that there is good perception and projection of hght. The tests for the perception and projection of light should never be omitted, since, if the eye is blind or the fundus is seriously diseased, the removal of the cataract would be useless and unjustifiable. In senile cataract it is usual to wait till the vision of one eye is reduced to mere per- ception of light, and the vision of the other is insufficient to allow the patient to follow his occupation. The general health of the patient must also be investigated, as senile cataract may be asso- ciated with gout, glycosuria, and arterial disease. {a) The extraction operations are numerous, but the only one described here will be the 3 miUimetre flap operation, which may be performed with or without iridectomy. Operation. — The first steps are as in operation for iridectomy (see p. 493). After the introduction of the spring speculum, fix the eye by seizing the conjunctiva with fixation-forceps immedi- ately beneath the cornea, pass the point of a Graefe's knife through the margin of the cornea at the outer extremity of a hori- zontal line 3 millimetres beneath the summit of the cornea (Fig. 222), and direct it carefully across the' anterior chamber to the inner corneal end of the above horizontal line ; complete the in- cision in the corneal margin above by slow to and fro upward movements of the knife. An iridectomy upwards is now per- formed if required (see p. 494). Fixing the eye, pass a cysti- 498 DISEASES OF REGIONS. Fig. 222. tome (Fig. 223) through the wound and divide the anterior cap- tule of the lens by horizontal incisions. Draw the eye now slightly downwards, and apply moderate pressure by a curette (Fig. 221) or spoon below the lower edge of the cornea till the upper edge of the lens presents in the wound (see Fig. 224) and the lens is gradually delivered. The speculum is now removed and the lids closed for a brief time, after which any soft matter is extracted by pressure applied to the lower surface of the cornea with a curette. The iris is now carefully replaced by the curette, and both eyes band- aged up. The after-treatment con- sists in keeping the eyes bandaged for about a week, removing the bandages and washing the lids gently every day. If there are any signs of iritis, characterized by pain and swelling of the lids, atropine and leeches must be prescribed ; if the corneal wound suppurates it should be cauterized or dusted with iodoform. The other complications are prolapse of the iris, in- traocular haemorrhage and panophthalmitis. After two months the vision should be tried for glasses, and if there is much mem- brane left in the pupillary area, producing unsatisfactory vision, a Showing speculum in eye, fixation- forceps, and Graele's knife in posi- tion for performing flap section in cataract extraction. The line ot flap is also shown dotted. Fig. 223. Cystitomc. secondary operation must be performed. This is done, the eye being under atropine and cocaine, by passing a needle through the periphery of the cornea and breaking up the membrane. {b) 'I'he discission or needling operation, for soft cataract. — I'lace the patient in the recumbent position and induce local anaesthesia by cocaine, or if the jiatient be nervous or a young child, give chloroform. 'The pupil must be fully dilated before- hand by atropine. Standing behind the patient's head introduce the spring speculum (Fig. 219), and pass a sharp, straight stop- needle (Fig. 225) through the periphery of the cornea into the anterior chamber. Push the needle firmly but gently till it PAPILLITIS. 499 Fig. 224. touches the anterior capsule of the lens near its centre, and by a crucial incision lacerate the capsule of the lens. Now slowly withdraw the needle, put atropine in the eye, and apply a band- age. The effect of this operation, which may have to be repeated, is that the lens-matter passes into the anterior chamber, and is softened by the aqueous and absorbed. Occasionally in young children repeated needlings may produce absorption of the whole lens. As a rule, however, after a week or ten days the soft matter must be evacuated, especially if it produces much irritation or increased tension. This is done by making an in- cision in the lower part of the cornea by a keratome (Fig. 220), as in the first steps of an iridectomy operation (page 493). After the corneal inci- sion has been made and the keratome withdrawn, a curette (Fig. 221) should be intro- duced through the corneal wound, and by manipulating the curette the soft matter passes out along its groove and can be removed. Care must be taken on completion of the operation that the iris is not caught in the edges of the wound. The CHIEF INJURIES of the lens are (i) traumatic cataract due to rupture of the capsule, and (2) Stop-needie. dislocations of the lens, usually downwards but sometimes into the anterior or posterior chambers. Showing the lens presenting in the wound from pressure by the spoon during the operation of extraction. VI. Diseases of the optic nerve, retina, and vitreous. The optic nerve fibres may be divided into two sets, axial (for the supply of the yellow spot region) ^.nd periphei-al (for the rest of the retina). Optic neuritis, or inflammation of the optic nerve, may be acute or chronic, and attack the whole or part of the fibres of the nerve ; and may be divided into ( i ) papillitis affecting the intra- ocular end of the nerve, and ( 2 ) retro-bulbar neuritris affecting the nerve behind the globe. I. Papillitis usually affects both eyes except when due to 500 DISEASES OF REGIONS. orbital mischief. The signs, chiefly opthahnoscopic, are hyper- gemia, swelUng and haziness of the edges of the disk, distended and tortuous retinal veins, and small or normal retinal arteries. In extreme cases the retina is much involved {papillo-rctinitis^, the distended veins being covered in part by greyish-white striae or opacities, and the retina itself cedematous with flame-shaped haemorrhages often radiating from the disk. The vision may be normal or much reduced, and the field for vision is usually peripherally limited. The chief causes are cerebral tumors, cerebral abscess, tubercular meningitis, and nephritis, also orbital inflammations, acute myelitis, syphilis, chlorosis, and lead poison- ing. The treaiinent is chiefly constitutional, but in uni-ocular papillitis incision into the nerve-sheath has by some been recom- mended. 2. Retro-bulbar neuritis may occur in one eye, due to orbital periostitis, etc., without at first any ophthalmoscopic signs, the only symptoms being loss of sight and generally pain on movement of the eye. There is usually a central scotoma. As a rule symptoms of optic atrophy follow. Chronic retro-bulbar ?ieuriiis {toxic amblyopia), affecting usually both eyes, is an inflammation of the axial fibres, and is found in persons using excess of tobacco or alcohol, and perhaps in diabetes. The symptoms are diminution of vision, usually of both eyes, the fields of vision being normal as to their periphery, but containing a central scotoma (blind spot) for red and green. By the ophthalmoscope there is usually no change to be seen. The patients complain of mist before the eyes, and of confusing gold and silver coins ; they generally exhibit want of tone, etc. The treatment is directed to improve the general health, and to avoid the exciting cause. Atrophy of the optic nerve may be a primary disease, or secondary to some other optic nerve or retinal affection. By the ophthalmoscope the optic disk is white or greyish, often slightly cupped or filled up ; the lamina cribrosa is too plainly visible ; the retinal vessels, especially the arteries, are too small ; the vessels may be accompanied by white streaks on each side ; and if there has been previous papillitis, the vessels are curved antero- po&teriorly and often obscured in places ; the scleral ring round the disk is too white, and the edges of the disk may be irregular. Atrophy may follow pajjillitis, retro-bulbar neuritis, embolism of the central artery of the retina, retinitis (especially ])igmentary), and glaucoma. A form called progressive atrophy is found in locomotor ataxia, insular sclerosis, general paralysis of the insane, and as a purely local disease ; it is marked by concentric con- traction of the fields of vision, loss of sight, color blindness, and GLIOMA OF THE RETINA. 5 01 sometimes central scotoma, and as its name implies, progresses to complete blindness. The treatment is generally the administra- tion of anti-syphilitic remedies, hypodermic injections of strychnia, and galvanism, but the prognosis is as a rule very bad. Retinitis, or inflammation of the retina, is usually accompanied by diminution of vision, especially at night or in dim lights, and is characterized ophthalmoscopically by loss of transparency and haze of the fundus ; soft white discrete or grouped spots ; haemor- rhages of various sizes and shapes (striated or flame-shaped in nerve-fibre layer, large and serai-circular in yellow spot region), and by vitreous opacities. Retinitis is associated with syphilis, nephritis, glycosuria, leukaemia, pyaemia {pttrulent retinitis) and with diseases of the circulatory system {hcBmorrhagic retinitis). The treatment is chiefly constitutional, and the eyes must be shaded and used as little as possible. Retinitis pigjnientosa is a chronic and symmetrical disease, occurring in early life, characterized by night blindness, and great contraction of the fields of vision, even though the central vision be normal. Ophthalmoscopically the optic disk is " waxy- looking " and atrophied, the retinal arteries are small, and there is much lace-work retinal pigment, especially near the equator. The loss of sight is progressive, and the disease often ends in blindness. Embolism of the central artery of the retina occurs usually on the left side and in connection with heart disease. Owing to this artery being a terminal one, complete plugging of it is fol- lowed by total and sudden bhndness. The ophthalmoscopic signs are pale optic disk, diffused retinal haze, bright red color at yellow spot, and retinal arteries near disk very small and often like white threads. The treatment \^ massage of the eyeball,. but the prognosis is bad. Detachment of the retina is due to separation of the retina from its pigment epithelium by haemorrhage or serous exudation. It is accompanied by defect in the field of vision corresponding to the detachment. With the ophthalmoscope the detachment looks greyish, and the retinal vessels passing over it are seen to be elevated. The causes are blows on the eye, myopia, cicatrices following wounds, choroidal tumors, etc. lyeatment, except complete rest, is usually unavailing. Glioma of the reiina, which has quite recently been shown by Collins to be an adenoid cancer and not a sarcoma, occurs in early Hfe, and the first symptom is a shining white or yellow reflex seen behind the pupil ; by focal illumination there is found a nodulated swelling, with small vessels and often haemorrhages on it. The tension may be normal or increased, and there may be 502 DISEASES OF REGIONS. secondary glaucomatous symptoms. The Uratiiicnt, unless the tumor is very large, is immediate excision of the eye and removal of as much of the optic nerve as possible. The prognosis is very unfavorable. Vitreous opacities are usually due to inflammation {Iixalitis) associated with diseases of the uveal tract or retina, but often occur in extreme myopia, and from retinal and choroidal haemor- rhages. The opacities may be of different shapes and sizes, and in syphilis are very minute and dust-like. The patient com- plains of seeing black specks floating about, and vision is some- times reduced. Owing to degeneration the vitreous may be fluid, and contain cholesterine crystals. SuppuR.-\TiON OF THE vitreous {suppurative hyalitis) is due to injury or to extension of a purulent uveitis, and is sometimes called pseudo-glionia, from its yellowish fundus-reflex. Foreign bodies, as steel, glass, etc., may be found in the vitreous, and, when steel or iron, can be removed by the electro-magnet intro- duced through the original wound when scleral, or through an incision in the sclerotic. VII. Glaucoma. Glaucoma is a condition of the eye dependent on excess of the intra-ocular pressure. The chief symptoms are increased intra- ocular tension (elicited by palpating the eyeball with both index fingers through the closed lids) ; pain and tenderness ; enlarge- ment of the perforating vessels ; impaired sensibility, steaminess, and pitted appearance of the cornea; shallow anterior chamber; dilatation of the pupil ; greenish fundus reflex ; pulsation of the retinal arteries, and engorgement of the retinal veins ; under- mining and cupping of the optic disk ; diminished acuity of vision and light sense ; and limitation of field of vision, chiefly at nasal side. 'I'hese symptoms are generally preceded or accompanied by smoky vision (everything seen in a grey or yellow fog), col- ored concentric rings (rainbows), round lights (red outside and bluish -green inside), neuralgia along the branches of the fifth nerve, and rapidly increasing presl)yopia, necessitating frequent changes of glasses. Varieties. — Glaucoma may be divided into (i) acute, (2) sub- acute, and (3) chronic. I. Acute glaucoma is characterized by the severity and sudden- ness of its onset, and from the vomiting, megrim, etc., accompa- nying it has often been mistaken for a bilious attack. The steami- ness of the cornea prevents as a rule any view being obtained of the fundus, although the jjupil is widely dilated. The optic disk GLAUCOMA. 503 when visible is found in first attacks not to be cupped, but there is marked pulsation of the retinal arteries and engorgement of the veins. Such an attack may pass off after a few days, but is generally followed by others until the eye may pass into a permanent glau- comatous condition {^absolute glaucoma) and vision be totally de- stroyed. Absolute glaucoma is accompanied by great pain and increased tension, intra-ocular haemorrhages, opacity of the lens, ulceration and staphyloma of the cornea, and shrinking of the whole globe. Some cases of acute glaucoma may be accompa- nied by severe intra-ocular haemorrhage (Jicemori'hagic glau- coma). 2. Subacute glaucoma is characterized by the symptoms of glaucoma as given above. There is generally a gradual progress, sometimes with exacerbations, and it may at any time give rise to acute glaucoma. 3. Chronic glaucoma may follow on an acute or subacute attack, but there is an insidious and progressive form usually attacking both eyes, in which all irritative signs are absent. With- out pain and often with no apparent increase of tension, there is gradual reduction of the amplitude of accommodation, and dimin- ished corneal sensibihty, with cupping and progressive atrophy of the optic disks often passing on to absolute bhndness. Pathology. — Glaucoma is produced by any circumstance tend- ing to upset the normal relation of the secretion and excretion of the intra-ocular fluids. These fluids, secreted by the ciliary pro- cesses, pass chiefly out at the angle between the iris and the cor- nea {iridic or filtration angle). This increased tension may be produced by hypersecretion of the ciliary processes, obstruction at the filtration angle, or by serosity of the fluids. The most fre- quent cause is obstruction of the filtration angle due to inflamma- tory products, or to mechanical means, as growth of the lens, or dilatation of the pupil, especially by atropine. Glaucoma occurs as a rule in persons over 40 years of age, is frequently hereditary, and is often associated with hypermetropia. It may be secondary to complete posterior synechia, perforating ulcers and wounds of the cornea, dislocation of the lens laterally and into the anterior chamber, cataract operations, intra-ocular tumors, and intra- ocular hsemorrhage. The treatment of acute glaucoma is by instillation of eserine (especially if the attack is caused by atropine) or by a large iri- dectomy, as much as one-fifth of the iris being removed. Several other operations have been recommended, as sclerotomy, etc. In glaucoma absolutum puncture of the sclerotic often relieves the pain. In subacute cases iridectomy is generally indicated, but in chronic glaucoma without tension operative procedure probably does little good. 504^ DISEASES OF REGIONS. VIII. Diseases of the oj'bit. SuBCONjL'NCTiVAL H.tjviORRHAGE, duc to a blow on the eye or to rupture of a small vessel, owing to cough, etc., is of a bright red color. The blood effusion is more marked anteriorly, and does not pass far back. Exactly the converse as to the position of the blood applies to deep orbital hcemorrhage following fracture of the anterior fossa of the skull, etc. Orbital abscess and orbital cellulitis, when acute, are diffi- cult to diagnose from each other. Though often traumatic, they may be due to cold, irritation of a tooth, erysipelas, pysemia, etc. They sometimes originate in periostitis. They are usually char- acterized by swelling of the lids, cheraosis of the conjunctiva, pain on movements of the eye and on pressing back of the eyeball, limitation of the ocular movements, facial neuralgia, and prop- tosis ; sometimes there is a defined, tender, fluctuating swelling. If the symptoms are not soon relieved, especially in orbital cellu- litis, papillitis and atrophy of the optic nerve may ensue, and also meningitis. Orbital abscess may be chronic and simulate a solid tumor. The treatment consists in early evacuation of the pus, hot fomentations and constitutional remedies. Tumors of ihe orbit usually cause protrusion of the eye {proptosis), impairment of its movements, and papillitis or optic atrophy. Generally one orbit only is affected. The origin of an orbital tumor may be primary, in the lachrymal gland, in the loose orbital tissues, in the periosteum, in the eyeball, or in the optic nerve ; or secondary, starting from a neighboring cavity. The primary tumors may be cystic (hydatid, dermoid) ; osseous (ivory exostosis), sarcomatous, and vascular (ngevi). Amongst the secondary tumors may be mentioned arterio-venous com- munication in the cavernous sinus giving rise to a pulsating tumor, and distension of the frontal sinus by retained mucus {frontal mucocele'). The treatment is chiefly the same as in other parts. Malignant tumors should be freely removed with, if necessary, the eyeball and the contents of the orbit, and chloride of zinc paste in some cases applied for a few days afterwards. Enucleation of the eye. — Patient lying down and as a rule under general anaesthesia ; operator standing behind the head ; spring speculum in lids. Divide conjunctiva and subconjunctival tissue all round the cornea with scissors ; raise each rectus tendon in succession on a squint hook (Fig. 227) and divide each one close to the globe ; now separate the limbs of the speculum and the eye-ball will project forwards ; pass a pair of stout curved scissors, closed, behind the globe from the outer side, and feel for the optic nerve ; then pull back the scissors slightly, open EMMETROPIA. * 505 them, and divide the nerve. The globe, now pushed forwards by the scissors, is taken between the fingers and thumb, and the other attachments are divided by the scissors. After the opera- tion, firm pressure is applied by a bandage. There is but rarely any trouble from any hgemorrhage. An artificial eye may be given about three months after operation, if the socket is healthy. IX. Errors of refraction and acconunodation. The light percipient portion of the eye exists at the external layer of the retina \rods and cones), and it is necessary for perfect vision that images of external objects should be accurately focussed on this layer. Rays of light passing into the eye are re- fracted at the anterior surfaces of the cornea, lens and vitreous, and brought to a focus at a point varying with the refraction. The human eye for the sake of simplicity may be represented by Fig. 226. Diagram to illustrate errors of refraction. L. Convex lens. X X. Principal axis. D. Divergent ray. P. Parallel ray. C. Convergent ray. H, Em. and My. Position of hypermetropic, emmetropic, and myopic retinae. a convex lens of 23 mm. focus; and the following laws regulating the passage of Hght through a convex lens will then be applicable to it. Rays of light passing through a convex lens (Fig. 226, L) parallel (P) to the principal axis (X X), and therefore coming from infinity, are brought to a focus at a point Em. {^principal focus') varying inversely in distance to the convexity of the lens ; rays coming from a point (D) closer than infinity {^divergent rays) are refracted further back (My.) from the lens than the focal point; and rays coming from a point (C) beyond infinity {^con- vergenf) are focused at H between the lens and its principal focus Em. Emmetropia. — In an eye of normal refraction {^emmetropia) with its accommodation relaxed, parallel rays (P) passing through 5o6 DISEASES OF REGIONS, the pupil will be focussed by the surfaces at a point (Em.) rep- resented by the external surfaces of the rod and cone layer of the retina; divergent rays (D) will be focussed behind the retina at My. ; and convergent rays (C) in front of the retina at H. In order to focus the divergent rays (D) upon the retina (Em.), it is necessary to increase the convexity of the lens and so shorten its focal length. This is done by accommodation, and a young emmetrope with normal accommodation should be able to focus on his retina all rays from parallel to divergent ones starting from a few inches from his cornea. Hypermetropia is the condition in v/hich in the eye at rest the retina (H) only receives convergent rays (C) ; parallel rays (P) and divergent rays (D) are refracted beyond the retina (H.) This takes place from too short a distance between the cornea and the retina, or from lessened convexity of the lens ; the usual cause is congenital shortness of the axis of the eye. Hyper- metropes from this fact are obliged to accommodate for parallel rays, and still more for divergent ones. The treati/ieni naturally is to increase the convexity of the lens artificially by giving a con- vex lens ; and by so doing allowing parallel rays to be refracted on the retina, and then the ciliary muscle will be able to focus divergent rays on the retina. In children and young adults, to find out their hypermetropia it is often necessary to order atropine before testing the refraction. The symptoms of hyper- metropia are pain and discomfort on reading, congested eyelids and conjunctivae, spasm and fibrillar twitchings of the lids, con- vergent strabismus, headache, etc. Hypermetropia is usually congenital, often hereditary, and is frequently associated with a flat-looking face, shallow orbits and small eyes. Myopia is the opposite condition to hypermetropia, and in it the retina (My) only receives certain divergent rays (D). It is due as a rule to the axis of the eye being too long, or in some cases to the ciliary muscle rendering the lens too convex {spasm of accommodation). 'I'he treatment^ except in cases of spasm of accommodation, is to give concave glasses to allow parallel and divergent rays to fall on the retina. In low degrees of myopia it is only necessary to order glasses for distance, but in high degrees it is usual to order a stronger pair for distance, and a weaker pair for reading, etc. In apparent myopia due to spasm of the ciliary muscle it is necessary to order atropine to find out the true refrac- tion. Myopes often have the head elongated in the antero- posterior diameter, a long face and large prominent eyes. Myopia is generally accompanied by a crescent at the outer side of the disk { posterior staphy/oma) , and there may be secondary choroidal trouble, detachments of the retina, vitreous, opaci- ties, etc. STRABISMUS. 507 Astigmatism is the condition in which one or more of the re- fractive surfaces have not the same curvature in all directions. Astigmatism may be divided into — (i), irregular, in which there is a difference of refraction in the different parts of the same meridian due to changes in the lens and cornea ; and (2), regular, where there is a difference in two meridians {chief meridia?is) at right angles to one another, and called those of maximum and minimum refraction. It is usually corneal {sialic asligtnalisvi) , but may be due to the ciliary muscle {dynamic asligmalism). Regular astigmatism may be — {a) simple, where one meridian is emmetropic and the other hypermetropic or myopic, and is then called simple hypermetropic or simple myopic astigmatism ; {b) compound, where the chief meridians are unequally myopic (com- pound myopic astigmatism) or unequally hypermetropic (com- pound hypermetropic astigmatism) ; or {c) mixed, where one chief meridian is hypermetropic and the other myopic. The Ireatment is by cylindrical glasses for simple astigmatism, and by cylindrical glasses in combination with sphericals for compound and mixed. Presbyopia. — In the eyes. of all persons from 40 to 45 years of age it is found that, owing to changes in the elasticity of the lens, the ciliary muscle begins perceptibly to lose its power of altering the convexity of the lens. The effect of this will be to prevent near objects being focussed on the retina; in order to counteract this condition and to help the ciliary muscle it is necessary to give convex glasses for reading. It has been found that the glass needed is about one dioptre for every five years after 40. In myopes wearing glasses for reading, this amount will have to be subtracted from their glasses. X. Strabismus and ocular paralysis. Strabismus {squint) is always present when the two eyes are not directed simultaneously towards the same object, and is usually accompanied at some time by double vision {diplopia). Strabismus occurs from over-action, weakness, or paralysis of one or more of the extrinsic ocular muscles. It is usually convergent or divergent, but may be upward or downward. It may be con- stant or occasional {periodic), and though usually only one eye squints, yet sometimes both eyes may do so in turn {alternating). When the squinting eye follows its fellow normally in all its move- ments, the squint is called concomitant in contra-distinction to paralytic. Diplopia is much more marked in paralytic than in concomitant squint. The non-squinting eye is called the fixing eye, and strabismus may be estimated by telling the patient to 5o8 DISEASES OF REGIONS. look at an object about two feet away with the fixing eye, and then taking the distance between the middle of the palpebral aperture and the middle of the cornea of the squinting eye {primary squint) ; on now making the squinting become the fix- ing eye, the amount of deviation of the original fixing eye is taken {secondary squint). In paralytic cases the secondary squint ex- ceeds the primary, but it is equal to the primary in concomitant squint. Convergent strabismus {internal squint) is most commonly due to hypermetropia, owing to the fact that the excessive accommo- dation necessitates a correspondingly great convergence ; but it may occur occasionally in myopia, and follows division or paraly- sis of an external rectus. Divergent strabismus {external squint) is caused from insuffi- ciency of convergence power, and weakness of the internal recti, especially in myopia ; from defective vision of an eye, as in corneal nebulae, etc., and from division or paralysis of an internal rectus. The treatment oi concomitant strabismus is by atropine, eserine, spectacles, prisms, and stereoscopic exercises. The operations that may be required are either tenotomy of the muscle of the affected side, or advancement of the muscle of the opposite side. As a rule only one eye should be operated on at a time. The treatment of paralytic strabismus is by constitutional remedies and galvanism of the affected muscle. Tenotomy of the internal rectus. — Patient lying down and under cocaine or general ansesthesia ; operator standing in front and to the right-hand side. Introduce the spring speculum, and pinch up with a pair of fixation forceps the conjunctiva and subconjunctival tissue at the point of junction of the lower horizontal and inter- vertical tangents to the F'G. 227. cornea. Divide this fold with a pair of blunt-pointed scissors, making the inci- sion only large enough to Strabismus hook. admit the iK)ints of the scissors, and then, passing the scissors through the incision, divide the capsule of Tenon. Pass the strabismus hook (Fig. 227) into the wound, directing its point backwards, and then turn the end of the hook upwards be- tween the globe and the tendon, until its point is seen beneath the conjunctiva, at the upper border of the tendon. Introduce the scissors through the wound and open the blades on either side of the tendon between the globe and the hook, and by one or two snips cut through the tendon. Remove the hook and then re-introduce it to see if the tendon is completely divided. The HERPES OF THE LIP. 5O9 eyes should be bandaged for about twelve hours. The method is the same for the external rectus, but it must be remembered that the tendon is situated a little further back. Ocular paralyses. — Complete Paralysis of the Thi7-d Nerve is characterized by complete ptosis ; external strabismus ; inability to move the eye completely up, down or in ; crossed diplopia ; moderate mydriasis and inactivity of the pupil to all the reflexes ; and paralysis of accommodation. Any one of the muscles sup- phed by the third nerve may be separately paralyzed, also the superior oblique (fourth nerve) and the external rectus (sixth nerve). Paralysis of the external rectus gives rise to internal strabismus, inability to move the eye outwards, and homonymous diplopia. It is the most common of the ocular palsies, probably from the long course of the sixth nerve. All the external ocular muscles may be paralyzed at the same time {^ophthalmoplegia ex- terna). The intra-ocular muscles are the pupillary {sphincter ptipillcB) and the ciliary. The pupillary muscle may be affected by paraly- sis of the third or short ciliary nerves, producing medium mydriasis, and by paralysis of the cervical sympathetic or long ciliary nerves, producing partial miosis. The ciliary muscle may be paralyzed {cycloplegia) by affections of the third or short cihary nerves, usually in conjunction with paralysis of the pupillary muscle. It may be paralyzed alone as in diphtheria. In certain diseases, especially locomotor ataxia, the pupil acts to accommo- dation but not to light {Argyll- Robe7-tson or spinal pupil). The treatment of ocular paralysis is chiefly constitutional. Many are of syphilitic origin and require mercury or iodide of potassium, but faradization of the affected muscle may also be em- ployed. In mydriasis and cycloplegia the use of eserine is indi- cated. NvsTGAMUS {involuntary oscillations of the eyeball) is generally binocular, and the movements of the eyes are usually horizontal or rotatory. It occurs generally in early Hfe, and is then due to defect of sight from corneal ulcer, etc., sometimes in adult life, in patients with diseases of the nervous system, such as disseminated sclerosis, and in coal miners, in whom it is probably due to their position at work. DISEASES OF THE LIPS, CHEEKS, AND MOUTH. Herpes of the lip. — A crop of herpetic vesicles which burst in a few day's leaving small scabs, are common on the lip during shght attacks of catarrh, indigestion, etc. Their occurrence in pneumonia is well known. SIO DISEASES OF REGIONS. Cracks and fissures of the lip following exposure to cold, etc., in dyspeptics, are very common, and if neglected, may form deep and painful fissures, prone to bleed and obstinate to heal. A simple ointment, and if persistent touching them with nitrate of silver, will generally suffice to cure them. They must not be mis- taken for the fissures about the corners of the mouth so common in congenital and acquired syphilis. Papillomata or warty growths of the lip are of interest in that they are liable as age advances to become epitheliomatous. They may sometimes grow out in the form of horns. Extirpation with the knife is the proper treatment. Superficial ulcers on the inner surface of the lip are common accompaniments of errors in digestion, and of secondary syphilis. There are usually similar ulcers on the side of the tongue and cheeks. Nitrate of silver or chromic acid lotions are the best local applications. N^vus of the lip when small may be touched with nitric acid or ethylate of sodium ; and when pendulous and projecting from the free margin, ligatured. When involving the whole substance of the lip it may be treated by electrolysis, or better, excised by means of a V-shaped incision. Hypertrophy of the up, generally the upper, is often met with in connection with cracks and fissures in strumous children, and is known as the strumous Up. A similar condition is some- times met with in congenital syphilis and in chronic nasal catarrh. The thickening, as a rule, disappears under constitutional treat- ment, and as the patient grows older. The removal of a wedge- shaped piece, as advised by some, can seldom be necessary. Carbuncle of the lip is a most dangerous disease, as it is very likely to lead to infective phlebitis of the facial vein, which may spread thence through the ophthalmic vein to the cavernous and other cranial sinuses, and terminate in infective meningitis or in general blood-poisoning. Free incisions should be made, the sloughs scraped away, antiseptics applied, and the strength sup- ported by fluid nourishment and stimulants. Adenomata, or lauial ca.ANDULAR tumors (Paget), occasionally occur in the lip as small, smooth, elastic growths projecting under the mucous membrane. They sometimes contain nodules of cartilage, and are then of harder consistency. They should be removed from the mucous surface to avoid scarring. Cysts due to obstruction of the mucous follicles are frequent in the lip. They contain a glairy fluid, and appear as small, tense, semi-translucent, globular, bluish-pink swellings on the mucous surface. A free incision through the mucous membrane, and re- moval of the cyst-wall with forceps, is perhaps the best treatment. HARE-LIP. 511 Epithelioma nearly always occurs in men, and on the lower lip ; and although it may affect non-smokers, it generally appears to be due to the irritation and heat of a short clay pipe. It be- gins as a crack, small ulcer, or indurated tubercle, and may either spread superficially along the free margin of the lip, or extend deeply into its substance. Sooner or later it involves the whole lip and adjoining parts, becomes adherent to the jaw, and invades the bone. The lymphatic glands in the neck become involved, but dissemination through internal organs is rare. If removed early, it may not recur till after a long period of immunity, or perhaps not at all. It seldom returns in the scar, but in the lymphatic glands, the patient dying of exhaustion induced by ulcerating and bleeding masses in the neck. The affection is very apt to be mistaken for ha^-d chancre, and the latter has ere now been cut away under the impression that it was an epithe- lioma. The following points should serve to distinguish them : — I. Epithelioma generally occurs in the old, and in men, and on the lower lip ; chancre in the young, in women, and on the upper lip. 2. The epitheliomatous ulcer has hard, sinuous, and everted edges, and an indurated and warty base ; the chancrous is raised, excoriated, smoother, and the induration is more circumscribed. 3. In the malignant affection, the glands are not affected till late in the disease — perhaps six months ; in the syphilitic early, say six weeks. Moreover, in chancre secondary symptoms will be present or soon appear, and the disease readily yields to anti- syphilitic remedies. Treatment. — Free and early excision is imperative. The growth may be either included in a V-shaped incision, the wound being afterwards united by hare-lip pins, or if superficial, freely shaved off. The glands in the neck, if enlarged and not too extensively diseased, should be extirpated at the same time. When the bone is involved, a portion of the jaw may be removed if the whole disease can be got away. Hare-lip is a congenital malformation in which the upper lip is vertically cleft on one or both sides of the median line. It is so named from its fancied resemblance to the lip of the hare. It is produced by the failure of union of the fronto-nasal process which forms the median portion of the lip with the superior maxillary processes which form the lateral portions. The fissure will, therefore, be opposite the suture between the superior max- illary and premaxillary bones, the situation at which the union between the above-mentioned processes normally occurs ; and it will be single or double, according as the failure of union occurs on one or both sides. It may exist as a mere notch on the free margin of the lip, but it more frequently extends deeply through the substance of the lip into the nostril above. Single hare-lip is 512 DISEASES OF REGIONS. far more common than double hare-lip, and occurs much more often on the left than on the right side. The two margins of the cleft are often unequal in length, the lip on one side of the cleft being on a lower level than on the other. In double hare-lip the central portion is generally shorter than natural, and along with the premaxillary bone and the incisor teeth frequently projects forwards, the two clefts being often of unequal extent. Cleft palate is a frequent concomitant of hare-lip, and malformations, such as club-foot, spina bifida, etc., are not uncommon in other parts of the body at the same time. Treat/ncrit. — The edges of the cleft should be pared, and the raw surfaces brought into contact, and there held by hare-lip pins or sutures, so that primary union may occur. The operation is best done between the third and fifth months of infancy, as very young infants bear haemorrhage badly, and laler, the troubles of teething begin. To ensure success the child should be brought into the best possible state of health by careful nursing and feed- ing, and any constitutional taint, as syphilis, corrected by appro- priate remedies. There are various methods of operating. Here only the more simple can be described. Whatever method is adopted, the ob- jects to be kept in view are — i, to obtain primary union through- out the wound, and hence the minimum of scarring ; 2, to ensure the margin of the prolabium and free border of the lip respect- ively being in line ; 3, to prevent the formation after the opera- tion of a notch at the line of union. These objects are best attained by well freeing the lip from the gums at the apex of the cleft so as to avoid tension ; by using a sharp knife so as to ensure clean incisions ; by taking care to completely pare the margins ot the cleft, and to remove sufficient tissue to secure broad, raw sur- faces ; by passing the hare-lip pins on the same level, and deeply enough to bring the whole of the raw surfaces into contact ; and by making the cuts in paring the edges concave towards the middle line of the cleft, so as to lengthen the line of union and allow for retraction. Operation for sini:;lc lia re-lip — Having placed a Smith's clamp (Fig. 228) on the lip on either side Fig. 228. of the cleft to control hemorrhage, pare the edges of the cleft with a sharp narrow-bladed scalpel, taking care to remove the whole of the rounded portion of the prolabium on Smhh's clamp for controllinRha;mor- ^ach sidc of the baSC of the clcft : and rhagt; during operation iorharc-Iip. ' having freed the li]) from the gums at the apex of the cleft, bring the raw surfaces together by hare-lip HARE- LIP. 513 pins, passing the lower one first to ensure the free edge of the Hp and prolabium being in Une. The lower pin should be entered a quarter of an inch from the margin of the cleft, and made to transfix the coronary artery ; but it should not penetrate the mucous membrane, as if this be done the mucous membrane will double in and prevent union . A second pin will generally be neces- sary, and should be passed in the same way, and a silk suture twisted round each. The sharp ends of the pins should be nipped off with pliers, a small piece of oiled lint placed beneath them to prevent injury to the cheek, and several sutures of horse-hair passed superficially to keep the edges of the wound in accurate apposition. The parts should then be dried, and covered with iodoforraized collodion, and a dumb-bell-shaped piece of Fig. 22Q. Fig. 230. G:.^ Operation for single hare-lip when the fissure does not extend into the nostril. Strapping applied across from cheek to cheek to prevent traction. The pins should be removed at the end of twenty-four to thirty- six hours, as otherwise they will leave scars. The twisted suture should be left on till firm union has occurred, and the strapping re-applied. Where the fissure does not extend through the whole lip, an inverted V-shaped incision may be made, with its angle just above the apex of the cleft (Fig. 229), each arm stopping short of the prolabium ; the tissues included in the arms of the V should now be drawn down, and a diamond-shaped wound thus formed (Fig. 230). On bringing the raw surfaces together, a pro- jection in place of the fissure will exist on the free border of the lip (Fig. 231) ; but this will disappear in time, leaving the lip nearly natural. When there is much irregularity between the two portions of the lip (Fig. 232), the incision on the shallower side should stop short of the prolabium, so as to allow the flap thus formed to remain attached at its base. On the deeper side the incision should slope off at an angle through the prolabium, com- pletely removing the tissue. The flap left on the shallower side should be now turned down and united to the sloped-oft' portion on the deeper side, and the vertical portions of the incision brought together as usual. Thus, what was the free edge of the 514 DISEASES OF REGIONS. cleft on the shallower side, now becomes the free edge of the lip (Fig. 233). Operation for double hare Up. — When the premaxillary process projects, it should not, as a rule, be removed, but previous to the operation for uniting the lip, be partially detached with the cutting pliers, having one blade blunted by being wrapped in lint, and then be forced back into place and there secured by a plug of gauze in the wound, a pad over it, and a dumb-bell-shaped piece of strapping fixed to the cheeks. In some cases the forcing into Fig. 233. Operation for single hare-lip when the sides of the fissure are unequal place of the premaxilla will be facilitated by excising a wedge- shaped portion of the nasal septum to which this bone is attached. There are many ways of uniting the lip. The simplest, perhaps (Figs. 234 and 235), consists in paring completely the central Fig. 234. Fig. 235. Operation for double hare- lip. portion, and then making two flaps from the lateral portions, bringing them down and uniting them to each other below the central i>ortion, and also to it, so that they may fill up the gap left by the deficient length of the central portion. RoDKNi' ui.cK.K most oftcn occurs on the face, especially near the inner canthus of the eyelids and the side of the nose, and is therefore conveniently described here. It is also met with on the scalp, the forehead, and the ear, and more rarely on the neck and chin, and even on the limbs and breast. Rodent ulcer is generally regarded as a form of carcinoma ; it differs from ordinary carci- noma, however, in that it is much slower in its growth, and does STOMATITIS. 515 not become disseminated, affect the lymphatics, nor return after complete removal. Pathology. — In the early stages the disease is not an ulcer but a new growth, and in exceptional cases the new growth preponderates over the ulceration, so that a mass of some size is formed. Rodent ulcer, unUke squamous-celled epithelioma, does not grow from the surface, but begins in the subcutaneous tissue, and it is only after it has spread some little distance super- ficially that the epidermis ulcerates. The new growth is believed to originate from the external root-sheath of the hair follicles, or from the sebaceous or the sweat glands. Microscopically the earli- est manifestation is the appearance under the epidermis of irreg- ular groups of small round or oval cells lying in a fibrous matrix. These cells may sometimes be seen continuous with the cells of the external root-sheath. Here and there irregular and ill-formed cell-nests occur. The ulceration is preceded, indeed is caused, by the extension of the new growth. From squamous-celled epi- thelioma rodent ulcer differs in that in the latter the cells are smaller and rounder, cell-nests are either absent or are ill-formed, and the processes of the growth spread superficially instead of deeply, and are flask-shaped and much branched. Signs. — The disease is one of advanced life, and seldom occurs before fifty. It is twice as common in men as in women. It generally begins as a small tubercle, which later becomes an ulcer. The ulcer is generally single ; its edges are irregular, sinuous, and a little raised, and but very slightly if at all indurated ; its base is shghtly depressed, glazed, void of granulations, generally of a pale pink color, and at times covered with a scab. The skin around is healthy. Although attempts at cicatrization are sometimes seen, the cicatrix readily breaks down, and the ulcer, which never quite heals, slowly extends, destroying muscle, cartilage, and bone, till at the end, perhaps, of twenty or thirty years it has destroyed a great part of the bones of the face, one or both of the eyes, and the cartilages and bones of the nose, leaving a horrible and un- sightly chasm. Treatment. — The growth or ulcer should be freely excised. If done early the prognosis is good, as it is only when some of the growth is left that a recurrence need be feared. Even in the later stages when much tissue has been destroyed, free removal with the knife and the application of caustics to what cannot be thus removed, will sometimes stop the further progress of the growth. Stomatitis, or inflammation of the mouth, may be divided into the aphthous, the parasitic, the ulcerative, the syphilitic, the mer- curial, and the gangrenous. Aphthous stomatitis generally depends upon some digesdve dis- turbance, and is common in young children. It is characterized 5l6 DISEASES OF REGIONS. by white patches of erosion on the mucous membrane of the Hps, cheek and tongue. Rhubarb and magnesia, and locally borax and honey, are the usual remedies. Parasitic stomatitis, or thrush, resembles the preceding, but depends upon the presence of a parasite known as the oidiiim albicaiis. It is generally merely symptomatic of other diseases, to the alleviation and cure of which the treatment should be directed. Ulcerative stomatitis is more serious, but is still, as a rule, superficial. It may depend upon digestive disturbance, local irri- tation of cutting teeth, or bad hygiene. The ulcers are covered with a gray slough, the gums are red and swollen, and the breath is foul. A stimulating plan of treatment is generally required, with attention to the digestive functions, hygienic surroundings, etc. Locally, the mouth should be rinsed out with a wash of chlorate of potash. Syphilitic stomatitis is common during the secondary and ter- tiary stages of syphilis, and requires no further mention. Mercurial stomatitis, depending upon an overdose of mercury, or some idiosyncrasy of the patient to the drug, is of less frequent occurrence in its severe forms than formerly. It is attended with foul breath, swollen tongue, spongy gums, profuse salivation, swell- ing of the parotid and submaxillary glands, and loosening of the teeth. It may terminate in gangrenous ulceration, with exten- sive destruction of the soft tissues, and perhaps necrosis of the bones. Chlorate of potash, both internally and as a mouth-wash, should be given ; and the strength supported by fluid nourish- ment and, if indicated, by stimulants. Gans;rcjioi(s stomatitis or cancrum oris, is a phagedtenic ulcer- ation, which begins on the inside of the cheek, and if not checked rapidly involves its whole thickness. It is very apt to terminate in blood-poisoning. It appears to depend upon thrombosis of the capillaries, a condition recently shown to be induced by the presence of a specific micro-organism. It is most frequently met with in under-fed, debilitated children recovering from one of the exanthemata, typhoid fever, etc., or subjected to bad hygienic conditions. A foul and black slough forms in the mouth, and a dusky patch soon appears on the surface of the cheek, which be- comes hard and brawny, and then black. If the disease is not soon arrested, extensive sloughing occurs, typhoid symptoms set in, and the patient dies comatose, of general blood-]K)isoning, or of bronchitis or pneumonia. It appears to be of a nature similar to the gangrenous inflammation of the female genitals known as noma. The treatment must be energetic. 'J'he parts should be well dried, and thoroughly destroyed with fuming nitric acid ; or BURSAL AND DERMOID CYSTS. 517 boroglyceride may be applied in milder cases. The strength must be supported with strong beef-tea, brandy-and-egg mixture and nutrient enemata. Recumbency should be insisted upon during convalescence, since there is a tendency to fatal syncope, which may remain for some time. Salivary calculi are sometimes met with blocking the orifice of Wharton's duct, or, more rarely, one of the ducts of the other salivary glands. They are composed of animal matter, impreg- nated with phosphate and a trace of carbonate of lime. Gen- erally they can be seen, or at any rate felt, in the interior of the mouth, as hard bodies in the course of the duct. They may give rise, by causing retention of the secretion of the gland, to swell- ing, pain, and tenderness in the obstructed gland, and sometimes to suppuration and salivary fistula. An incision through the mucous micmbrane over the calculus will allow of its removal with a scoop or forceps. Should stricture of the duct follow it must be divided transversely. Ranula is a bluish-white, semi-translucent, globular or ovoid swelling situated in the floor of the mouth beneath the tongue, and containing a glairy mucoid fluid. It is probably produced by the enlargement of one of the mucous follicles so numerous in that situation. Mr. Morrant Baker has conclusively shown, by introducing a small bristle into the duct by the side of the swell- ing, that it is not usually a dilatation of Wharton's duct, as was formerly taught. It is painless, but interferes, to a greater or less extent according to its size, with the movements of the tongue in speech and deglutition. Sometimes these cysts attain a large size and extend deeply in the neck, presenting below the jaw. Treatment. — After painting the parts with a twenty per cent, solution of cocaine, a portion of the cyst-wall should be pinched up with nibbed forceps, and a good-sized piece of it ex- cised with curved scissors. A deep hold must be taken, or the mucous membrane, which adheres but loosely to the cyst, will alone be caught up. The fluid should be squeezed out, and the lining membrane cauterized with a stick of nitrate of silver, and the opening kept free by the daily passage of a probe, so that healing may take place from the bottom. If a mere incision is made, the cyst is nearly sure to fill again. A seton will sometimes answer, but it is not always reliable ; if, therefore, the treatment above indicated fails, the cyst should be dissected out. Bursal and dermoid cysts. — Pathology. — These cysts, which contain a glairy fluid or a grumous sebaceous material, project both under the tongue and in the neck below the jaw. Those in the middle line of the neck or tongue may be due to, i. En- largement of the hyoid bursa, 2. Dermoid formations, and 3. 5t8 diseases of regions. Remains of the thyroid duct {J^is's duct). In the last case they are situated («) near the foramen caecum, bulging under the tongue, or {b) in the neck, projecting perhaps as low as the pyramidal or middle lobe of the thyroid body. Those on one side of the neck are dermoid formations in the regions of the branchial clefts. As they increase in size, they send prolonga- tions in various directions, and sometimes become connected with the carotid sheath. Signs. — The middle-line cysts form fluctuating swellings in the front of the neck, and when due to enlargement of the hyoid bursa are often translucent. In the lateral cysts fluctuation may sometimes be obtained by one finger in the mouth and another on the cyst in the neck. When they extend to the sheath of the great vessels the pulsation of the carotid may be communicated to them. Treatment. — The bursal cysts should be removed through a vertical incision over them in the middle line of the neck. The dermoids, when they project under the tongue and are not too large and apparently movable, may at times be shelled out through an incision in the floor of the mouth to prevent scarring. Otherwise they must be dissected out through an incision in the neck. diseases of the tongue. Tongue-tie is due to the tongue being more or less tightly bound down to the floor of the mouth by the shortness of the fraenura. It is apt, when well marked, to interfere with sucking, and later, with distinct speech. It is easily remedied by divid- ing the fraenum with probe-pointed scissors, care being taken to direct the points downwards and backwards and merely to notch the free border, lest the ranine artery be wounded, an accident which, in infants, has been attended with severe, and in some cases fatal, haemorrhage. If the division of the fraenum is too free, the tongue may loll backwards, pressing the epiglottis over the entrance of the larynx, and produce severe dyspnoea or even fatal asphyxia — " swallowing the tongue," as it has been called. On drawing the tongue forwards the symptoms will at once cease ; but a ligature should be passed through its tip and secured to the cheek, with instructions to again draw the tongue forwards with the ligature, should the symptoms recur. NoN-DiFFEREN'iiATioN of the tonguc from the surrounding tissues gives rise to the rare malformation in which the tongue appears bound down to the floor of the mouth. This condition must not be mistaken for that called ankyloi^/ossia, in which the tongue, in consequence of cicatricial adhesions, presents a similar appearance. Division of the adhesions in the latter case will do much to remedy the affection. CHRONIC SUPERFICIAL GLOSSITIS. 519 Macroglossia, or hypertrophy of the tongue may be congenital or acquired. In either case it is rare. Signs. — The whole tongue is uniformly enlarged, and sometimes so much so that it presses forwards the alveolar process of the lower jaw with the incisor teeth, and protrudes from the mouth, hanging downwards as low as the chin. When thus exposed the mucous membrane becomes cracked, spongy, and bluish- red, and is subject to repeated attacks of subacute glossitis. Pathology. — The affection appears to be due to a blocking of the lymphatics at the base of the tongue ; at any rate the lymphatics are found enlarged and distended with lymph, and the connective tissue is increased in amount and in- filtrated with lymphoid corpuscles. It appears related, therefore, with elephantiasis — a condition sometimes found co-existing in the neck and other parts of the body. The only treairnent of much avail is excision of part of the organ. The removal of a V-shaped piece has been attended with excellent results. It should be done before the teeth and jaw have been deformed by the pressure. Acute parenchymatous glossitis, or deep inflammation of the tongue, may be due to mercury, fever, iodism, injury, carious teeth, stings of insects, abscesses beneath the jaw ; sometimes there is no apparent cause. Signs. — In severe cases the whole tongue is swollen, and protrudes from the mouth, interfering with speech and deglutition, and sometimes threatening suffocation. It frequently ends in abscess. It is often attended with high fever and salivation, and may be quite sudden in its onset. Treat- ment. — Should a brisk purge and the milder measures applicable to acute inflammations fail, free longitudinal incisions, which need not be deep, should be made along the dorsum of the tongue, and the svveUing will usually subside in a few hours. Suppuration and abscess sometimes follow an attack of acute glossitis ; but the preceding inflammation may be so slight as to be overlooked. The abscess, which then forms a firm, tense, elastic swelling in the substance of the tongue, may be mistaken for a gumma or carcinoma ; but the diagnosis is readily made by an exploratory puncture. A free incision is the proper treatment, the cavity filling up in a few days. Chronic superficial glossitis, also known as psoriasis, ichthy- osis, or leucoplakia of the tongue, is a chronic inflammation of the mucous membrane, and may be induced by syphilis, excessive smoking, some forms of dyspepsia, the abuse of spirits, jagged teeth, etc. It begins as a hypersemia of the papillary layer, and presents at this stage slightly-raised red patches better seen if the tongue be dried. This is followed by excessive growth of epithe- lium, the cells of which assume a horny character, and the patches, 520 DISEASES OF REGIONS. which were previously red, become bluish white, and later, opaque white. Several of the patches may now coalesce, covering in severe cases the whole or greater part of the dorsum of the tongue. It is this condition to which the term psoriasis has been applied, from its superficial resemblance to psoriasis of the skin. Still later, from excessive heaping up of the epithelium, the surface of the organ becomes cracked and nodular, stimulating ichthyosis, a name by which it has also been called. As the pathology of the affection, however, is distinct from that of the above-named affec- tions of the skin, it would be better to drop these terms, and to call the affection either leucoplakia {white patches) or chronic glossitis. After variable periods, the hypertrophied papillae may atrophy, or ulceration may occur ; or the epithelium may grow into the substance of the tongue and the disease become epithe- liomatous. At times the inflammation does not give rise to an increase of epithelium, the tongue then appearing smooth, glazed and red. The disease, except when ulceration occurs, causes little or no pain, and often gives rise to no inconvenience ; but it should always be carefully watched for any sign of its becoming epitheliomatous. A similar condition of the mucous surface of the lips and cheeks is a common accompaniment, especially in smokers {smoker'' s patches). Treatment. — All sources of irrita- tion, especially smoking, stimulants and condiments, should be avoided ; anti-syphilitic remedies given where indicated ; and soothing washes of chlorate of potash or borax applied. Should any of the leucoplakial patches show signs of ulceration, the whole patch should be at once' excised ; or should signs of epithelioma already be present, the whole or half of the tongue should be re- moved. Ulceration of the tongue may be simple, tubercular, syphi- litic, lupoid, or epitheliomatous. Aphthous ulceration, and that following mercurial salivation, have been described under stoma- titis. Simple ulceration may depend on digestive disturbance {dys- peptic ulcer) or on irritation, as of a sharp or carious tooth, hot pipe stem, etc. {dental or irritable ulcer). Both varieties are generally superficial, and unattended with the induration and in- filtration characteristic of epithelioma. The dyspeptic ulcer usu- ally occurs on the dorsum of the tongue near the tip. The ulceration is sometimes extensive and multiple, and is often accompanied by some superficial glossitis at other parts of the tongue. The dental ulcer is situated on the side of the tongue, and generally corresponds with a carious or sharp tooth. At first it may be a mere superficial red abrasion, but if neglected, it be- comes a distinct ulcer, irregular in shape, and surrounded with an ULCERATION OF THE TONGUE. 52 1 inflammatory area. The edges are abrupt and a little raised, but not everted ; the base is depressed, sloughing, and sometimes phagedaenic, but not indurated unless the ulcer has existed some time, when it may become callous. It is always unattended with infiltration. Treatment. — In the dyspeptic ulcer the diet and bowels must be carefully regulated, bismuth or soda in infusion of calumba, given internally, and soothing washes or borax and honey applied locally. Caustics must be avoided. In the dental ulcer any offending tooth must be filed, stopped, scraped, or ex- tracted, in short, every source of irritation removed. The ulcer will then rapidly heal, but if neglected it may become epithelio- matous. On the first appearance of infiltration, therefore, free excision is imperative. Tubercular ulceration of the tongue is rare, and generally occurs in young adult males, the subjects of phthisis or of general tuberculosis. It usually begins as a small pimple or nodule on the dorsum of the tongue, especially near the tip. This, after a short time, breaks do.vvn into round, oval or irregular, painful ulcer. The edges are slightly raised, vertical, inverted, or under- mined, sometimes slightly thickened, but never everted or greatly indurated. The base is uneven or nodular, and covered with coarse, pinkish-grey granulations, or with a grey or yellow shreddy slough. Sometimes several smaller ulcers appear around the one first formed, and coalesce with it. The ulceration usually progresses in spite of treatment, the patient dying of phthisis or other tuber- cular affection. The absence of glandular enlargement, of indu- ration, and of signs of syphilis, along with the presence of tubercle elsewhere, and the characters given above, should serve to distin- guish it from syphilitic and epitheliomatous ulceration. Treat- ment has hitherto been of httle service. The ulcer, however, may be soothed by Ferrier's snuff or cocaine ; or if the constitutional state does not forbid, it may be scraped with a Volkmann's spoon, and dusted with iodoform, cauterized with nitrate of silver, or cut out. The usual constitutional treatment for tubercle should, of course, at the same time be employed. Syphilitic ulceration may be divided for practical purposes into the superficial and deep ; the former commonly occurring in the early, the latter in the later stages of syphilis, {a) The superfi- cial ulcers direct the side of the tongue, and are frequently associ- ated with similar ulcers on the lips, cheeks, palate, gums and fauces. They are usually of an oval or irregular shape, and have sharply cut edges, an ash-grey base, and a surrounding areola of inflammation. They readily disappear under the influence of mercury, and the local application of a lotion of nitrate of silver or chromic acid. These ulcers are sometimes associated with a 22* 522 DISEASES OF REGIONS. heaping-up of epithelium similar to that which occurs in mucous tubercles, (d) The deep ulcers are due to the breaking down of syphilitic gummata. They generally occur in the centre of the dorsum of the tongue as deeply irregular excavations, with raised, slightly concave or undermined edges, and a base covered vv^ith a yellow, slough and di-bris of breaking-down tissue. They are usu- ally surrounded with a red areola. On healing, they have char- acteristic, cracked or stellate-looking scars. Their situation at or near the middle of the tongue, the absence of induration and of glandular enlargement, the history of the previous gummatous swellings and of syphilis, and their amenability to anti-syphilitic remedies, should serve to distinguish them from squamous or other forms of carcinoma. Treatment. — Large doses of iodide of potassium, combined with quinine, if the constitution is at all broken, and the local application of a cleansing gargle, as chlorate of potash, will rapidly cause them to heal. The scars left by these ulcers sometimes, though rarely, degenerate into epithelioma. Should any induration therefore appear in them, their free removal with the knife should at once be undertaken. Lupoid ulceration of the tongue is very rare. I have only seen one case during an expeiience of twenty years at St. Bartholo- mew's Hospital. This was under the care of my colleague, Mr. Butlin. The case occurred in a young girl with extensive lupus about the nose, lips, and mouth. Scraping with a Volkmann's spoon was the treatment adopted. Epithelioviatous ulceration is due to the breaking down of squamous carcinoma. It is described under ulceration instead of amongst new growths, as in consequence of the irritation from the teeth, and the movements of the tongue, epithelioma in this situation very rapidly ulcerates, even if it does not begin as an ulcer ; hence it is from other ulcers rather than from new growths that it has to be distinguished. It is much more common in men than in women, and seldom occurs under the age of forty. Often it is due to the irritation of a carious or sharp tooth, and then begins as a dental ulcer ; or it may arise in the scar left by a syphilitic ulcer, or follow upon the condition of the tongue known as chronic superficial glossitis. Occasionally it begins as a wart or pimple in i)atients in whom no cause for it can be assigned. It is most common on the side of the tongue opposite the molar or bicuspid teeth. The ulcer is irregular, with raised, sinuous, hard and everted edges, and uneven, excavated, or warty base ; while the tissues around are infiltrated and indurated. Its growth is generally rapid, and attended with neuralgic pain and copious salivation. If allowed to take its course it spreads backwards to the pillars of the fauces, downwards to the floor of the mouth, and TUMORS OF THE TONGUE. 523 inwards to the opposite half of the tongue ; while the submaxillary lymphatic glands, and later the lymphatic glands in the neck, be- come enlarged, and the parts about the angle of the jaw infiltrated and matted together by the disease. Secondary ulcers then form from the breaking down of the glands in the neck, and the patient dies, worn out by pain and irritation, or exhausted by haemor- rhage ; but hke squamous carcinoma in other parts, it seldom be- comes disseminated in distant organs. Treatment. — Early and free extirpation ought in every instance to be undertaken, but even then a recurrence in the glands of the neck is only too fre- quent. When the disease has attained some magnitude, the pro priety of removal becomes a question, and opinions differ under what circumstances it ought to be attempted. Its removal is con- traindicated : — i, when it has extended so far backwards that the finger cannot reach healthy tissue beyond it ; 2, when it is iirmly and extensively adherent to the jaw ; 3, when the tongue is firmly bound down to the floor of the mouth ; 4, when the glands not only below the jaw, but deep in the neck, are much implicated ; and 5, when the patient is too weak or emaciated from the dis- ease itself, or from disease of other organs, to stand an operation. Moderate enlargement of the glands, slight adhesion to the jaw, and some infiltration of the floor of the mouth, do not, in my opinion, forbid an operation (especially if the patient is suffering from much pain, and is otherwise in good health), provided the whole of the disease with the enlarged glands can be got away. Where the disease is regarded as beyond the reach of extirpation, the pain and salivation may often be relieved by removing, not only decayed, but sound teeth that may be irritating the growth, or by stretching or dividing the gustatory nerve. This, which however is sometimes impracticable on account of the extension of the growth, may be done by making a small incision transversely from the last molar tooth through the mucous membrane to the side of the tongue, then passing an aneurysm needle into the wound, and hooking up the nerve, which is here quite superficial. Cocaine, or morphia and glycerine, may be painted on the part, whilst the patient's remaining span of Ufa may be rendered bearable by in- creasing doses of opium or morphia. Tumors of the tongue. — Papillomatous »r warty growths are not uncommon, and may be distinguished from epithelioma, into which they are liable to degenerate as age advances, by the ab- sence of induration about their base. They should be freely re- moved by the knife or scissors. Vascular tumors or ncevi and lymphangiomata are occasionally met with, and may be destroyed by the ligature or knife. Fibrous, fatty, myxomatous, adenomatous, sarcomatous and carcinomatous tumors other than the squamous 524 DISEASES OF REGIONS. variety, which has already been described under epitheliomatous ulceration, are too rare in the tongue to call for further remark. For mucous tubercles and gummata see Syphilis of the Tongue. Syphilis of the Tongue may occur as: i. Primary chancre. 2. Mucous tubercles. 3. Superficial glossitis. 4. Superficial and deep ulceration, and 5. Gummata. Primary chancres, which are very rare in this situation, require no description. Mucous tubercles consist, as elsewhere, of heapings up of epithelium over infiltrated and enlarged papillse, and appear as flattened elevations of a grayish-white color. They are generally present on the palate and fauces at the same time. Mercury internally, and black-wash locally, cause them rapidly to disappear. Superficial glossitis and the superficial and deep ulcerations have already been described. Gummata occur as hard, globular masses in the fibrous tissue of the septum, and also in the substance of the muscles. They may be single or multiple. The mucous mem- brane covering them is at first natural in appearance, but, as the gumma softens, it gives way, and a deep syphilitic ulcer is pro- duced. Iodide of potassium is the remedy. Excision of the tongue may be performed in many ways. Only those methods in most general use will be here described. They will be considered under the heads of, excision with (i) the knife, (2) the ecraseur, (3) the scissors, (4) the galvano- cautery. The tongue is also frequently excised simultan- eously with infiltrated glands through an incision in the side of the neck by (5) Kocher's method. 1. Excision with the knife, on account of the profuse haemorrhage which attends it, is only applicable when the an- terior portion of the tongue requires removal. The tongue should be well drawn forward and the diseased portion cut away with one sweep of the knife, and the bleeding vessels tied. 2. The ecraseurx'a much less Fig. 236. .^* / Excision of the tongue with the i-craseur. used than formerly. The mouth having been widely opened by a gag, two ligatures are i)assed through the tongue, one on either side of the tip, and the mucous membrane, where it is reflected from the tongue to the jaw, is divided with scissors along with EXCISION OF THE TONGUE. 525 some of the fibres of the genio-hyo-glossus. The mucous mem- brane covering the dorsum ot the tongue 'is next divided in the middle line by a bistoury from the tip as far back as to be well beyond the disease. This allows the tongue to be readily spht with the fingers into two halves. The cord of the ecraseur is now passed over one- half, and well behind the disease, and, if the whole tongue is to be removed, the cord of a second ecraseur over the other half. The cord being tightened by screwing up the ecraseur, the tongue is cut through. The lingual artery, with the gustatory nerve, is drawn out in the form of a loop by the cord of the ecraseur (Fig. 236). A ligature should be passed round the artery with an aneurysm needle, and the artery severed in front of the ligature. The anterior part of the tongue will now come away, leaving the ligature on the artery in the stump of the tongue. The above is a sUght modification of the operation in- troduced by Mr. Morrant Baker. 3. Excision with the scissors (Whitehead's method), consists in drawing the tongue well forward by two ligatures through its tip, dividing the frsenum, splitting the tongue as described above, and then separating the diseased half from its attachments, beginning from below by a series of short snips with blunt-pointed scissors, clamping or tying the lingual artery, if seen, before it is divided, or else immediately it is cut. The lingual artery lies immediately below the muscle-substance about a quarter of an inch from the middle line. If the disease involves both sides of the tongue the opposite half can next be removed in the same way. To prevent haemorrhage during the operation, some Surgeons first tie the lin- gual artery in the neck, whilst others, for fear of blood entering the trachea, perform tracheotomy, and plug the trachea with Hahn's tampon cannula, or merely introduce an ordinary trache- otomy tube, and plug the pharynx firmly with a sponge during the operation. All such measures are, however, in my opinion quite unnecessary, and only add to the danger of the operation. Should bleeding occur it can always be arrested temporarily by merely passing the finger into the pharynx and pressing the tongue against the inner surface of the jaw, and then as soon as the mouth has been sponged clear of blood the bleeding vessel can be seized and tied. Or Lockwood's clamp for compressing the lingual artery may be used during the operation if the Surgeon is at all nervous of bleeding, the only objection to it being that it is apt to get a little in the operator's way. Some Surgeons operate with the head hanging over the end of the table, so that the blood may not run down into the throat. When Hahn's cannula is used it is often kept in for several days after the operation, for the pur- pose of excluding septic discharges from the air-passages and so 526 DISEASES OF REGIONS. preventing septic pneumonia. The advantages of the scissors over the ecraseur are that a cleaner-cut surface is left and conse- quently that the Surgeon can be more certain of having removed the whole of the disease, that less sloughing occurs, and that the operation is more quickly performed. Where, however, the tongue is adherent to the floor of the mouth and hence cannot be drawn forward, or the mouth cannot be opened sufficiently wide, or the light is bad, or a reliable assistant is not at hand, removal with the scissors is attended with considerable difficulty, and under these circumstances removal with the ecraseur will be found safer. As regards the amount of sloughing, I am not convinced that more attends the use of the ecraseur than the scissors, and if care is taken to pass the cord of the ecraseur well beyond the dis- ease, as complete a removal can be ensured. 4. Excision with the galvano-cautery is strongly recommended by some Surgeons, but is open to the serious objection that it is liable to be followed by secondary haemorrhage on the separation of the sloughs. Whatever operation is undertaken, it will be facilitated when the disease is far back by splitting the cheek from the angle of the mouth to the masseter muscle ; whilst, if the disease has in- vaded the bone, the lower lip may be vertically divided in the middle line, the incision continued on each side for a short distance along the lower border of the ramus of the jaw, the soft parts dissected up, and the infiltrated bone removed by the saw or bone-pliers. Division of the lower jaw in the middle line and separation of the two halves is a useful procedure when the floor of the mouth is implicated and the disease extends far back. The jaw should be united at the conclusion of the operation by silver wire or by ivory pegs. 5. Kocher's operatio?t. — This is an exceedingly useful method of excising one-half of the tongue with the infiltrated glands when the disease extends far back and is limited to one side of the organ. Make an incision from the mastoid process to the hyoid bone, and thence to the symphysis of the jaw. Divide the platysma ; tie the facial artery ; extirpate the submaxillary lym- phatic glands, and especially the gland over the carotid sheath ; tie the lingual artery where it dips behind the hyo-glossus ; extir- pate the submaxillary salivary gland ; divide the mylo-hyoid mus- cle ; remove the sublingual gland, and cut through the mucous membrane of the floor of the mouth. The tongue will now be exposed as far as its root ; split it down the middle line, draw the affected half out of the wound, and sever it from its connec- tions well behind the disease with scissors. During the removal of the tongue chloroform should be admin- CLEFT PALATE. 527 istered by a tube passed through the nose (Junker's method), or if tracheotomy is performed and the trachea plugged, through the cannula. The after-treatment coxi'ii'iX?, in dusting the stump with iodoform, or painting it with Whitehead's iodoform varnish, packing the mouth with iodoform gauze, or frequently syringing it with Condy's fluid or other antiseptic lotion. Some Surgeons recom- mend feeding with a tube passed through the mouth or nose for the first few days, or by the rectum. The nasal tube, however, is often a source of great irritation, and feeding is better accom- plished by a spoon or "feeder" passed well to the back of the mouth. It is well to leave a ligature through the stump of the tongue, so that should recurrent hsemorrhage occur, the stump may be drawn forwards and the bleeding vessel more easily secured. DISEASES OF THE UVULA, PALATE, FAUCES AND TONSILS. UvuLiTis, or inflammation of the uvula, is a frequent accom- paniment of pharyngeal catarrh. The uvula appears red, swollen and oedematous, and often considerably elongated. If the mflam- mation does not yield to the remedies employed for the catarrh, scarification should be practiced. Elongation of the uvula may depend upon chronic catarrh of the pharynx, or upon conditions similar to those leading tp chronic enlargement of the tonsils. The elongated uvula may come into contact with the back of the tongue or even with the mucous membrane of the larynx, and in either case is productive of a troublesome tickling cough. If astringents fail, the end of the uvula may be amputated. Cleft palate is a congenital defect due to an arrest of devel- opment of the processes which normally grow inwards from the superior maxillary and palate bones, and meeting each other and the vomer in the Fig. 237. middle line, and the premaxillary bone in front, form the hard and soft palate. This ar- rest of development may be complete, the fissure extending in the middle hne through the uvula and the soft and hard palate, and hence through the alveolar process in the line of suture either on one or both sides of the premaxillary bone (Fig. 237). It will in this case be generafly combined with double or the hard paiate.""^^ '" single hare-lip respectively. When the arrest is only partial, the cleft may extend through the uvula alone, or through the soft palate as well, or through the soft palate and part of the hard ; whilst in other instances the alveolar process only on 528 DISEASES OF REGIONS. one or both sides of the middle line may be notched, as occurs so often in hare-lip. The vomer, which is continuous in front with the premaxillary bone, either presents a free border in the middle of the cleft, or is attached to one or other margin of the cleft. The cojisequeiiccs of cleft palate vary with the age of the patient and extent of the cleft. In infoncy, suction and deglutition are seriously interfered with ; whilst later, the voice, articulation, taste, smell, and hearing, may all be impaired. Treatment. — The infant, if unable to take the breast in an erect or semi-recumbent posture, must be fed with the mother's milk by a spoon passed well to the back of the mouth, or by a feeding-bottle with a large teat to act as a plug to the cleft. The operation for the cure of the deformity should be undertaken before the child begins to speak, which is generally about a year later than usual ; but not in infancy, as bleeding is then badly borne, and the cleft of the bony palate diminishes in width during the first three years of life. Infants, moreover, are very hable to such ailments as catarrh of the pharynx and lungs, and coughing and sneezing tend to tear the parts asunder. The cleft in the hard and soft palate should be closed at the same time. Hare-hp, if present, should be operated on in infancy. Staphylorraphy or closure of the soft palate. Chloroform hav- ing been given by Junker's apparatus with the tube passed through the nose, and the mouth Fig. 2^8. widely opened by a Smith's gag, which depresses the tongue at the same time (Fig. 238), one end of the bifid uvula is seized with long forceps, and the edge of the cleft pared from below upwards, and the paring re- ^ peated on the opposite side. The c„;,. .. „,„ r , ., , , . . uvula and the lower part of the palate bmitn s gag for cleft palate, with ,'■ . ' key. are then united with horsehair, the upper part with silver wire. The wire sutures are best passed by Smith's needle, by which they can be carried through both sides of the cleft by one transit of the needle. This needle, shown in Fig. 239, has "a small reel Fig. 239. .Smith's needle for passing wire sutures in cleft palate. attached behind the handle to hold the wire, and a small serrated wheel half way up the handle to protrude the wire from its tubu- CLEFT PALATE. 529 lar point." The horsehair may be passed across the cleft by the needle shown in Fig. 240, and as the point of the needle pro- FiG. 240. I Smith's palate needle for passing horsehair sutures in cleft palate. trudes from the palate, the end of the horsehair is seized and drawn out by nibbed palate forceps or by the suture-catcher (Fig. 241), and the needle withdrawn. The silver sutures should Fig. 241. Suture-catcher. be fastened by the wire twister (Fig. 242) and cut off short, care being taken to hold the edges of the cleft merely in apposition and not to apply any tension. The horsehair should be tied with a treble Surgeon's knot. When the parts have been brought to- gether any undue tension should be relieved by making lateral in- cisions through each side of the soft palate parallel to the cleft and just internal to the hamular process, with a tenotome on a long handle. By these incisions the levator palati muscles are divided. The palato-pharyngei may also be divided if neces- sary by notching the posterior pillars of the fauces with scissors. Fig. 242. Wire-twister. Uranoplasty, or closure of the hard palate. The soft palate having been previously brought together in the way described, the operation on the hard may be begun at that stage where the tension becomes such that the soft parts can no longer be brought together. The edges of the cleft having been pared, an incision from a quarter to three-quarters of an inch long should be made on either side of, and parallel to, the cleft through the muco- periosteum down to the bone (Fig. 243 e, e). The incisions should fall a little distance from the alveolar process, so as to avoid wounding the anterior palatine artery. Into one of these 23 530 DISEASES OF REGIONS. Fig. 243. incisions a raspatory or an aneurysm needle with a short curve should be introduced, and the muco-periosteum separated from the bone along the whole length of the cleft in the hard palate, avoiding the neighborhood of the posterior palatine foramen through which the anterior palatine artery nms. The attachment of the muco- periosteum to the posterior margin of the hard palate should be divided with curved scissors passed through the cleft and behind the soft palate, which should be drawn forwards to facilitate this step of the operation. Pressure should be made upon the parts with a small sponge by an assistant, whilst the muco- periosteum is being separated in like manner on the opposite side. Wire su- tures should now be passed in the way described for uniting the soft palate, and any tension relieved by prolonging the cuts made for the introduction of the raspatory forwards or backwards, as the case may require. Haemorrhage, though often sharp, is seldom severe, and may generally be stopped by pressure or syringing with ice-cold water, the head being turned over to one side to let the blood escape, or if it becomes serious, by plugging t V /...M^he posterior palatine canal with a small peg of wood. ,^ ^^^^ After-treatment. — The patient should be fed on iced milk for ' the first few days, and then on soft food for a fortnight. The sutures may be left in for three weeks or a month ; if the patient is unruly they should be removed under chloroform. The cleft ought to heal by the first intention, and the lateral cuts for taking off tension, by granulation. If a portion of the cleft fails to unite by the first intention it will often heal up subsequently by granu- lation ; if not, a second ojjcration must be undertaken. It is somewhat doubtful whether the muco-periosteum ossifies. Necrosis of the hard palate is generally due to the breaking down of syphilitic gummata, and is followed by perforation and at times by destruction of the greater part of the hard and soft palates, and septum of the nose. Ti-eatment. — Large doses of iodide of potassium, and when the ulceration has ceased, an ob- turator to close the perforation, and later a plastic operation if practicable. Acute 'jonsii.i.ius may be the result of taking cold in a person in feeble health, or the subject of the rheumatic diathesis, or who Position of the lateral incisions, E, E, through the muco-peri- osteum, in the operation for cleft of hard palate. The dotted line indicates the line of junction of the hard and soft palate. (Bryant's Sur- gery.) CHRONIC ENLARGEMENT OF THE TONSILS. 53 1 from previous attacks has become predisposed to the disease ; sometimes it is due to septic poisoning, as from the inhalation of sewer gas ; or it may occur in the course of other diseases, as scarlet fever. Sig/is. — It generally begins with a slight chill, or even a rigor, followed by high temperature, furred tongue, offen- sive breath, salivation, pain darting to the ear and increased on SAvallowing, and swelling of the glands behind the angle of the jaw. If the mouth can be sufficiently opened, one or both of the tonsils are found to be red and swollen, and often in contact, blocking up the fauces. The neighboring parts are congested and swollen, and, in the variety known as foUiadar tonsillitis, a secretion is seen oozing from the mouths of the inflamed follicles. The inflammation may now subside, or terminate in suppuration {quinsy), which may be known by the pain becoming of a throb- bing character, and a sense of fluctuation or softening on palpa- tion. Treatment. — At the onset a sharp purge should be given, whilst large doses of perchloride of iron, quinine, or salicylate of soda, with local insufflations of bicarbonate of soda, may be tried as abortives. Where suppuration threatens, the throat should be steamed, and hot camomile mattresses or linseed poultices applied externally. As soon as the abscess has formed, an incision should be made with a bistoury, guarded by wrapping it round with sticking-plaster to within half an inch from the end, and directing the point towards the middle line to avoid injuring the tonsillar arteries and the internal carotid. Chronic enlargemfnt of the tonsils consists of an hyper- trophy of the normal tissue of the tonsil, and is very common in strumous children, in whom it is frequently associated with adenoid growths in the vault of the pharynx. At times it appears due to oft-repeated attacks of acute tonsillitis. The symptotns to which it may give rise are : a nasal tone of voice ; a peculiar vacant expression, acquired by the child constantly breathing with the mouth half open ; regurgitation of fluids through the nose ; snoring during sleep ; distressing dreams, from the imperfect aeration of the blood ; and recurring attacks of acute or sub-acute tonsillitis ; whilst deafness, from implication of the Eustachian tube and middle ear in the chronic inflammation, may sometimes be induced, and even an alteration in the shape of the chest, and possibly phthisis. The tonsils appear irregularly enlarged, often almost blocking up the fauces, but, unless inflamed, of a natural color, or perhaps slightly paler than natural. Treatment. — In young children the affection may be cured by persistent painting with the tincture of perchloride of iron or tincture of iodine, com- bined with the internal use of cod-liver oil and syrup of the phos- phate or the iodide of iron. In older children, or where the 532 DISEASES OF REGIONS. tonsils are much enlarged, they should be excised, either with the knife, or better with the guillotine (Fig. 244), and this should be done before the voice has be- come seriously affected or other mischief has ensued. The ''^=^'~"''"'-°»""^ ^ hcemorrhage attending the Tonsil guillotine. Operation, though usually slight, has at times been alarming. GargHng with cold water will generally stop it ; but if this fails, ice, or astringents, as tannic acid, or pressure with a pencil guarded with lint, will nearly always succeed. Should a bleeding vessel be seen, it should be tied or twisted. In exceptional- cases, the common carotid has had to be tied. Should adenoid growths be present they should be removed at the same time as the tonsils. Ulceration of the fauces, palate, and tonsils may be simple, gangrenous, syphilitic, tubercular, or malignant. Simple iilceration, the so-called ulcerated sore throat, is gen- erally the result of debility, induced by over-work in a close at- mosphere, and hence is frequent in workers in hospital wards, where it is known as hospital sore-throat. Change of air, a nourishing diet, quinine and port wine, with a gargle of chlorate of potash, will usually relieve it. If neglected it may assume a gangrenous form, and extensive sloughing may then ensue, with constitutional symptoms of blood-poisoning, which often proves rapidly fatal. Stimulants and fluid nourishment should be fre- quently administered, and quinine, perchloride of iron, or am- monia and bark, given internally. Tracheotomy, if the larynx becomes involved, may be necessary. Syphilitic ulceration may be superficial or deep. The superficial ulcers are common in the early stages of syphilis, and may be ac- companied by mucous tubercles. Deep ulcers, due to the break- ing down of gummata, occur in the later stages as irregular excavations with sharply-cut edges and a sloughy base, but are unattended with induration. On healing they are often produc- tive of much contraction (see Pharyngeal Stenosis). The so-called tubei-cular ulceration occurring in strumous chil- dren bears a general resemblance to the syphilitic, and is believed by some to be really the result of congenital syphilis. Like the syphilitic, it may lead to extensive destruction of the parts. Malignant ulceration is due to the breaking down of epithelio- matous and sarcomatous growths. It may be known by the sinuous, everted, and indurated edges of the ulcer, and other signs of malignancy. 'J'uMOkS ok 'ihe 'jonsil. — Sarcoma and epithelioma occasionally occur in the tonsil. They grow rapidly, soon affect the lym- EPULIS. 533 phatic glands in the neck, and extend to surrounding parts. Un- less detected and removed whilst they are quite small and localized to the tonsil, they are beyond the reach of surgery. Other tumors in this region are rare. DISEASES OF THE GUMS AND JAWS. Hypertrophy of the gums has been observed as a congenital affection, and may be met with where there is overcrowding of the teeth as a lobulated fringe -like growth of the gums, which, in se- vere cases, may so surround the teeth that they appear as if buried in it. The hypertrophied portion should be shaved off, and one or more of the teeth extracted. Polypi of the gums, as they are called, are merely overgrowths of the httle tongue of gum between the teeth, and appear gener- ally to depend on the presence of tartar or caries. The offending tooth should be scaled, stopped or extracted, and the growth cut off. Papillomata, or warty growths, occasionally occur on the gums. They are generally pedunculated, and can be readily snipped off with scissors. Spongy gums may occur as the result of scurvy or the abuse of mercury, and are sometimes met with in strumous children. The condition is often associated with superficial ulceration. The treatme7it consists in the removal of the cause, the use of an astringent mouth-wash, and the constitutional remedies appropri- ate to scurvy or struma. Alveolar abscess may be quite superficial {gum-boil) and merely require a slight prick ; or it may form around the fang of a carious tooth, and then either make its way to the surface by the side of the tooth, or expand the alveolus and perforate the bone. In the latter case it may track below the reflexion of the mucous membrane from the gums to the cheek, and point about the angle of the jaw or on the cheek, and after opening leave an intractable sinus. In the upper jaw it sometimes also tracks along the hard palate, and may lead to necrosis of the bone. It is at- tended with severe throbbing pain, deep-seated swelling, and often great oedema of the face and eyehd. Treatment. — The offending tooth should be extracted, hot fomentations and bread-poultices applied inside the mouth, and the sinus divided transversely from within the mouth to prevent an external opening being formed. If a sinus exists the carious tooth or dead bone must be removed before it will heal ; scraping the sinus will then facilitate the healing. Epulis. — This term, though formerly employed to signify any 534 DISEASES OF REGIONS. tumor growing upon the gums, is now usually restricted to the variety that was then distinguished as the fibrous or common epulis. An epulis consists principally of fibrous tissue, but may sometimes contain a few myeloid cells. It frequently appears to depend upon the irritation of a carious stump, and springs from the periodontal membrane lining an alveolus. Beginning as a swelling of the little tongue-like process of gum between the teeth, as it increases in size it appears as a hard, fleshy, circumscribed, smooth or slightly lobulated elastic growth, covered by mucous membrane. When it has existed some time ulceration of the sur- face may occur, and one or more teeth become loosened or fall out. Treatment. — It should be excised with bone forceps or a small saw, care being taken to cut away a small piece of the bone beneath, as otherwise it is apt to return. When quite small it may be shaved off, a thin layer of the bone at its base gouged away, and the offending tooth or teeth removed. Myeloid sarcoma {myeloid epulis) is occasionally met with on the gums as a rapidly-growing vascular tumor of a purplish-red color and soft spongy consistency. It should be very freely re- moved with the underlying bone, as otherwise it will return. The hemorrhage during removal is generally free, and may require the actual cautery to restrain it. Epuhelioma {malignant epulis) of the gums is rare. In the upper jaw it has a marked tendency to creep up into the antrum {creeping epithelioma^ and to simulate caries or necrosis of the jaw. Free excision, with removal of the upper jaw if the antrum is involved, should be undertaken if there is a fair chance of get- ting the whole of the disease away and the glands are not much involved. Inflammation and abscess of the antrum is generally due to the irritation of the fiing of a carious tooth. It is attended with deep-seated pain, followed by swelling, f«dema, heat, and redness of the cheek and lower eyelid, and when very acute, by sharp constitutional disturbance. The pus may overflow into the nose, or escape by the side of a tooth ; or, in other instances, may dis- tend the cavity and cause the bony walls to bulge. The treatment consists in providing a free exit for the pus as soon as formed, either by removing the carious tooth and perforating the antrum through the bottom of the alveolus, or, if the teeth are sound, by perforating the anterior wall within the mouth through the canine fossa. The cavity should then be kept aseptic by antiseptic lotions. Closure of the jaws is the term applied to a condition in which the lower jaw cannot be oj^ened, at least not to any extent. It may be due to — i, spasm of the masseter muscle, consequent upon the iritation attending the eruption of a wisdom-tooth for NECROSIS OF THE JAWS. 535 which there is not room; 2, cicatricial contraction, following ulceration of the mucous membrane induced by cancrum oris, syphiHs, lupus, the abuse of mercury, etc. ; 3, ankylosis of the temporo-maxillary joint ; and 4, hysteria. Treatment. — When dependent upon the eruption of a wisdom-tooth, the tooth itself, or under some circumstances the second molar, must be extracted. When dependent upon cicatricial contractions, the forcible open- ing of the mouth by a screw-gag and maintaining it open by a cork placed between the teeth will, in slight cases, suffice. In other instances I have found division of the cicatricial bands, and sub- sequently keeping the jaws separated, successful, although this proceeding does not appear to have always answered in the hands of others. When the bands are very dense or the closure depends upon ankylosis of the temporo-maxillary joint, a new articulation must be made by dividing the ramus of the jaw and removing a wedge-shaped piece of bone in front of the cicatricial contractions. Necrosis of the jaws. — Necrosis is more common, and when it occurs, more extensive in the lower than in the upper jaw, a fact due in part to the poorer blood-supply of the former, and in part to the predilection of necrosis for compact rather than for cancellous bone. Though the necrosis may affect the whole of the jaw, it is more often limited to the alveolar process or to the anterior wall. The teeth may loosen and fall out ; but at times^ they retain their connection with the gums and remain in situ after the removal of the sequestrum. The causes of necrosis of the jaw, as of necrosis elsewhere, generally depend upon inflam- mation of the periosteum or bone, which in the case of the jaw appears especially to be induced by the fumes of phosphorus, the abuse of mercury, carious teeth in strumous subjects, syphilis, the exanthemata, cancrum oris, and lastly, injury, as in extracting a tooth. Phosphorus-necrosis is generally believed only to affect the subjects of carious teeth, but some maintain that it is a local manifestation of a general phosphorus-poisoning. It is much less common since the amorphous form of phosphorus has been used for making matches. The production of new bone in necrosis of the lower jaw is generally extensive ; and there are several speci- mens in St. Bartholomew's Hospital Museum showing almost complete reproduction of the whole jaw. In the upper jaw new bone is not formed after complete removal. In phosphorus- necrosis a characteristic pumice-like deposit of new bone is formed. Symptoms. — Necrosis generally begins with severe pain and deep-seated swelling, which may at first be mistaken for toothache or alveolar abscess, followed by suppuration and burst- ing of the abscess, either in the mouth or externally on the face, and the formation of sinuses. The breath, as a rule, is horribly 536 DISEASES OF REGIONS. foetid, and there is sharp constitutional disturbance, which, in phosphorus-necrosis, is sometimes excessive, and may end in septicaemia or pyaemia. On probing the sinus, dead bone is de- tected. This sign will usually distinguish necrosis from the creeping form of epithelioma, for which, especially in the upper jaw, it is apt to be mistaken. Trea/i/ieiif. — The bone as soon as loose should be removed, if possible, through the mouth. In the meantime the parts should be kept aseptic by syringing with Condy's fluid or carbolic lotion, or by insufflation of iodoform, incisions being made through the periosteum to ensure a free drain, or Cargill's respirator may be worn to neutralize the foetor. Inteinally, tonics and stimulants and nourishing diet should be given, and iodide of potassium if there is a syphilitic taint. Tumors of the upper jaw may be cystic or solid, and the latter innocent or malignant ; whilst cysts may likewise occur in the malignant solid tumors. Cystic tumo7-s may be produced : i. In connection with the fang of a carious tooth. 2. By an error in development of the enamel sac covering the crown of a tooth {deutigcroiis cysts) ; and 3. By obstruction of a mucous follicle in the lining mem- brane of the antrum. These cysts usually contain a serous, gelatinous, or a brownish fluid in which cholesterine is often found. The condition known as dropsy of the antrum, and form- erly believed to depend merely upon an accumulation of fluid ni that cavity owing to the occlusion of the opening into the nose, would appear to be due to one of these mucous cysts completely filling the antrum. JDentigeroi/s cysts, which may also occur in the lower jaw, are due to an error in the development of the enamel sac, usually of the permanent teeth. They differ from the ordinary dental cyst depending upon the irritation of a decayed fang, in that in the latter the fang will generally be found projecting into the cyst, whereas in the dentigerous variety the crown alone, which has not been cut, or in some cases the whole tooth, will be found in the cyst. So/id tumors may spring from the jjeriosteum covering the exterior of the bone, or from the mucous or the periosteal lining of the antrum. They may have a fibrous, cartilaginous, osseous, myxomatous, adenomatous, sarcomatous or carcinomatous struc- ture ; but fibrous and sarcomatous tumors are the most common, whilst cartilaginous are very rare. Ossification of the sarco- matous growths is of occasional occurrence. They may be closely simulated by tumors of a like diversity of structure grow- ing from the malar bone, the spheno-maxillary fossa, or the base of the skull. TUMORS OF THE UPPER JAW. 537 Symptoms and Diagnosis. — Clinically, it is not always possible to determine the exact structure of these tumors, nor is it essen- tial, the surgeon's aim being rather to distinguish the solid from the fluid, and the innocent from the malignant, and to make out their origin and present attachments. When the tumor, whether cystic or solid, innocent or malignant, begins in the antrum, it sooner or later fills that cavity, and then in its further growth causes its walls to bulge in various directions. Thus, the bulging of the anterior wall causes a swelling on the cheek, of the internal wall an obstruction in the nose, of the inferior wall a depression of the palate, and of the superior wall a protrusion of the eye. A rounded projection on the cheek; a sensation of fluctuation felt through the anterior wall of the antrum with the finger in the mouth, or egg-shell-like crackling produced by the yielding of the thinned and partially absorbed walls ; the presence of a carious tooth, or the absence of one of the teeth in the series (in the case of a dentigerous cyst) will point to the cystic nature of the swell- ing, and puncture with a trocar and cannula will clear up any doubt. Should the tumor be solid, it will probably be innocent if of slow growth and there be absence of pain and glandular en- largement, non-impHcation of the skin, and non-infillration of surrounding parts ; but malignant if of rapid growth and there is severe pain, early escape through the walls of the antrum, impU- cation of the skin, involvement of glands, and protrusion of a fungous mass in the mouth, nose, or on the cheek. In malignant disease, moreover, the patient will probably be either young in the case of sarcoma, or advanced in life in the case of carcinoma, but if a small piece of the growth can be obtained, a microscopical examination will settle the point. When the growth springs from the malar bone, it may either project forwards on the cheek, or into the mouth between the cheek and the bone, and the bulging of the walls of the antrum will be absent. When it arises from the spheno-maxillary fossa or base of the skull, it will commonly project into the naso-pharynx, where it may be detected by the finger or rhinoscope, while the whole maxillary bone will be pushed forward. It should not be forgotten, however, that tumors beginning in the antrum, especially the fibrous and sar- comatous, encroach upon the surrounding parts, and conversely, that the cavity of the antrum may be invaded by growths not primarily connected with it ; so that when a tumor in this region has attained a large size it may be impossible to determine its origin, or, indeed, the whole of its actual attachments. Treatment. — For cystic tumors, excision of a portion of the wall from within the mouth will generally sufiice, if a free drain is subsequently ensured. At times the thinned walls of the cyst 538 DISEASES OF REGIONS. may be crushed together by the fingers with advantage. Where the cyst is associated with a solid growth, the latter may some- times be scraped away, otherwise the upper jaw must be partially or completely removed. Where the tumor is solid, and of an imjocent nature, and entirely confined to the antrum, it may be removed by excision of the superior maxilla, but as a rule no more of the bone should be taken away than is absolutely neces- sary, the orbital plate and hard palate being preserved if possible. When the tumor arises behind the bone, there is often great diffi- culty in getting it away, as its attachments may be more extensive than is imagined. If thought advisable to attempt its removal, this may be done by excising the superior maxilla, and clearing away the growth ; or the maxilla may be turned outwards, the growth removed, and the bone replaced i^Langenbeck's method). When the growth is vialignant and confined to the antrum, the superior maxilla may also be excised ; but when it has invaded the surrounding parts, it becomes not only a question whether it can be completely got away, but whether the immunity from its return will not be of too short duration for the patient to undergo the risk of the operation. Complete excision of the upper jaw. — Having extracted the central incisor tooth on the diseased side, make an incision down to the bone in the direction shown by the dark line in Fig. 245. Dissect back the flap thus marked out from the bone, securing the larger arteries as they are divided. Make .a longitudinal in- cision through the mucous membrane lining respectively the floor of the nose, and roof of the mouth as far back as the soft palate, and then a transverse one along the junction of the soft with the hard palate on the diseased side. Now pass one blade of the long jaw-forceps into the mouth and the other into the nose, and divide the alveolar process and hard palate ; cut through the nasal process of the superior maxilla, and then through the malar bone, carrying the forceps into the spheno-maxillary fissure. Seize the bone with lion-forceps, and wrench it away from its re- maining attachments. The internal maxillary, or any other large artery, should be tied, and haemorrhage from smaller vessels re- strained by plugging the wound with strips of iodoform gauze. When the bleeding has stopped, any growth that may remain should be cut away or destroyed with the actual cautery. Unite the edges of the wound with horse-hair sutures, and the lip with hare-lip pins. Healing occurs readily and with little deformity. An obturator with false teeth should subsequently be fitted to the mouth. Partial excision of the upper jaw usually consists in leaving the orbital plate, and is done by dividing with a key-hole saw the TUMORS OF THE LOWER JAW. 539 front wall of the antrum along the margin of the orbit, and com- pleting the operation as above described. Resection of the upper jaw {Laiigenbeck's operation) consists in turning the maxillary bone outwards so as to get at a tumor behind it, and then replacing the bone. As the connections of the bone along its outer part are left intact, its vascular supply is not completely cut off, and it soon forms fresh adhesions when placed back in position. Tumors of the lower jaw, like those of the upper, may be cystic or solid, innocent or malignant. Cystic ttimors, as in the upper jaw, may be developed in connection with an uncut tooth {dentigerous cyst), or around the fang of a decayed tooth. They are then unilocular. Multilocular cystic iiunors have a marked predilection for the lower jaw. They are probably due to invasion of the jaw by epithelium from the gum. The epithelial masses undergo degeneration, leading to cysts often of considerable size. These tumors grow very slowly, and may gradually destroy the whole bone, reducing it to a mere shell, but if completely re- moved do not recur locally. They never affect the glands or be- come disseminated. The solid tu7?iors may grow from the per- iosteum covering either the outer or the buccal aspect of the jaw, or from the interior of the bone, which they then expand around them. The osseous tumors usually take the form of exostoses, and are not uncommon about the angle of the jaw. The more regular shape of the lower jaw, its compact structure, the absence of a cavity like the antrum, its more isolated condition, and the absence of surrounding cavities like the nose, orbit and spheno- maxillary fossa, make the diagnosis of tumors in it more easy. The signs are similar to tumors of the upper jaw, which see (P- 536). Treatment. — Cystic tumors are best treated by free incision of a portion of their wall. In the case of the multilocular cysts the whole or part of the jaw may be removed. In excising solid in- nocent tumors no more of the bone should be sacrificed than is necessary to extirpate the disease ; and such removal, when pos- sible, should be done from within the mouth. Myeloid growths springing from the interior of bone may often be enucleated, and not recur for many years, or not at all. Where the tumor is large and encroaches upon the ramus, the affected half of the jaw, or if both halves are affected, the whole jaw should be removed by disarticulation, as if the ramus is merely sawn across, leaving the coronoid process and condyle, these are apt to be drawn for- ward by the temporal and external pterygoid muscles and prove a constant source of annoyance. When the growth is malignant or of large size, and the skin and neighboring soft parts are im- 540 DISEASES OF REGIONS. Fig. 245. plicated and the glands extensively involved, no operation as a rule is admissible. Cysts developed in connection with solid growths may be laid open and the tumor scraped away, or part or the whole of the jaw, if the growth is malignant, may be removed. Excision of the lower jaw. — Having ex- tracted the central or the lateral incisor tooth, make an incision down to the bone (in the way shown in the black line in Fig. 245) through the lower lip, along the lower border of the jaw, and thence up the ramus, nearly but not quite to the lobule of the ear to avoid the facial nerve, tying both ends of the facial artery as it is cut. Dissect up the flap thus formed from the bone, and divide the bone with saw and forceps opposite to where the tooth has been extracted. Seize the bone with the lion-forceps, drawing it outwards and upwards, and divide the soft tissues on the inner surface with a narrovv- bladed-scalpel, keeping close to the bone to avoid the gustatory nerve and the sub-maxillary gland. The origin of the genio-hyo- glossus should be spared if possible, as otherwise the tongue tends to fall backwards, and has before now caused suffocation. If this muscle must be divided, pull the tongue forward by a ligature through its tip. Next separate the internal pterygoid, depress the jaw, and divide the temporal muscle at its insertion into the coronoid process. Open the articulation from the front, divide the external pterygoid, and carry the knife beyond the condyle, taking care not to rotate the jaw outwards lest the internal maxillary artery be stretched round the neck of the condyle and be thus torn or divided. Lines of incision for re- moval of upper and lower jaw. DISEASES OF THE NOSE, NASO-PHARYNX, AND ACCESSORY CAVITIES. AcNE ROSACEA is a dilated or congested condition of the capil- laries of the nose, usually accompanied in its later stages by hyper- trophy of the sebaceous follicles. It is attributed to indigestion, exposure to cold, sexual disturbance or the abuse of alcohol, and is most common in women. Treatment. — Remove the cause, regulate the diet, and attend to the general health. Locally apply sulphur ointment or perchloride of mercury lotions. In severe cases the dilated vessels may be incised and the resulting haem- orrhage restrained by touching them with perchloride of iron, but only small portions of the disease should be thus treated at a time. BLEEDING FROM THE NQSE. 54 1 Lipoma nasi is an hypertrophy of the skin, subcutaneous tissue, and sebaceous follicles of the nose, and not, as the name impUes, an increase in the fatty tissue. It is characterized by the forma- tion of irregular pendulous lobe-like masses, usually situated on the tip and alse of the nose, and often of a bluish-red color. It occurs in elderly men, generally as the result of alcohohsm. Treatment. — The masses should be shaved off, care being taken not to cut through the cartilages into the nostrils, and the parts left to granulate. The treatment is usually very successful. Syphilis, rodent ulcer, lupus and epithelioma may all attack the exterior of the nose, but require no special description here. Epistaxis or bleeding from the nose is a symptom of many and various conditions. Thus — i. In the young it often appears to occur spontaneously from congestion of the mucous membrane, and is especially common in girls about the age of puberty. 2. In the plethoric it may be due to the congestion of the brain or liver, and then appears to give relief to the over-full vessels. 3. In the old or cachetic, on the contrary, it may be due to a poor or watery condition of the blood, such as is present in cirrhosis of the liver, heart disease, granular kidney, etc. 4. It may also occur in scurvy, some forms of fever, and in the hsemorrhagic dia- thesis. 5. It is common after blows or other injuries of the nose ; and 6. It may be a symptom of fracture of the base of the skull, or of a fibrous or malignant polypus in the nose or naso-pharynx. The symptoms are usually evident. The blood generally comes from one nostril, occasionally from both ; but it may pass through the posterior nares and be swallowed, §nd being afterwards vomited, simulate hsematemesis ; or it may irritate the larynx, cause cough, and may then be mistaken for haemoptysis. On looking into the mouth in such cases, however, the blood will be seen trickling down the back of the throat ; whilst it may also be apparent on examining the nose with a speculum. In some cases the blood may be seen flowing from a small vessel on the anterior and lower part of the septum {^seat of election^. The treatvient will depend upon the cause. Spontaneous haemorrhages occurring in the young, except as the result of the hsemorrhagic diathesis, generally stop of their own accord, and require no special treat- ment beyond those remedies common in domestic use. When due to congestion and apparently salutary, the bleeding should not be too soon checked. In cachectic subjects it is often diffi- cult to control ; rest on the back with the arms raised, sucking ice, cold or hot douches, ice to the nose, subcutaneous injections of ergotine (grs. iij.), gallic acid, lead and opium and small doses of ergot or of perchloride of iron, may then be tried. Or pellets of cotton-wool soaked in solutions of cocaine (20/^) may be 542 DISEASES OF REGIONS. placed in the nostril, or pressure made on the upper lip just be- low the ala of the nose, in order to compress the nasal branch of the superior coronary artery from which the blood is said often to be derived. When the blood comes from the seat of election, touching the bleeding point with the galvano-cautery will at once arrest the flow. If the heemorrhage cannot be controlled, the posterior nares should be plugged. The best means of effecting this is by the india-rubber inflating tampon. This consists of an india-rubber tube, with two dilatations upon it, so sized and shaped that when inflated they will accurately fill the posterior and an- terior nares respectively. It is passed in flaccid by means of a long probe, and inflated when in position by the mouth or a small syringe, the escape of air being prevented by clamping the tube. Re-inflation is necesaary from time to time. The posterior nares may also be plugged by Bellocq's sound (Fig. 246) in the follow- ing manner. A pledget of F'°- 246. lint or cotton-wool rather larger than the aperture to be filled (that is, about half an inch by an inch, or roughly, the size of the last joint of the thumb) is taken, and round Bellocq's sound. the middle of this is tied a double piece of stout thread, a long loop being thus left on one side, and two ends on the other, one of which is cut off short. The sound is then threaded with a separate length of thread, and passed closed through the nostril, and when the end has reached the pharynx, the spring is projected, coils round under the soft palate, and appears with the thread in the mouth. The thread is then seized, pulled forwards and the sound withdrawn, thus leaving one end of the thread through the mouth and the other through the nostril. The mouth end is now tied to the loop of thread attached to the pledget ; and by making traction on the thread hanging from the nose the pledget, guided by the finger in the mouth, is drawn behind the soft palate into the posterior nares. The loop of thread is finally cut and tied over a pledget of cotton-wool or lint, which is forced into the nostril to form an anterior plug. Meantime the other end of the thread attached to the plug has been retained hanging out of the mouth, and is now fastened loosely to the cheek, or it may be allowed to fall back into the pharynx. The plugs should be kept in for about two days. They are readily removed by cutting the thread over the anterior plug, and then withdrawing the posterior one through the mouth by means of the thread that is fastened to the cheek or is hanging loose in the pharynx. A NASAL CATARRH, RHINITIS, CORYZA. 543 substitute for Bellocq's sound, if this is not at hand, may be found in a soft india-rubber or gum-elastic catheter, which, with a hole drilled through its end, can be used in a similar way. Examination of the nasal cavities. — For the diagnosis of internal diseases the nasal cavities should be illuminated by the laryngoscopic mirror (Fig. 264) or the electric lamp, the alse being separated by some form of nasal speculum, of which Duplay's and Frankel's are the best (Figs. 247, 248). 'J'he posterior part of the nasal cavities can be explored by the finger Fig. 247. Fig. 248. Duplay's nasal speculum. Frankel's nasal speculum. passed behind the palate, or by a small mirror passed to the back of the throat {posterior rhinoscopy). For detecting necrosed bone the nasal probe may be used. Nasal catarrh, rhinitis, coryza, or inflammation of the mucous membrane of the nose, may be acute or chronic. Acute cataf^rh, coryza, or cold in the head, will be found treated of in works on Medicine. Chronic nasal catai-rh or rhitiitis is most common in the young, especially in children of a strumous habit. As exciting causes may be mentioned oft-repeated attacks of acute catarrh, adenoid vegetations in the vault of the pharynx, nasal stenosis, deflected septum, the irritation of noxious vapors or dust, the abuse of spirits, snuff-taking, etc. Several forms, all of which are believed by some surgeons to be different stages of the same disease, have been described. They will be classed here under the three heads of 1, the simple; 2, the hypertrophic; and 3, the atrophic, which is generally attended with foetor. i. The simple form is characterized by a thin mucous or muco-purulent discharge, and a congested appearance of the mucous membrane, but is unattended with any thickening, or formation of crusts, or with foetor. If neglected, it is apt to pass into the next variety. 2. In the hypertrophic the mucous membrane, especially over the turbinated bones, is greatly swollen and congested, and infiltrated with inflammatory material ; while the glands are stimulated to excessive secretion, and pour out a thick yellowish-green muco- 544_ DISEASES OF REGIONS. purulent discharge. It is characterized by symptoms of nasal obstruction, viz., stuffiness or blocking of the nose, nasal tone of voice, constant need to blow the nose, a vacant expression of countenance acquired by keeping the mouth open, trickling of the discharge down the pharynx and subsequent hawking of it up by coughing, and sometimes deafness from the spread of inflam- mation to the Eustachian tube. At times certain reflex phe- nomena are present, such as spasmodic cough, asthma, and even epilepsy. The al?e of the nose often appear thickened and the inferior turbinated bodies greatly enlarged. On posterior rhinoscopic examination granular pharyngitis is frequently dis- covered, with increase of the glandular tissue of the vault of the pharynx ; whilst the hypertrophied posterior ends of the inferior turbinated bodies may at times be seen almost completely block- ing up the choanse in the form of globular, irregularly-furrowed tumors (Figs. 249, 250). This variety is said by some, but Fig. 249. Fig. 250. Hypertrophic nasal catarrh. (St. Bartholomew's Ho.spital Museum.) Hypertrophy of the posterior ends of the inferior turbinated bodies, with adenoid vegetations in the vault of the pharyn.\. without sufificient evidence I think, to pass, after it has lasted some years, into the third variety. 3. Atrophic rhinitis, some- times called dry ox fmtid catarrh, and by some ozcena, is appar- ently due to the shrinking of inflammatory new formation infiltrating the tissues, and the consequent atrophy of the mucous membrane and the greater or less destruction of the glands. It is characterized by the nasal cavities appearing preternaturally large, so much so in some cases that the wall of the pharynx and F.ustachian tube may be seen on looking through the nostril. The turbinated bodies appear decreased in si/e, and the mucous membrane is atrophied and j^aler than natural, and covered with hard yellowish-green adherent crusts. Generally, though not CHRONIC NASAL CATARRH. 545 invariably, the disease is attended with a horrible fcetor, which is usually thought to be due to the decomposition of the discharge beneath the crusts, the discharge being secreted in too small quantities and too thick to allow of the throwing-off of the crusts. By some the fcetor is believed to be due to the retention of the secretions in some of the sinuses communicating with the nose. In all forms an important point to remember is that ulceration does not occur. Treatment. — In the early stages much can be done in the way of treatment, and by perseverance a cure may be obtained. In the atrophic variety reUef from the distressing symptom of foetor only can be expected. In all forms the general health must be attended to. Thus, in the strumous, cod-liver oil or maltine, and the syrup of the iodide or phosphate of iron, are indicated. Locally, in the simple and milder forms of the hypertrophic, the treatment consists in cleansing the parts and then applying astringents ; the cleansing may be accomplished by simply blow- ing the nose, or if this is not sufficient, a cleansing fluid must be used. There are many of these. The one I have found most useful is that known as Uobell's solution, but peroxide of hydit)gen is perhaps equally as good. The cleansing lotion should not be used, as is so frequently done, by Thudichum's nasal douche, as by its means the deeper recesses and upper portions of the nasal fossae cannot be reached, and not only may much harm be done to the mucous membrane of the nose, but inflammation of the middle ear may be set up. The solution is best applied in the form of a coarse spray, either by the anter- ior or posterior nasal spray-producer worked by double handballs (Fig. 251). When thoroughly cleansed, astringent or sedative solutions — best in the form of sprays— should be applied, and of these SpraTTroducer. a. Nozzle may be mentioned tannic acid, sulpho- for anterior nares; b. VI. j'j-j c • i.1.1 Nozzle for posterior nares. carbolate and iodide of zmc or menthol, eucalyptol (^ss. to .^j.), terebene (gr. xx. to 5J.), cocaine and thymol (gr. x. to .^j.}, dissolved in liquid petroleum, a better vehicle than water for intra-nasal medication. Or astringents or iodoform may be applied in the form of powders by the insuffla- tor, or in the form of gelatine bougies. Where there is great hy- pertrophy, the hypertrophied tissues must be destroyed by the local application of chromic acid, or the galvano-cautery ] or the ends of the inferior turbinated body if much enlarged may be removed by the cold wire or galvanic ecraseur. At times the whole of the 23* 546 DISEASES OF REGIONS. turbinated body may be removed with advantage. If the septum is deflected, it must be straightened ; and if adenoid growths are present, they must be removed. In the atrophic form, little more can be done than cleansing and disinfecting the cavities by lotions of carbolic acid, borax, aristol (3ss. to ^j.), and the like; whilst the mucous membrane may be stimulated to secretion by the use of Gottstein's nasal tampons, or by the insufflation of sanguinaria, galanga, etc. Cubebs internally is often of service. TuRBiNAL ERECTION, /. €., transient and oft-recurring congestion of the turbinal bodies, is very common. The patient complains of intermittent attacks of obstruction to free nasal breathing, espec- ially at night or on entering a hot room, and of an attending flow of a watery fluid from the nostrils. On examination the turbinals are seen enlarged, but the enlargement may be distinguished from hypertrophy by the turbinals dimpling when touched with a probe and becoming small when painted with cocaine. Touching the turbinals in two or three places with the galvano-cautery will generally effect a cure. Tuberculous ulceration sometimes occurs. It may lead to nectosis of the bone, falling in of the nose, and much deformity. Constitutional remedies, as cod- liver oil, must be given, and the parts cleansed by lotions, application of iodoform, etc. When obstinate, scraping the part with a Volkmann's spoon, and removal of the dead bone, is the treatment indicated. Syphilitic affections of the nose. In the early stages of syphihs, catarrhal inflammation and mucous tubercles are often met with, especially in infants, in whom they give rise to the ob- structed and noisy respiration popularly known as snuffles. Later, extensive ulcerations, gummata followed by deep ulcers, necrosis or caries of the bones and cartilages, destruction of the septum with falling in of the nose and perforation of the palate, may occur, and when combined with destruction of the soft tissues and skin, are productive of great deformity. When a small portion of bone in the deeper recesses is necrosed, it may not always be easy to find, but may be suspected by the continuance of a moco-puru- lent discharge and the foetor so peculiar to dead bone, the pres- ence of foul ulcers, the history of constitutional signs of syphilis, and the absence of signs of hypertrophic or atrophic catarrh. Often the bone may be struck on examination with the nasnl probe. Treatment. — Iodide of potassium should be given in large doses, combined, if necessary, with quinine or bark, and at times with mercury. Locally the parts should be cleansed and disin- fected by the application of carbolic or other sprays, and when dead bone can be detected it should be removed, if loose, through the anterior nares or from behind the palate by forceps ; but P0L\Tr. 547 sometimes it may be necessary for obtaining a sufficient exposure to resort to the method of Rouge, or to cut through the upper Up and turn aside the ala of the nose. In congenital syphihs the administration of small doses of gray powder, followed by iodide of potassium and cod-Uver oil, is productive of the most happy results. In the ulcerative form, iodide of potassium in large doses should be given. Lupus, though far more common on the exterior of the nose, may sometimes be met with in the interior. It then generally attacks the cartilage of the septum, leading to perforation. It is attended with a foetid discharge. The ulcer is covered with scabs, and surrounded with reddish tubercles. Treatment. — Cod-liver oil, arsenic, and the complete destruction of the affected tissue by caustics, or by scraping, is the proper treatment. Rhinoliths or nose stones may occasionally form in the nose from the deposition of phosphate of lime and mucus upon either a foreign body which has become lodged in the nose, or a portion of hardened secretion. They give rise to inflammation, swelHng of the mucous membrane, and a foetid discharge, and have been mistaken for osteomata, and even carcinomata. When detected they should be removed by forceps, or if too large for this, first broken by the nasal lithotrite. For the treatment of foreign bodies in the nose, see p. 349. Polypi. — Three forms are here described — the gelatinous, the fibrous, and the malignant. I. Gelatinous or mucous polypi most frequently spring from the mucous membrane covering the turbinal bones, rarely from the roof of the nares, and scarcely ever from the septum. They usually have a myxomatous structure, that is, they consist of deli- cate connective tissue infiltrated with large quantities of mucin containing round and stellate cells, and are covered with ciliated epithelium. They are usually multiple sessile or pedunculated, and of an oval, pyriform, or lobulated shape. The usual symp- toms are a feehng of stuffiness in one or both nostrils, worse in damp weather, a nasal tone of voice, and a mucous discharge. Certain reflex symptoms, such as asthma, cough, etc., are also occasionally present. On inspection, they appear as pinkish or grayish-white, semi-translucent, gelatinous, movable bodies, soft and dimpling when touched with a probe. When high up, or far back in the nasal cavities, the speculum or rhinoscope may be necessary to detect them. With the rhinoscope I have often succeeded in detecting a polypus at the posterior nares that had been previously overlooked. Treatment. — They are best removed by the galvano-cautery, as this is attended with less pain and with practically no hgemor- 548 DISEASES OF REGIONS. rhage. The parts should be previously sprayed with a 20 percent, solution of cocaine, and after the removal of the polypi the sur- face from which they sprang should be touched with the galvano- cautery to prevent a recurrence. If the cautery is not at hand, the polypi may be removed by the cold wire snare or be twisted off by the ordinary polypus forceps. When they project into the naso- pharynx, they may be removed, either with the galvano-cautery loop passed through the nose, or by the forceps introduced behind the palate. A snuff of tannic acid, used subsequently to their removal, is said to prevent recurrence, but I have not found it of much service. 2. Fibrous polypi 2iC\M2\\y arising from the interior of the nasal cavities are very rare. Those commonly met with usually spring from the basilar process of the occipital bone or body of the sphenoid, that is, from the roof of the naso-pharynx, and then ought properly to be called naso-pharyugeal, as it is only after they have attained some size that they encroach upon the nasal cavities. They consist of fibrous tissue not infrequently mixed with spindle cells, and often contain large thin-walled blood-ves- sels, which give them an almost cavernous structure. The mucous membrane covering them is also very vascular. They may be sessile or pedunculated. As they increase in size, they invade and displace the surrounding bones, making their way into the nasal cavities, and into the pharynx, and projecting below the palate, and even into the interior of the skull. They are usually met with in young adult life. The symptoms are ob- struction of one or both nostrils, a mucous and often foul-smelling discharge, repeated attacks of haemorrhage, deafness, obstruction to breathing and sometimes to swallowing, and in the later periods of the growth the characteristic deformity of the facial bones known as frog-face. They may be seen on looking into the nos- tril from the front, or by the rhinoscopic mirror from the back, or maybe felt by the finger behind the soft palate. If not removed, they may end fatally from haemorrhage, although they have appa- rently a tendency to undergo atrophy as the patient gets older. Treatment. — When of moderate size they are best removed by the galvano-cautery, the wire being passed through the nostril and directed over the base of the growth by the finger behind the palate. The pedicle should be then completely destroyed by the post-nasal electrode. When too large for this, an attempt may be made to remove them by electrolysis; this failing, or not being considered advisable, they must be exposed by a preliminary ope- ration. If chiefly confined to the naso-pharynx, the soft i)alate should be split, and the two halves held aside by silk ligature, whilst if more room isrerpiired part of the hard palate may be cut OZ^NA. 549 away after reflecting the muco-periosteum (^Nclatori's operation) . When encroaching chiefly on the nose, a good exposure may be obtained by dividing the lip in the middle line, and turning it to one side with the ala of the nose ; or if more room is required, the superior maxilla must be removed. Rouge's operation of turning up the upper Hp and the cartilaginous portion of the nose after division of the septum, and the operation of Langenbeck of turn- ing the maxillary bone outwards on the cheek, and then replacing it after removal of the growth, have their advocates. My experi- ence of these last-mentioned procedures is not very favorable. The exposure obtained by the former is no better than that gained by turning back the ala ; and the shock and haemorrhage attend- ing the latter renders it very dangerous. Many other methods and modifications of the above have been proposed, but for an account of these a larger work on Surgery must be consulted. Having well exposed the growth it should be removed with the ecraseur or cutting forceps, or be scraped off with a raspatory, and the bone destroyed by the actual or galvano-cautery. The naso- pharynx may then be plugged with iodoform gauze, the end of the strips being brought out through the nose, and removed through this passage after twenty-four hours. At the end of the operation the palate should be united, the lip sutured or the parts replaced, according to which method of exposure has been prac- ticed. 3. Alalignant polypi. — Sarcomatous and cancerous tumors may arise both in the nasal cavities and naso-pharynx, and then con-, stitute what are called malignant polypi. They give rise to symp- toms similar to those of the fibrous polypi already described, but their growth is more rapid, and they quickly infiltrate surrounding parts and involve the neighboring glands. They may occur both in the young and in the old. If a small piece can be removed, the microscope will reveal its nature. Treatment. — When the growth can be got completely away, early and free extirpation by one of the methods above described is the only treatment. Oz^NA is a term which has been used very loosely by authors. By some it has been applied to all diseases of the nose attended with a foul-smelling discharge, whilst by others it has been re- stricted to the foetid form of atrophic nasal catarrh. The term, therefore, as designating a disease, is misleading, and should be discontinued in this sense. For purposes of diagnosis it may be mentioned that it is a prominent symptom in the following affec- tions of the nose: i, atrophic nasal catarrh; 2, necrosis and caries, whether of syphilitic or other origin ; 3, tuberculous, syphilitic and lupoid ulceration of the mucous membrane ; 4, for- eign bodies and rhinoliths in the nasal cavities; 5, purulent 550 DISEASES OF REGIONS. catarrh of the antrum or one of the other accessory sinuses, and 6, some forms of new growth. Diseases of the sefium nasi. — Blood tumors are occasionally met with as the result of injury. The blood is extravasated be- tween the cartilage and the soft tissues, generally on both sides of the septum, causing in both nostrils a fluctuating circumscribed swelling which may be readily distinguished from abscess by its coming on immediately after the injury and by the absence of signs of inflammation. It should not be opened, as the blood will become slowly absorbed. It sometimes appears to be asso- ciated with fracture of the septum. Abscesses of the septum are not very common. They may be due to injury or the breaking down of gummata, but occasionally occur without any apparent cause. When acute they may lead to perforation of the septum. The parts are hot, red and swollen, and fluctuation may soon be detected. A free and early incision should be made. Gummata of the septum occasionally form beneath the perichon- drium in the course of syphilis. They are readily dispersed with iodide of potassium, but if neglected may lead to necrosis and perforation of the septum and to destruction of the bones, which may sometimes be so extensive as to cause falling in of the bridge of the nose. Deflection of the septum to one or other side may occur as the result of an injury, or as a congenital malformation. It appears as a swelling projecting into and obstructing one of the nasal cavi- ties whilst in the other cavity a corresponding depression is seen. The inferior turbinated bone on the side of the concavity is often much hypertrophied. The deflection is generally attended with some lateral deviation or even depression of the lateral cartilages, Fig. 252. Author's forceps for straightening nasal septum. Retentive apparatus for deflected septum. and frequently gives rise to chronic nasal catarrh, and to many distressing symptoms, such as frontal headache, nasal tone of voice, passage of mucus into the pharynx, etc. Treatment. — The septum may generally be forcibly straightened by the forceps shown in I'ig. 252, and then retained in position for the first few days, while the parts are becoming consolidated, by the retentive apparatus shown in Fig. 253, and subsequently by ivory or vul- ADENOID VEGETATIONS. 551 canite plugs (Fig. 254). I have found hollow plugs (Fig. 255) useful, in that they do not so completely obstruct nasal respiration. In some instances portions of the prominent septum may be re- moved by the nasal saw with advantage. Where the lateral car- tilages and nasal bones are deviated they can generally be straightened, even after many years have elapsed since the injury. Fig. 254. Fig. 255. Nasal plugs. Hollow nasal plugs. Great force, however, is required, and care must be taken, by properly padding the forceps, not to injure the soft parts. One of the best forms of retentive apparatus then is, perhaps, the mask shown in the accompanying diagram (Fig. 256), since by its means a fixed point is secured to work from. As a mask, Fig. 256. Fig. 257. Author's nasal mask. Author's fixation cap and nasal truss. however, is irksome to some patients I have more recently, for suitable cases, employed the nasal cap and truss depicted in Fig. 257- Ca?-tiIaginoiis and osseous tumors of the septum, though rare, occasionally occur, and can be readily diagnosed from a deflec- tion of the septum, by their hard and resisting nature and the absence of a corresponding depression in the opposite nostril. Their removal is the proper treatment. Adenoid vegetations in the vault of the pharynx are very common in childhood. They are produced by the hypertrophy 552 DISEASES OF REGIONS. of the adenoid tissue which is so abundant in this situation, and are frequently met with in connection with enlargement of the tonsils, granular pharyngitis, and nasal catarrh, and if neglected may set up catarrhal otitis and incurable deafness. The chief symptoms to which they give rise are deafness, obstruction to nasal respiration, a nasal or "dead" tone of voice, and a vacant expression of countenance from the child breathing with the Fig. 258. Author's modification of Loewenberg's forceps for removing adenoid vegetations. mouth half open. To the finger, behind the palate, they feel soft, pulpy and velvety, "like a bag of earthworms;" whilst in the mirror they appear as pink or reddish, sessile or pedunculated fringe-like masses more or less obscuring the posterior nares (Fig. 250). The treatment consists in removing them, which may be done in several ways. The softer ones may be scraped away with the nail of the finger behind the palate ; those about the Eustachian tubes and side of the pharynx are best extirpated by Meyer's ring-knife (Fig. 259) introduced through the nose; Fig. 259. Meyer's ring knife. and the larger ones, which are situated on the roof and back of the pharynx, by Loewenberg's forceps (Fig. 258) passed behind the palate. The pharyngeal tonsil, which is usually hypertrophied in connection with adenoid growths, can be readily removed by these forceps. Ether followed by chloroform should be given ; gas does not afford sufficient time for thorough removal. I have had to repeat the operation when gas had been employed by others. The anaesthetic should not be pushed beyond "pin-point pupil." Some Surgeons recommend the hanging-head position, but this interferes with the complete removal of the growths. I always myself have the head on its side, so that the blood may run into the cavity of the cheek, whence it can be readily sponged away. No after-treatment, beyond compelling the child to breathe ETHMOIDAL AND SPHENOIDAL SINUSES. 553 through the nose by keeping the mouth closed at night with a bandage, is usually required. I never employ the syringe, as I believe it is one of the chief causes of the middle-ear trouble which sometimes occurs after the removal of these growths. As a precaution against cold I always confine the patient to his bed or room for a few days. The antrum and ihe frontal, ethmoidal and sphenoidal SINUSES may be the seat of purulent catarrh. The catarrh may be due to simple extension from the nose or to the presence of nasal polypi, or the irritation of a carious tooth fang. The most char- acteristic sign is a unilateral discharge of pale yellow pus. This, in the absence of a foreign body or rhinolith, necrosed bone, or syphilitic ulceration, is almost pathognomonic of catarrh of one of these sinuses. In catarrh of the antnnn the discharge is nearly always intermittent, and after a period of retention is often foetid. The pus usually flows anteriorly from beneath the middle turbinal, and more freely when the head is depressed or laid on the oppo- site side. Some pain or tenderness may be elicited by pressing on the cheek or on tapping a tooth, but often there is neither pain nor tenderness. On percussion there may be marked dulness, and on placing an electric lamp in the mouth the affected cheek lights up less brilliantly than the other ; but an exploratory punc- ture through the canine fossa, an empty tooth socket, or beneath the inferior turbinal, may be necessary to settle the diagnosis. In catarrh of the other sinuses the flow of pus is more or less contin- uous, and is promoted by the erect position. It may or may not be foetid. When it comes from \ht fro?jtal ox an/erior ethmoidal celts it flows anteriorly also from beneath the middle turbinal ; when from the posterior ethmoidal or sphenoidal cells, either pos- teriorly or anteriorly, and then over the middle turbinal. There is usually deep-seated pain at the back of the nose in posterior ethmoidal and sphenoidal trouble, pain in the orbit and forehead in anterior ethmoidal and frontal. Exophthalmos points to eth moidal or sphenoidal mischief; ptosis, strabismus and sudden blindness to sphenoidal. A cautious exploratory puncture through the nose, the forehead, or near the inner angle of the orbit will settle the question of pus in the frontal or anterior ethmoidal cells. Treatment. — Sprays such as those mentioned at page 545 should first be used to subdue the nasal catarrh. If the discharge still continues an attempt may be made to wash out ih.t frontal sinus through the nares by the frontal catheter, or, if this fail, the sinuses may be opened externally by the trephine and drained. The antrum may be opened and washed out through the nares, the front wall or the alveolus of a tooth. The sphenoidal or eth- moidal sinuses may be drained by cautiously puncturing through 24 554 DISEASES OF REGIONS. the nose, or in the case of the anterior ethmoidal at the inner angle of the orbit. DISEASES OF THE PHARYNX AND CESOPHAGUS. Pharyngitis, or inflammation of the pharynx, is commonly of the catarrhal variety {acute and chronic pharvngitis), but it may fall chiefly on the glands of the pharynx {foUicuhxr or granular pharyngitis) , or more rarely, may spread deeply and end in sup- puration {phlegmonous pharyngitis) . At times it is attended with deficient secretion and atrophy of the mucous membrane {pharyn- gitis sicca), and occasionally assumes an erysipelatous character, and is then generally associated with erysipelas of the face. Here a few words only can be said on the phlegmonous form, which, perhaps, more commonly comes under the care of the general Surgeon. It is usually the result of an injury. The pharynx is intensely red and swollen, the neck often brawny and oedematous, swallowing is difficult or nnpossible, respiration is labored, and death may occur in a few days from sudden spasm of the glottis, or from exhaustion and blood-poisoning. The treatment consists in inhalations of steam impregnated with carbolic acid ; free inci- sions if pus forms in accessible situations ; the administration of fluid nourishment and stimulants, in the form of enemata if the patient is unable to swallow ; and the performance of instant tracheotomy if oedematous laryngitis supervenes. Ulceration generally occurs in connection with like ulceration of the palate, fauces, and tonsils. (See Tonsils.) Here it need only be said that the healing of the ulcers, especially those of the tertiary syphilitic variety, is sometimes productive of great de- formity. Thus, I, the soft palate may become glued to the back of the pharynx ; or 2, to the base of the tongue ; and 3, the lower part of the pharynx may be narrowed just above the entrance to the larynx, rendering deglutition difficult, and subjecting the patient to the risk of suffocation from the lodgment of food at the constricted part. Treatment. — Adhesions between the palate and pharynx can hardly be remedied ; but when contraction or ste- nosis of the lower pharynx has occurred, the cicatricial bands should be divided in a backward direction with a guarded knife and recontraction ])revented by the daily passage of a bougie. I h.ave found a Ricord's urethrotome answer admirably for making the division. If the introduction of instruments causes much spasm, tracheotomy should be previously i)erformed. Pos'] pharyngeal AI5SCKSS is a collection of pus in the loose cel- lular tissue behind the pharynx, and is most often met with in children. It is generally chronic, and due to disease of the cer- STRICTURE OF THE CESOPHAGUS. 555 vical vertebrae, or more rarely of the base of the skull ; but it may be acute, and is then usually the result of an injury, as swallowing acids or the impaction of a foreign body, or of the exanthemata, phlegmonous pharyngitis, etc. It sometimes occurs without ap- parent cause ; there is then often a history of syphihs or tubercle. It may break into the pharynx, or at the side of the neck, or even make its way into the mediastinum. Symptoms. — Pain, difficulty in opening the mouth, obstructed deglutition and respiration, the presence of a fluctuating swelling at the back of the throat, and more or less swelling about the angle of the jaw. When the ab- scess is acute, there is commonly some febrile disturbance. Tirat- vient. — A vertical incision should be made in the middle line through the posterior pharyngeal wall with a properly guarded knife, the swelling having been previously punctured with a long grooved needle if there is any doubt as to its nature. If opened under chloroform, the head should be turned rapidly to the side to allow the escape of pus through the mouth, as suffocation has occured through a sudden gush into the air-passages. When it depends upon disease of the spine, if an opening is thought neces- sary it should be made through the side of the neck. Tumors of the pharynx are rare, though all varieties may occur. When arising in the loose cellular tissue behind the pharynx, the more common situation, they are spoken of as post-phai-yngeal tumors. The softer varieties closely simulate abscess, but the ab- sence of fluctuation and of pus on puncture will settle the diag- nosis. Innocent growths, when small and unattached to the ver- tebrae, may be enucleated through a vertical incision over them. The malignant, as a rule, should be left alone. Pouches of the cesophagus are occasionally met with. They nearly always arise from the back of the tube and at its junction with the pharynx, and as they increase in size bulge in the neck on one or both sides of. the cricoid cartilage. 'Wit symptoms \.o which they give rise are regurgitation of undigested food some hours after it has been taken, difficulty in swallowing, and later in- anition. A sound can at times be passed into the pouch from the mouth, and food can be squeezed out of the pouch into the oeso- phagus, the pouch becoming flaccid. The treatment coxi^x'sX^ m removing the pouch through an incision in the neck, and closing the wound in the cesophagus with sutures. Stricture of the cesophagus may be due to spasm of the muscular fibres {spasmodic stricture^ to cicatricial contraction {fibrous stricture), or to epitheliomatous or other malignant growths of its walls {malignant stricture). Further, stricture may be simulated by compression of the oesophagus from without as by an aneurysm, enlarged thyroid gland, post- oesophageal abscess, 556 DISEASES OF REGIONS. or mediastinal tumor; or by a foreign body impacted in the tube, disease at the back of the larynx, etc. Spasmodic stricture or spastn of the msophagus generally occurs in young hysterical women. The patient may be quite unable to swallow, and a bougie, perhaps, will not pass. The diagnosis will then rest on the obstruction existing only at times ; on the age and sex of the patient ; the presence of other signs of hysteria ; but chiefly on the fact that, under an anjesthetic, the bougie, which could not previously be passed, slips down easily into the stomach. The treatment should consist in the administration of anti-hysterical remedies ; whilst the patient may be persuaded that the bougie has cleared the passage. Fibrous stricture is generally due to cicatricial contraction fol- lowing an injury, as swallowing boiling water or corrosive fluids, Fibrous strictre of oesophagus at region of cricoid cartilage. (St. Bartholomew's Hospital Museum.) Malignant stricture of oesophagus at entrance of stomach. (St. Baitholomew's Hos- pital Museum.) or the impaction of a foreign body. More rarely it results from the healing of a syphilitic ulcer. At times it appears to be con- genital ; at other times no cause can be discovered. It may exist at any part of the tube, but is most common in the upper half (Fig. 260). It is much rarer than the nialignant form, but is liable to become malignant when it has existed for some time. As the result of the constriction, the tube above the stricture be- comes dilated and the nuiscular coat hypertrophied. The dilata- tion may be general or pouch-like, in the latter case consisting either of a dilatation of all the coats, or of a hernia of the mucous membrane through the muscular fibres. STRICTURE OF THE CESOPHAGUS. 557 Ma/ignant stricture is generally epitheliomatous, and may occur at any part of the oesophagus, but is most common opposite the cricoid cartilage, at the bifurcation of the trachea, and at the cardiac end of the stomach (Fig. 261), situations at which nor- mally slight obstruction to a bolus of food larger than usual exists, and at which "developmental processes are complicated, and where, therefore, errors of nutrition are more hkely to occur." Thus, at the cardiac orifice the epithelium changes its character ; and where the oesophagus is crossed by the bronchus the food and air-passages were originally one. Epithelioma may begin as a distinct cauliflower like excrescence springing from one side of the tube ; or as a nodular induration of the mucous membrane involving ring-Hke the whole calibre of the oesophagus. It gradually encroaches upon the lumen of the tube, causing more or less complete obstruction. The growth sooner or later ulce- rates, and invades the surrounding tissues, the mediastinum, pleura and glands ; and sinuses may form between the oesophagus and the trachea or left broechus, or open externally when the disease is high up in the neck. The patient, if he does not die of starvation, succumbs to pain or exhaustion, or to haemorrhage from the laying open of a large vessel, or to pleurisy or pneumonia. The symptoms, common to both the fibrous and malignant stricture, are — i, increasmg difficulty of swallowing, first of solids, then of liquids, and finally inabihty to swallow either; 2, a feeling of obstruction, generally referred to the top of the sternum ; 3, regurgitation of food after it has been swallowed for a short time (where the stricture is low down or pouch-like dilatations have formed) ; 4, a trickhng sound on auscultation between the shoulders whilst the patient is swallowing fluid ; and 5, progressive wasting and loss of strength. The diagnosis, however, can only be made with certainty, and the situation of the stricture ascer- tained, by the passage of a bougie. But before attempting to pass a bougie, a careful examination of the chest should be made for the purpose of excluding aneurysm as a cause of the symptoms, lest such should be ruptured, as has before now happened. The diagnosis of the malignant from the fibrous stricture will rest on the advanced age of the patient, the absence of any discoverable injury, the presence of blood or foul-smelling discharge on the end of the bougie, a sensation of passing over an ulcerated sur- face, and the presence of enlarged glands or an indurated mass in the situation of the tube when the stricture occurs in the neck. Treatment. — In the fibrous form the stricture should be grad- ually dilated by bougies. When the stricture is very tight, a cat- gut bougie may sometimes by delicate manipulation be insinuated through it ; and over this a larger tube may then be passed. 558 DISEASES OF REGIONS. When the stricture is very resiUent, its division posteriorly in the middle line may be called for {^infernal (xsophagotomy'). When the stricture is situated at the cardiac end, and a well-directed trial at dilatation has failed, gastrostomy may be performed, and the stricture forcibly dilated by the finger or an instrument passed into the oesophagus from the interior of the stomach. It need hardly be said that so serious an operation should not be lightly undertaken, nor until other means have failed. In maUgnant <;trictitre dilatation by bougies or tubes, in the way recommended in fibrous stricture, must not be attempted, as the walls of the oesophagus are so softened by the ulceration and disease that great danger of perforation and extravasation into the mediastinum or pleura would be incurred. The methods of treatment then open to us are — i, to pass an oesophagus tube and keep it in situ ; 2, to perform gastrostomy, and 3, when the stricture occurs in the neck, to open the cesaphagus in the neck, if possible below the seat of stricture, and stitch the tube to the wound in the skin ; or if not possible to get below the stricture, to dilate it from the wound. When a soft tube can be passed and kept /;/ si/u this appears to be undoubtedly the best treatment. The tube may be introduced through the mouth or nose, and under favorable cir- cumstances will not need chang- ing for a month or more. Oc- casionally, however, it causes ir- ritation of the back of the tongue or larynx, or of the mucous mem- brane of the nose. Should this occur, Mr. Charters Symonds' plan may be adopted of passing, by means of a suitable director, a short tube, shaped like a funnel at one end, into the stricture, and leaving it there merely attached by a strong string, which is se- cured to the cheek or ear by strapping (Fig. 262). Care must be taken that the patient does not swallow the string, an accident which has ha])pened during this treatment. Excellent results have followed the use of tubes ; patients have regained flesh, have fairly enjoyed life for some months, and then have died in comparative ease. When a tube cannot be passed, or is not tolerated, the oesophagus, if the dis- ease is high in the neck, may be opened, or if the disease is low down, gastrostomy performed. A Symonds' tube in situ. GASTROSTOMY. 559 Gastrostomy is the operation of establishing a fistulous opening into the stomach for the purpose of feeding the patient in stricture of the oesophagus. The operation is now usually performed in two stages. In the first, the abdomen is opened, and the stomach secured by suture to the abdominal parietes ; in the second, which is not performed till from four to six days after the first, the stomach, which by this time has become adherent to the abdo- minal parietes, is punctured, and a tube introduced, i. An ob- lique incision (Fig. 284, e) is made between two and three inches long, about an inch below, and parallel with the left costal car- tilages, beginning about an inch and a half from the middle line (Howse). The sheath of the rectus is next opened, the fibres of the muscle separated, not cut, the posterior layer of the sheath divided, and the peritoneum exposed. Mr. Howse thinks that the fibres of the rectus subsequently play the part of a sphincter to the opening. All bleeding having been stopped, the peritoneal cavity is opened on a director, and the stomach sought and drawn into the wound if it does not already present there. It may be distinguished from the transverse colon by its thick, smooth and pinkish-red coat and the absence of appendices epiploicje. Two loops of silk are passed through the peritoneal and muscular coat for the purpose of securing a good hold of the stomach whilst the sutures are being introduced, and also for the purpose of steady- ing it during the subsequent operation of opening it, and thus pre- venting the risk of the adhesions being broken Fig. 263. down. The stomach, as near the cardiac end as possible, is now \^ i / stitched to the parieties i | | by a double ring of lf^# 1 sutures, so as to ensure ,_^''i''^__ a good inch of the ,^ stomach-wall (that be- tween the outer and / inner ring of sutures) %^ being in contact with Howse's method of suture.in gastrostomy. the parietal peritoneum (Fig, 263). The outer ring of sutures is passed^first, by carrying the needle, armed with a silk suture, through the serous and mus- cular coat of the stomach, and then through the abdominal parieties, a good inch from the edge of the wound. The needle is now unthreaded and withdrawn, re-threaded with the stomach end of the suture, and passed through the abdominal parietes, un- threaded, and finally withdrawn. _ When_[all the sutures are in 560 DISEASES OF REGIONS. situ they are tied over a quill. The inner ring of sutures are then passed through the serous and muscular coat of the stomach and the skin and peritoneum only of the parietes, and tied. The wound is dressed antiseptically. 2. At the end of from four to six days the stomach will generally be found adherent, and should then be punctured with a long sharp tenotomy knife, while it is drawn well forwards by the silk ligatures left in for the purpose. A No. 6 or 8 English catheter is passed through the puncture, and the wound again dressed antiseptically, the catheter passing through the antiseptic dressings. At first only teaspoonfuls at a time of fluid nourishment should be given; later a larger tube may be passed, and minced sohd food introduced. DISEASES OF THE LARYNX. , Physical examination of the larynx. — For the diagnosis and efficient treatment of the diseases of the larynx the laryngo- scope is required. To use this instrument, place yourself in front of the patient and the light, in the way shown in Fig. 264. Throw the light reflected from the head mirror into the back of the patient's mouth ; draw the tongue, held by a towel with the left hand, gently forward, and press the throat mirror, held in the right hand, firmly but gently against the uvula and soft palate. With a little practice an image of the larynx is obtained. Ask the patient to pronounce the sounds ah, ee, and the vocal cords will come into view. The image of the larynx is of course re- versed, the front appearing in the throat mirror as the back. If any difficulty is experienced in obtaining a good view the soft palate and back of the mouth should be sprayed or painted with a 20 per cent, solution of cocaine. If any operation or manipu- lation is required in the larynx itself, it also should be swabbed with cocaine by the laryngeal brush. Laryngitis, or inflammation of the larynx, may be conveniently divided into — i, acute catarrhal ; 2, chronic catarrhal ; 3, oedema- tous ; and 4, membraneous laryngitis. Acute cataYrhal laryngitis may be due to sudden exposure to cold or damp, violent exertion of the voice, or inhalation of noxious vapors or impure air ; or the inflammation may spread to the larynx from the pharynx ; or occur in the course of other diseases, as the eruptive fevers. Symptoms. — Soreness of the throat, hoarseness or even aphonia, laryngeal cough, and tender- ness on pressure over the thyroid cartilage, accompanied by febrile sym])toms. On laryngoscopic examination the parts are seen red and swollen, and the cords do not come together properly. l"he treatment consists in rendering the atmosphere LARYNGITIS. 561 moist by the steam kettle, in inhaling soothing vapors, and ab- staining from using the voice ; whilst if the attack is very acute, leeches or cold in the earlier stages may be appUed over the Fig. 264. Method ot using the 1 in ngoscope thyroid cartilage. Should the inflammation assume the oedema- tous form, scarification, intubation, or tracheotomy may become necessary (see CEdematous Laryngitis^. Chronic laryngitis may be due to exposure to wet and cold, over-exertion of the voice, excessive smoking, inhalations of dust or noxious vapors, syphilis, tubercle, and malignant disease. The mucous membrane appears thickened and indurated and covered with a muco-purulent discharge, whilst the glottis is narrowed in consequence of the thickening of the mucous membrane. The syinptoms are cough, hoarseness, laryngeal voice, dryness and irritation of the throat, and dyspnoea, varying with the amount of narrowing of the glottis. A variety of chronic laryngitis, in which the mucous follicles are chiefly aff"ected, is known as follicular or granular laryngitis, or clergyman's sore throat, and is frequently associated with a similar condition of the pharynx. Treatment. — The application with the brush of a strong solution of nitrate of 562 DISEASES OF REGIONS. Fig. 265. silver (half a drachm to the ounce, or even stronger), absolute rest of the voice, residence at a suitable spa, avoidance of all sources of irritation, and appropriate remedies if there is any specific disease. CEdematoiis laryngitis or oedema of the glottis.^ln this form there is an effusion of serous fluid into the sub-mucous tissue of the larynx, especially that about the aryteno-epiglottidean folds (Fig. 265). But the oedema does not extend below the vocal cords, as the mucous membrane is tightly attached to them with- out the intervention of any submucous tissue. Cause. — It gen- erally comes on suddenly, and often supervenes upon some previous inflammatory condition of the larynx or neighboring parts. It is of common occurrence after scalds or burns of the throat, stings of insects, or the impac- tion in the larynx of a foreign body ; or it may occur in the course of such dis- eases as eysipelas, fevers, and small- pox ; or be engrafted on tubercular or syphilitic ulceration of the larynx, peri- chondritis, or necrosis of the cartilage. CEdema of the larynx of a passive char- acter is also a frequent termination of Bright's disease. The symptoms in the acuter forms are most urgent, the dyspncea is extreme, and if not relieved rapidly ends in spasm and death. When less acute the voice is affected, inspiration is often stridulous and labored, and swallowing is painful and difficult — symptoms which may be fol- lowed by cyanosis, coma, and death. The treatment must be energetic ; an emetic should be given at the onset, and leeches, ice, or, if preferred, hot sponges, applied over the thyroid cartilage. These means failing, the cedematous part must be scarified by the laryngeal lancet, or an O'Dwyer's tube, if at hand, ])assed through the glottis, and re- tained there until the oedema subsides ; otherwise laryngotomy or tracheotomy must be performed. Membraneous larxngiiis, laryngeal croup or laryngeal diphthei-ia, is a disease of childhood, and may either begin in the larynx, or spread to it from the fauces and pharynx. It is characterized by the formation of a false membrane, which may extend into the trachea and bronchi (Fig. 266). The membrane, which may be hard and tough, or soft and crumbling, and of a yellowish or Gidematous Laryngitis, i St. Bar- tholomew's Ho.spital Museum.) LARYNGITIS. 563 grayish-white color, is produced by the coagulation of fibrinous material exuded on the surface of the mucous membrane. It consists of a delicate network of fibres enclosing leucocytes, cast- ofF epithelium, and granular debris iu its meshes. I.oeffler's ba- cillus has been found in the membrane. On its separation the mucous membrane beneath is generally though not invariably found to be denuded of epithelium, congested and inflamed ; but the mucosa is not usually involved, as is the case in diphtheritic inflammation of the fauces and pharynx. This diff'erence would appear to depend on the site of the inflammation and the intensity of the process, though some consider it a point in favor of the non-identity of croup and diphtheria, a question, however, which cannot here be discussed. The symptoms, when the disease be- gins in the larynx, generally come on very gradually ; and ^'g- at first cannot be distinguished from an ordinary catarrh. Soon, however, and often first during the night, the cough acquires a ringing or brassy character, and soon afterwards, if not simul- taneously, the inspiration be- comes stridulous, and later the voice "hoarse, cracked, and whispering, or in young chil- dren totally suppressed." Dys- pnoea is now marked ; the soft parts of the chest-walls recede during inspiration ; the inspira- tion is heaving ; expiration as well as inspiration may also be- come impeded, and the child, if not relieved, rapidly becomes cyanosed and dies. When the disease spreads from the pharynx, the laryngeal signs may at first be masked ; but later, they are similar to those given above. Ti-eatment. — Internally quinine and perchloride of iron may be given, whilst locally when any membrane is visible on the fauces and pharynx it should be removed, and prevented, if possi- ble, from re-furming by swabbing out the throat at frequent inter- vals with boro-glyceride, carbolic acid, or other disinfectant. The child may be placed under chloroform, if necessary, to en- sure the thorough removal of the membrane. Although it is per- haps too early to pronounce an opinion as to the exact value of Membraneous laryngitis or croup ( St. tholomew's Hospital Museum). 564 DISEASES OF REGIONS. the subcutaneous injection of diphtheria antitoxin, its efficacy seems to some extent to be undoubted, since a marked decrease in the percentage of mortality from diphtheria has resulted in the hospitals where it has been used. It would appear that the earher the injections are made in the disease the more prospect there is of success, since the antitoxin can only neutralize the toxin present in the system, not undo the damage to the muscles and nerves already done, nor control the secondary septic processes which may have been set up. The dose must be sufficiently large, and regulated more by the severity of the symptoms than by the age of the patient. The minimum dose for a child, according to Klein, is 3j. to 3J^. Washburn and Goodall recommend the following doses of a serum of which 0.000 1 c.cm. neutralizes a dose of diphtheria toxm otherwise fatal to guinea-pigs : in severe cases, 20 c.cm. (about gv) when the patient is first seen, followed by 10 c.cm. in from eighteen to twenty-four hours, and again another 5 to 10 c.cm. in another eighteen to twenty-four hours, and proportionately smaller doses for less severe cases. Should the larynx become obstructed, tracheotomy must be performed. The chief indications for this operation are — i, retrocession of the soft parts of the chest-walls ; 2, suppression of the voice ; and especially 3, impeded expiration. Before intro- ducing the tracheotomy tube the membrane should be thoroughly removed both- from the trachea and larynx by a feather or by the suction-tube apparatus, and its re-formation if possible prevented by constant spraying of the part through the tube with an alkaline lotion. The patient's bed should be surrounded with curtains, and the atmosphere kept moist by steam to which an antiseptic is added. He should be fed with soft solid nourishment, and if necessary by a flexible silk tube passed through the nose. Stim- ulants are generally required. The recumbent posture should be insisted on, as there is grave danger, if the patient attempts to sit up, of sudden and fatal cardiac syncope. Tui'.FKCLE OF THE LARYNX, also called laryngeal phthisis, may sometimes occur as a primary affection, though it is generally secondary to tubercle of the lung. It is characterized by the formation of miliary tubercles under the mucous membrane, which subsequently break down, leading to ulceration. The symptoms are those of ordinary chronic laryngitis, but in addition to these, the y)atient often presents signs of pulmonary phthisis. On examination the mucous membrane looks pale, and the aryteno-epiglottidean folds swollen and often of a pyriform shape ; later, ulceration will be discovered, and may be followed by caries and necrosis of the laryngeal cartilages, dysphagia, and oedema of the glottis. — Treatment, — The usual constitutional treatment for SYPHILIS OF THE LARYNX. 565 tubercular diseases must be employed. When ulceration has occurred, insufflation of morphia and painting the part with cocaine before taking food may be tried, to relieve the cough and the difficulty and pain in swallowing. Should swallowing become impossible, the patient should be fed with the oesophageal tube whilst lying face downwards. Tracheotomy must be performed if suffocation threatens. Syphilis of the larynx. — In the secondary stages of syphilis, catarrhal inflammation, superficial ulceration, and mucous patches may occur ; whilst in the tertiary stages characteristic ulcers due to breaking down of gummata are not very uncommon. Tertiary ulceration may extend to the perichondrium, or a gumma may begin beneath that membrane, and in either case lead to necrosis or caries of the cartilages. On the healing of the ulcers con- tractions and adhesions producing stenosis of the larynx may ensue. General syphilitic treatment, appropriate to the stage, should be employed. Scarification or tracheotomy are called for in tertiary affections should oedema of the glottis supervene. In stenosis an attempt may be made to dilate the contracted glottis by means of O'Dwyer's tubes, or the stricture may be divided with a guarded knife, or with the galyano-cautery. Tumors both innocent and malignant occur in the larynx. Of Fig. 267. Fig. 268. Papilloma of laryn.x. (St P.artholomew's Sarcoma of larynx. (St. Bartholomew's Ho-;- Hospital .Museum.) pital Museuin.j the form.er the papillomata and fibromata are the most common, of the latter the epitheliomata. The papillomata occur as warty 566- DISEASES OF REGIONS. or pedunculated excrescences, or as soft, flocculent, villous-like bodies, and generally grow from the vocal cords, and front of the larynx (Fig: 267). They may be single or multiple, llic fibro- 7nata are less common, and occur as small, smooth, solitary, spherical, pedunculated or sessile growths, springing from the vocal cords. The epithchomata usually grow from the mucous membrane covering the arytenoid cartilages, or from the ventri- cular bands or cords. A sarcomatous tumor is shown in the accompanying illustration (Fig. 268). The chief symptoms of a growth in the larynx are hoarseness or aphonia, and dyspnoea. When the growth is pedunculated the symptoms are often paroxysmal and intermittent in character, in consequence of the growth being moved by the current of air in respiration. The laryngoscope is essential for the diagnosis. In the early stages it may be difficult to distinguish an innocent from a malignant tumor, but if a small piece can be removed, a microscopical examination will usually clear up the point. Later, the rapid growth of the tumor, its tendency to ulcerate, its indura- tion, its involvement of surrounding parts, the enlargement of lymphatic glands, and the accompanying pain and cachexiae, will indicate malignancy. Frequently, however, the lymphatic glands are not involved, and there may be no cachexia. Treatmetit. — Innocent growths should be removed if possible by the intralaryngeal method. This may be done by evulsion with the laryngeal forceps, or by excision with the cutting forceps, or with the cold wire or galvano-cautery snare, local anaesthesia being induced by cocaine. When of very large size, or broad- based, or situated below the cords, or in other parts where they cannot be removed by this method, laryngo-tracheotomy or thyrotomy may have to be performed. When a malignant growth is confined entirely to the larynx, and the glands of the neck are not involved, thyrotomy may still be performed, and the growth completely cut and scraped away from the cartilages ; or if the cartilages are found invaded, part, or even the whole of the larynx may be extirpated. Otherwise palliative treatment only can be employed, or tracheotomy performed if suffocation threatens. OPERATIONS ON 'JHE AIR PASSAGES. Under this head are included tracheotomy, laryngotomy, lar- yngo-t}-acheoio?ny, thyrotomy, subhyoid pharyngotomy and intuba- tion and extirpation of the larynx. A. 'J'racheotomy, laryngo- tomy, and laryngo-tracheotomy may be required, i, for establish- ing a ])ermanent opening below an obstruction of the larynx ; 2, as a temporary exi)edient until such an obstruction can be re- moved ; 3, for the extraction of a foreign body or growth ; and 4, OPERATIONS ON THE AIR PASSAGES. 567 to prevent blood entering the trachea during operations about the mouth, jaws, tongue and pharynx. B. Thyrotomy 'and subhyoid pharyngotomy may be necessary for the removal of a growth or foreign body when such cannot be extracted by the intralaryn- geal method or by one of the former operations. C. Complete or partial extirpation of the larynx may have to be undertaken for a malignant growth confined to the larynx. Before performing any of these operations, the Surgeon should consider well the an- atomy of the middle line of the neck. Beginning at the chin is the raphe between the mylo-hyoid muscles, next the hyoid bone, and then the thyro-hyoid membrane, through which an incision is made in the operation of subhyoid pharyngotomy (Fig. 269, a). Below this is the pomum Adami, or the notch in the thyroid carti- lage, which though prominent in adults, especially in males, can hardly be felt in the fat neck of a child. An incision exactly in the middle line through the thyroid cartilage is known as thyrotomy (Fig. 269, b). A little below the thyroid cartilage the cricoid Fig. 269. can be felt. It is situated op- ^.^--.~.. posite the fifth or sixth cervical "''" "- vertebra, and is an excellent landmark, as it can always be distinguished however fat the neck. Between it and the thy- roid cartilage is the crico-thyroid membrane, which is quite super- ficial, being covered only by the skin, superficial and deep fascia, and the overlapping sterno- hyoid muscles. This is the spot where laryngotomy is performed (Fig. 269, c). Below the cricoid cartilage are two or three rings of the trachea, and then the thyroid isthmus. There is usually a space between the cricoid car- tilage and the isthmus of a quarter to half an inch. Here the trachea is merely covered by the skin, superficial and deep fascia, and the overlapping sterno-hyoid muscles on either side, and it is in this situation that tracheotomy is best performed (Fig. 269, d). When the incision is extended upwards through the cricoid as well as through the upper rings of the trachea, it is called taryngo- tracheotomy. After the isthmus of the thyroid gland, which, in adults, is usually about half an inch wide, follow Situation of incisions for operations in middle line of neck. a. Subhyoid pharyn- gotomy. b. Thyrotomy. c. Lar^'ngo- tomy. d. Tracheotomy above isthmus. e. Tracheotomy below isthmus. The hnes only show the relative situation of the incisions, not their correct length. 568 DISEASES OF REGIONS. four or five rings of the trachea, and then the upper border of the sternum. Below the isthmus the trachea recedes from the surface, and in addition to the skin and superficial and deep fascia, is covered by the sterno-thyroids as well as the sterno-hyoids, and by two layers of deep fascia between which is the large inferior thyroid plexus cf veins. Superficial to the muscles, the anasto- motic branch between the anterior jugular veins also crosses the trachea. On the trachea itself are several small branches from the inferior thyroid arteries, pnd sometimes the thyroidea ima, an abnormal branch coming off from the aorta; whilst, rarely, the innominate vein may be higher than usual, and cross the trachea above the level of the sternum. On either side of the trachea low in the neck are the carotid arteries. Some surgeons perform tracheotomy below the isthmus (Fig. 269, e) ; but a review of these anatomical relations makes it evident how much greater is the risk and difficulty then attending it. Tracheotomy may be performed either above or below the thyroid isthmus. The former situation should, as a rule, be chosen, as here the operation can be performed with greater ease and less risk. Moreover, there is less danger of suppuration ex- tending between the layers of the cervical fascia which are neces- sarily opened if the low operation is done. In favor of the low operation, on the other hand, it is argued that the opening is further from the disease when the larynx is affected, and nearer to the bronchi when a foreign body has to be extracted ; and that there is more room than above the isthmus, as the latter sometimes touches the cricoid cartilage. The isthmus, however, can be drawn downwards quite easily with blunt hooks, or, if necessary, may be divided in the middle line with perfect safety and practically no haemorrhage. If there be any advantage in the low operation in that the treachea is opened further from the disease, it is, in my opinion, fully compensated for by the less risk attending the high operation. The hi^h operation only will be here described. It may be done either with or without chloroform. Chloroform should, as a rule, be given to children, as otherwise their struggles are apt to embarrass the operator. In adults, however, it is not necessary, as after the skin-incision has been made no pain is felt, and chloroform is liable to increase the dyspnoea, if present, to a dangerous extent and necessitate the operation being rapidly per- formed, whereas the more deliberately it can be done, the less are the risks attending it. A small pillow having been placed beneath the neck so as to render it prominent, make an incision from the cricoid cartilage, exactly in the middle line, for an inch and a half to two inches downwards according to the age of the patient, TRACHEOTOMY. 569 fatness of the neck, etc. (Figs. 269, 273, d). Divide the skin and superficial fascia, and having found the interval between the sterno-hyoid muscles continue your incision between them, care- fully avoiding any large veins, 'i he isthmus of the thyroid will now be seen in the lower part of the wound as a bluish-red body, and if sufficient room does not exist between it and the cricoid cartilage, draw it down gently with a blunt hook ; or if this can- not be readily done, notch it in the middle Une or divide it. The drawing downwards of the isthmus is greatly facilitated by divid- ing transversely on the cricoid the layer of fascia which extends from the cricoid cartilage to the isthmus. By doing this, more- over, the wounding of the veins between the layers of fascia will be avoided. The first two or three rings of the trachea having now been fully exposed, and all arterial haemorrhage arrested by ligature or pressure-forceps, thrust the sharp hook into the trachea immediately below the cricoid cartilage, and steadying it in this way, divide the first two or three rings by thrusting in the knife with the back of the blade directed downwards and by cut- ting towards the cricoid. Venous haemorrhage, except from a large vein, which, of course, should be tied or clamped, need not delay the opening of the trachea, as it depends on engorgement of the right side of the heart, and will disappear after two or three inspirations through the tracheal wound. The wound in the trachea being held open by the tracheal dilator, pass the outer tube, made wedge-shaped by pressing it between the finger and thumb, into the trachea, and then imme- diately insert the inner cannula, as until this ^"^- '^^°• is done, air cannot freely pass through the tube. Secure the tube /;/ situ by tracheotomy tapes tied behind the neck. Where the operation is performed for croup or diph- theria, the tube should not, as a rule, be in- serted at once, but the wound held open by the dilator, and any false membrane removed Parker's cannula. by a feather passed both down into the trachea and up into the larynx, or if this does not succeed, by a Parker's suction-tube apparatus. The bivalve cannula in general use is apt, on account of its shape, to produce ulceration of the anterior wall of the trachea, on which from its curve it must nec- essarily impinge ; it has even been known to perforate the wall and to enter the innominate artery. This can be prevented by the improved shaped cannula invented by Mr. R. W. Parker (Fig. 270). Should the breathing cease during the operation, the trachea should still be opened, the obstructing membranes re- moved, and artificial respiration persevered in for some time. 24* 57° DISEASES OF REGIONS. Dangers and difficulties of the operation. — Where the operation can be done deliberately, and on a patient with a thin neck, it is attended with no great difficulty ; but where, as is frequently the case, it has to be undertaken on an emergency, possibly with in- sufficient light and with no skilled assistant at hand, or on a young child or infant with a fat neck, and has to be completed rapidly to prevent death from suffocation, it is perhaps one of the most trying that the Surgeon is called upon to perform. 'I'he dangers into which the inexperienced and unwary may then fall are the following : — 1. The hyoid bone or the thyroid cartilage may be mistaken for the cricoid cartilage, and the incision made through the thyro- hyoid membrane or into the thyroid cartilage. This mistake could hardly occur except in a fat-necked child, and then only through carelessness in not determining the position of the cri- coid cartilage before beginning the operation. 2. The interval betiaeen the sterno-hyoid muscle may be missed, and the dissection carried to one or other side of the trachea. The thyroid body and even the carotid artery has in this way been wounded. To avoid such a disaster the head should be held perfectly straight and the incision made "accurately in the middle hne ; one side of the wound should not be retracted more than the other ; and the index finger should be used from time to time to make sure that the dissection is being made over the trachea. 3. Too short an incision may be made, and consequently be a source of embarrassment in drawing down the thyroid isthmus, and in defining the trachea before it is opened. The incision should never be less than an inch and a half long, even in a child. 4. One or more hage veins may be wounded, and the steps of the operation be considerably impeded by haemorrhage, 'llieir walls are very thin ; great care, therefore, is necessary to avoid injuring them. 5 . The knife may perforate the poste^-ior wall of the trachea and enter the oesoi)hagus. Caution, therefore, is necessary, and some advise that the knife should be held, whilst incising the trachea, with the forefinger placed on one side half an inch from its point, so that it cannot penetrate too deeply. 6. The knife may slip to one side, instead of entering the trachea. This can hardly happen if the trachea is fixed by the sharp hook and drawn well forward into the wound whilst being perforated. 7. 7'he innotnifiate vein and even the innominate artery have been wounded in incising the trachea during the performance of the low operation. The knife, therefore, should be introduced with the back of the blade towards the sternum, and the incision made from below upwards. TRACHEOTOMY. 571 8. Blood may enter the trachea, and if allowed to remain there will coagulate, and the clots being drawn into the bronchi and acting as plugs may cause suffocation. This danger should be guarded against by tying all bleeding vessels, and thoroughly ex- posing the trachea before incising it, lest there should be a vessel in front of it. Should only a little blood enter the trachea, it can be coughed up : but if the amount is large, the patient should be turned on his side, and the head depressed, the wound of course being held open by retractors, to allow it to run out ; or if this does not suffice, an attempt must be made to remove it by suction. When there is a general oozing of blood from the wound, the in- troduction of the tube will prevent more escaping into the trachea. 9. The tracheotomy tube may be forced between the fascia and the front wall of the trachea; or one valve of the tube may be passed inside the trachea, and the other outside. — To escape these accidents, the incision in the trachea should be free, and its edges well retracted, or one edge may be held up by a sharp hook. To ensure both valves entering- the trachea, they should be pressed well together ; this may be conveniently done by Sankey's forceps (Fig. 271). 10. The tube, where a membrane is pj'esent, may be passed be- FlG. 271. Sankey's forceps for introducing tracheotomy tube. Fig. 272. Author's pilot for Mr. Morrant Baker's soft tube. tween the tracheal wall and the false membrane, a danger that may be guarded against by removing the membrane before intro- ducing the tube. II. The tube has been passed upwards into the larynx instead of dowmvards into the trachea. — No excuse, and it is to be feared no remedy, could be found for such gross ignorance. After-treatment. — The room should be kept at a uniform tem- perature, the air rendered moist by means of a steam-spray ap- paratus, and the bed well surrounded with curtains. The inner tube, especially if the operation is performed for diphtheria or croup, should be freed at frequent intervals with a feather, or with a small sponge fixed on a wire ; and well cleansed by the nurse at least two or three times a day. The outer tube, which also re- quires cleansing once a day, should only be removed by the sur- 5 72 DISEASES OF REGIONS. geon himself. Where it is necessary that a tube should be worn for any length of time, Mr. Morrant Baker's india-rubber cannula should be substituted for a silver tube. I have employed this im- mediately after the operation, but it is perhaps safer not to do so until the wound has been dilated for a few days by the silver can- nula, as at first the resiliency of the tracheal rings tends to close the wound, and the india-rubber has been found in some in- stances not sufficiently stiff to resist their pressure. The pilot shown in Fig. 272, inasmuch as it renders the end of the tube stiff and wedge-shaped, facilitates its introduction. The india- rubber tubes may be worn with the greatest comfort, and for pro- longed periods. I have now a patient who has worn them for upwards of five and a half years. When lined with canvas, as suggested by Mr. Baker, the tube will last in very good condition for nearly twelve months. If a silver tube be worn it should be examined on each removal, any blackening of the end, and, of course, the presence of blood, being an indication that ulceration is in progress. The tube should only be worn as long as respira- tion through the glottis is impeded. To determine when the tube may be dispensed with it is merely necessary to close the wound with the finger and thus test the breathing. As a rule, it is bet- ter to remove the tube at first only during the day, or for a few hours at a time, or where a fenestrated cannula is used the ex- ternal opening may be stopped for certain periods with a plug to gradually accustom the patient to breathe through the glottis. When the tube has been worn for any length of time some diffi- culty is often experienced in leaving it off. Iliis may depend chiefly on : i, the formation of granulations in the trachea above the opening for the tube ; 2, adhesions of the vocal cords to one another, and 3, paralysis complete or partial, of the intrinsic mus- cles of the larynx. Where granulations are the cause of the ob- struction, they should be touched at intervals with nitrate of silver. Where there is adhesion of the vocal cords, the glottis may either be dilated by O'Dwyer's tubes, or the adhesions broken down by probes passed up through the wound or down through the mouth. The power of the muscles may be restored by galvanism, one pole being placed in the larynx, and the other over the situation of the recurrent laryngeal nerve. In children the condition improves as they grow older and as the larynx be- comes more developed. Larvn(;otomv. — Feel for the cricoid cartilage, and if the case is urgent, and the patient evidently /// extremis, plunge a pen- knife through the skin and subjacent crico thyroid membrane transversely, immediately above the cricoid cartilage, and hold the wound open by a hair-pin, piece of wire from a champagne LARYNGO-TRACHEOTOINIY. 5 73 bottle, etc. When the operation can be done deliberately, make an incision exactly in the middle line cf the neck from a little above the lower border of the thyroid cartilage to a little below the upper border of the cricoid cartilage (Figs. 269 and 273, c), and the crico-thyroid membrane having been thus exposed, incise it transversely, introducing the knife immediately above the cri- coid cartilage, so as to be as far as possible from the vocal cords, and in order to avoid wounding the little crico-thyroid artery which anastomoses with its fellow usually across the upper part of the space. This artery, though commonly so insignificant that any haemorrhage from it could be readily controlled by the tube, is sometimes of considerable size, and, if then wounded, would require tying. The laryngotomy tube should be somewhat com- pressed from above downwards, so as better to correspond with the shape of the crico-thyroid space. Some surgeons recommend that the incision through the crico-thyroid membrane should be vertical, as the anterior jugular veins and the crico-thyroid mus- cles have been injured in making the transverse incision, and an aerial fistula has at times remained after the latter has been em- ployed. Further the vertical incision has this advantage, that it can be prolonged downward through the cricoid cartilage if more room is required. Laryngo-tracheotomy consists in prolonging the incision in the trachea through the cricoid cartilage. It is sometimes done when there is not room between the cricoid cartilage and the isthmus for the performance of tracheotomy ; also for the purpose of removing a growth from the larynx. Although no harm may follow the division of the cricoid, it should be avoided, if possible, as the integrity of the larynx is thereby interfered with, and serious impairment of the vocal apparatus has occasionally been the result. Comparison of the operations of tracheotomy and laryngotomy. Laryngotomy is a much easier operation and can be done with greater rapidity than tracheotomy. For this reason it is par ex- cellence the one to be undertaken on an emergency, as, for instance, threatened suffocation from the impaction of a portion of food at the entrance of the larynx. In children tracheotomy, or, in the case of an emergency, laryngo-tracheotomy, should al- ways be undertaken, as the crico-thyroid space in them is too small to admit a tube. In adults, when either laryngotomy or tracheotomy can be performed deliberately, the opinions of Sur- geons are somewhat at variance as to which operation ought to be undertaken for the varying conditions calling for an opening into the air-passages below the glottis. For my own part I always do tracheotomy (except in cases of emergency), as this operation does not interfere with the integrity of the larynx ; whereas after 574 DISEASKS OF REGIONS. laryngotomy the voice has at times been lost or impaired owing to contraction of the crico-thyroid membrane, or to inflammation of the crico-thyroid joint or crico-arytenoid joint. Further, there is often difficulty with the tube. This opinion, however, is not held by all. Thus, according to Mr. Erichsen, laryngotomy should be performed in: i. Acute cederaatous laryngitis. 2. Membraneous laryngitis in adults. 3. Chronic syphilitic and ulcerative laryngitis. 4. Tumors and foreign bodies obstructing the larynx. 5. Scalds and injuries of the larynx by acids. 6. Accidents during operations about the head and face in which blood accumulates in the larynx; and 7. Laryngeal spasm and Incisions in certain operations on the neck. a. Subhyoid pharyngotomy. b. Thyrotomy. c. Laryngotomy. d. Tracheotomy above, anil r below, the isthmus of thyroid. /. Liga- ture of subclavian (3rd part), g. Ligature of lingual, k. Ligature of temporal, t. Liga- ture of common carotid. paralysis from compression of the recurrent nerve. Tracheotomy, on the other hand, he advises to be done for: i. Membraneous laryngitis in children ; 2. Foreign bodies in the trachea or bronchi; 3. Impaction of foreign substances in the larynx; 4. Necrosis of the cartilages with obstructive thickening of the tissues; and 5. As a preliminary to certain operations attended with haemorrhage about the face or mouth. Thvro'iomv, or laying open the larynx from the front by divid- ing the thyroid cartilage in the middle line, may be required for the removal of a tumor or a foreign body impacted in the larynx, after a thorough and carfeful attempt has been made to extract it , LARYNGECTOMY OR EXTIRPATION OF THE LAR\'NX, 575 by the natural passages {^intralaryngeal method). Make an in- cision accurately in the middle line of the neck from the hyoid bone to the cricoid cartilage (Figs. 269 and 273, b), and, having exposed the thyroid cartilage, and stopped all bleeding, divide it along the angle formed by the junction of the alae, taking care to do so in the middle line so as not to injure the vocal cords. Separate the alee, and remove the growth, etc., and bring the alse accurately together again, and unite them by silver wire or kangaroo-tail-tendon sutures, which should not, however, be passed through the whole thickness of the cardlage. When the removal of the growth is Ukely to be attended with haemorrhage, tracheotomy should first be performed and- the trachea plugged by Hahn's cannula. The head should be kept low and on one side after the operation, and the tube removed if possible at once or within twenty-four hours. Subhyoid pharyngotojvh.' consists in opening the pharynx through the thyro-hyoid membrane (Figs. 269 and 273, a), for the purpose of removing a tumor or impacted foreign body at the entrance, or in the upper part of the larynx. It is so rarely re- quired that the steps of the operation are not given in detail. Initjbation of THE LARYNX consists in passing a properly- shaped tube through the glottis by means of a forceps or pilot invented for the purpose. The tubes now used are those known as O'Dwyer's. Intubation is employed as a substitute for laryn- gotomy or tracheotomy in certain cases, as oedematous laryngitis, membraneous laryngitis, etc. It does not seem likely that intuba- tion, as has been maintained by some, will replace tracheotomy for membraneous laryngitis, since there is a danger of the mem- branes being forced into the trachea by the tube, thus causing obstruction, nor does the intubation admit of the removal of the membranes as can be done after tracheotomy. In cedematous laryngitis, however, it is a very useful procedure. Laryngectomy or extirpation of the laryntc. — Partial or complete removal of the cartilages of the larynx may be required for malignant disease when the growth is confined to that organ and the glands in the neck are not involved. First perform tracheotomy, and plug the trachea with Hahn's tampon cannula, and continue the administration of the anaesthetic through it. Next make an incision in the middle line of the neck from the hyoid bone to the tracheotomy wound ; free the upper part of the trachea and the larynx from their attachments by dissecting close to these structures, securing all bleeding vessels as they are divided. Divide the trachea above the cannula and detach the larynx from the remaining connections, working from below up- wards. Where part of the larynx can be saved, the risks of the 576 DISEASES OF REGIONS. operation will be greatly lessened. Lightly plug the wound with antiseptic gauze, leaving the cannula /// situ for twenty-four hours. The patient should lie with his head low and on one side and should be fed at first through a soft tube passed down the oesoph- agus, and by nutrient enemata. On the healing of the wound an ardficial larynx, if the whole organ has been removed, may be fitted to the parts, by the help of which the patient will be able to speak moderately distinctly. DISEASES OF IHE PAROTID GLAND. Parotitis or mumps, is an acute infectious disease attended with sharp febrile disturbance, and with a local inflammation of the parotid gland. There is generally much pain and swelling, but neither redness nor tendency to suppuration. On the subsidence of the inflammation in the one gland, the opposite, if not already affected, generally becomes inflamed, or more rarely the testicle, ovary, or mamma is attacked — a condition spoken of as metastasis. Confinement to the house, a gentle laxative, and a belladonna or opiate liniment or poppy fomentations to soothe the pain is all that is usually required. Parotitis may follow surgical operations, especially those involv- ing the abdominal cavity. It soon subsides if the original wound runs an aseptic course, but if it be due to septic absorption sup- puration quickly ensues (pysemia). Parotid abscesses should be opened by an incision in front of the posterior border of the jaw to avoid the external carotid artery, and parallel to the facial nerve. Parotid tumors may begin in the parotid gland itself, or, as is perhaps more often the case, in one of the lymphatic glands situated over it. They have a great tendency to displace or de- stroy the parotid, and to extend deeply amongst the important structures behind the ramus of the jaw, where they may surround the carotid arteries, or even encroach upon the pharynx. In structure they may be fibrous, myxomatous, cartilaginous, sarco- matous or carcinomatous. The tumor, however, most common in the parotid region consists of cartilage intermixed with fibrous tissue, with atrophied glandular elements, and often with mucous tissue. The cartilage which so frequently exists in parotid tumors is believed to be derived from the elements of the rudimentary fcetal structure concerned in the development of the lower jaw, and known as Meckel's cartilag<;. Cysts are very rare, but cystic degeneration of the solid tumors is not infrequent. Symptoms and diai^ndsis. — The differential diagnosis of the various parotid tumors cannot be here attempted. Nor is it of consequence, as it is often impossible before removal to determine BRONCHOCELE GOITRE. 577 their exact nature. The practical points for the Surgeon to con- sider are: — Is the growth innocent or mahgnant? Can it be safely removed? Iiiiiocefit tumors grow slowly, and are at first freely movable, smooth or slightly lobulated, circumscribed, hard and firm or semi- elastic ; but as they increase in size they may become soft or fluctuating in places, either from mucoid softening or cystic degeneration. The skin over them, though stretched and thinned, is non-adherent, and the glands are not affected. Malignant tumors, on the other hand, grow rapidly, are ill-defined in outHne, generally soft or semi-fluctuating, and become firmly fixed to the surrounding parts ; the skin is adherent, purplish-red, brawny, infiltrated with the growth, and later ulcerated ; and the lymphatic glands are enlarged. An innocent tumor, however, after having grown slowly for many years may suddenly take on rapid growth and malignant characters. Treatment. — When the tumor appears innocent, of moderate size, and freely movable, indicating that its attachments are not deep, there can be no question about its excision. But when of very large size, especially if firmly fixed to surrounding parts, or if malignant, unless quite small and the skin and glands are not to any extent involved, it should be left alone. The Operatio?i. — Make a free longitudinal incision through the skin and fascia to thoroughly expose the tumor ; it will then often readily shell out of its capsule ; if not draw it forward with vulsellum forceps, and separate its deeper attachments v/ith the handle of the scalpel and occasional touches of the knife, the edge of which should be turned towards the tumor to avoid the branches of the facial nerve and other important structures. The proximity of the carotids should not be forgotten. DISEASES OF THE THYROID GLAND. Bronchocele goitre or DERBYSHIRE NECK is an enlargement of the thyroid gland. It may be due, as is commonly the case, to simple hypertrophy of the normal tissues of the organ {ordi?iary goitre), and may then involve the whole gland or one of the lateral lobes, or rarely only the isthmus. In other instances the hypertrophy may fall chiefly on the fibrous tissue constituting the septa of the gland {fibrous goitre). Or along with some amount of simple hypertrophy and increase of fibrous tissue {adenoma), one or more of the normal alveolar spaces may become enlarged, forming single or multiple cysts {cystic goitre). Such cysts con- tain when single a serous fluid, or when multiple a colloid or a dark grumous material sometimes mixed with altered blood ; whilst occasionally proliferating growths project into their interior from the cyst-walls. In other instances again, but more rarely, 25 578 DISEASES OF REGIONS. the hypertrophy is associated with a great increase in the vessels, and a forcible and expansile pulsation is given to the gland . {puhaiing goitre) . But the tissues, besides hypertrophy, may undergo secondary changes. Thus calcification may occur, and the enlarged gland become in places of stony hardness {calcified goitre), or the fluid normally contained in the alveolar cavities may assume a colloid character. Lastly, the enlargement of the thyroid may be due to malignant disease {malignant goitre). Goitre in certain districts is endemic, especially in the Rhone Valley in Switzerland, and in Derbyshire, and is then frequently associated with the condition known as cretinism. It also occurs sporadically ; and in some cases again is accompanied by a peculiar jerking beat in the carotids, by ansemia, and by a prom- inence of the eyeballs {exophthalmic goitre), for a full account of which a work on Medicine must be consulted. The Symptoms common to any form of enlargement of the thyroid is a swelling taking more or less the characteristic shape of the thyroid gland, and moving with the larynx in deglutition. In this country the enlargement is generally moderate ; but sometimes, and especially in Switzerland, the goitre forms a large mass hanging down in front of the neck, and may press upon or even displace the trachea and oesophagus. It occurs chiefly in women. In the ordinary variety it feels soft, semi-fluctuating, and of uniform consistency ; in the cystic, one or more fluctuat- ing places may be felt ; whilst in the fibrous it will be firm and hard and more or less lobed or irregular, and where calcification has taken place of stony hardness. Malignant goitre, which is very rare, may be known by rapid growth, enlarged glands, and the other signs of malignancy mentioned at page 79. The Cause of endemic goitre is not known. It has been attributed to impure water, water from limestone, and snow water, but without conclusive evidence. It is said to be most prevalent in valleys where from their direction the sun does not penetrate, on damp soil, and in damp parts of towns, but according to Mr. Berry these influences have little or nothing to do with its causa- tion. In sporadic cases, heredity, disturbance of the sexual functions, and conditions producing congestion of the head and neck, are given as causes. Treatment. — Sporadic cases of ordinary goitre should be treated by the internal and external application of iodine. Thus the syrup of the iodide of iron may be given internally and an ointment of iodine and iodide of potassium applied externally. The use of biniodide of mercury ointment, followed by exposure to a hot sun, has been attended with much success in India. An ice collar has sometimes been of service. Injection of iodine or BRONCHOCELE GOITRE. 579 of perchloride of iron into the solid parts of the growth is highly dangerous, sudden death having occurred either from the acci- dental entrance of air or injection of the iron or iodine into a vein. In cystic goihr the cyst can as a rule be readily shelled out from the rest of the gland. Where great dyspnoea has threatened suffocation, the whole gland has been removed ; but since it has been shown that such removal is productive of myxoedema or a condition like it (^stnimapriva), it is a question whether com- plete removal is ever justifiable. It is better to divide the isthmus in the middle line for the purpose of freeing the trachea (which is compressed laterally, not from before backwards) or to remove the isthmus or one lobe of the gland, when the rest will generally shrink. If necessary to remove both lateral lobes the lower end of each should be left, namely that part into which the inferior thyroid artery enters. The recurrent nerves are not then en- dangered {Mikulicz's operation). In removing either lateral lobe of the gland it should be borne in mind that, although the common carotid artery is pushed outwards, the internal jugular vein usually runs over the tumor, being held more or less in position by the veins opening into it. The pulsation of the artery is, therefore, no guide to the position of the vein, which may run in front of, or internal to the artery. Care should also be taken not to open the thin capsule of fascia surrounding the gland either in front or at the outer side in order to avoid wounding the large and thin-walled veins which lie beneath it. Behind, where this capsule is reflected on to the larynx and trachea, it must necessarily be divided. At this spot the veins should be tied. Endemic goitre admits of little treatment other than removal of the patient from the goitrous district. Malignant goitre except when it involves only a portion of the gland is not amenable to treatment. The propriety of partial extirpation of the thyroid for exophthalmic goitre is still an open question. For the general treatment of this disease a work on Medicine must be consulted. Acute goitre. — Goitre, though usually chronic, sometimes oc- curs in an acute fv.rm, the gland increasing to the size of an orange in a few days, and causing severe, or it may be fatal, dyspnoea, from presiuie on the trachea, in consequence of the en- largement taking place so rapidly that the fascia of the neck has not time to yielit. It occurs in young subjects both sporadically and endemically. In these instances it sometimes makes its way behind the sternum, so that it is difficult to get below it, even if tracheotomy is performed. The cause of the dyspnoea may not be very evident before the operation. Treatme^it. — The pressure may sometimes be removed by simply incising the fascia of the neck. Or tracheotomy may be done, and a long tube passed S8o DISEASES OF REGIONS. down the trachea beyond the obstruction • or the isthmus, or one lobe, may be excised. The patient, in the meanwhile, should be removed from the goitrous district. DISEASES OF THE SPINE. Scoliosis or lateral curvature is a complicated distortion in which the spine forms two or more lateral curves with their convexities in opposite directions, whilst the vertebrae involved in the curves are rotated on their vertical axes so that the spinous processes are directed towards the concavity of the curves. Cause. — The immediate cause that underlies the formation of lateral curvature is the unequal compression of the mto-vertebral cartilages for long periods. This unequal compression may be induced by i, any condition causing permanent or habitual ob- liquity of the pelvis and the consequent throwing of the spine over to the opposite side ; such as unequal length of the legs, knock-knee, flat-foot, the use of a wooden leg, habit of standing on one leg, sitting cross-legged, congenital dislocation of the hip, etc. ; 2, a one-sided position of the F'ti-274- body in sitting, standing, or lying, or produced by certain employments, as nursing or carrying with one arm, etc. ; 3, contraction of one side of the chest following empyema ; 4, unilateral con- traction of the spinal muscles following paralysis of the opposing muscles. The conditions mentioned under i and 2 are, however, by far the most fre- quent causes of the deformity. Al- though lateral curvature may be in- duced by these causes acting alone, there are certain circumstances that appear es])ecially to predispose to the deformity, by producing a general want of tone in the muscles, and structural weakness of the ligaments and bones. Such are, 1 , heredity : 2, general de- bility ; 3, the strumous diathesis; 4, rickets ; and 5, rapid growth. It is much more frequently met with in girls than in boys, and is most common from about the age of fourteen to eighteen. J\it}tology. — The long-continued un- equal compression of the intervertebral cartilages causes them to become wedge-shaped, and the portion of the spine correspond- Latcral curvature of the spine. (St. Bartholomew's Hospital Museum.) SCOLIOSIS OR LATERAL CURVATURE. 581 ing to the compressed cartilages to assume sooner or later a permanent lateral curve. Whilst, however, a curve is thus being produced, say, in the dorsal region with its convexity to the right, a compensating curve in order to maintain the equilibrium of the spine is being simultaneously produced in the lumbar region with its convexity to the left (Fig. 274). Coincidently with these changes a rotary movement of the aifected vertebrae upon their vertical axes is taking place, so that while the bodies turn towards the convexity of the curve the apices of the spinous processes turn towards the concavity. Hence, in addition to the formation of the primary and the secondary or compensating curves, we have a twisting round of the spine within these curves, as a con- _sequence of which the ribs on the convex side are carried back- wards with the transverse processes, causing the angle of the scapula on that side to project ; whilst the ribs on the concave side are for the same reason carried forwards, producing a prom- inence of the corresponding breast (Fig. 275). The cause of the rotation has been variously explained. The theory, perhaps, most generally accepted is that of Dr. Judson, who beheves that the rotation is due to the fact that the posterior portion of the vertebral column, being a part of the dorsal parietes of the chest and abdomen, is confined by the ligaments and muscles to the median plane of the trunk ; whilst the anterior portion, projecting into the thoracic and abdominal cavities, being devoid of lateral attachments, is free to move either to the right or left of the median plane when the spine is inclined to either side. i\t first the bones are not af- fected, but when the Fig. 275. compression of the car- tilages has become per- manent the bodies of the vertebrse also gradually assume a wedge shape, whilst the articular pro- cesses become con- tracted and flattened on the concave side and elongated on the convex. The ligaments and mus- cles on the concave side are shortened and atrophied, whilst on the convex side the ligaments are stretched and the muscles be- come hypertrophied. Signs. — Pain or a feeling of weakness in the back, general lassi- tude, and a stooping gait, are amongst the early symptoms ; but the patient is generally first brought for consultation on account To show the effect of rotation in lateral curvature of the spine. 582 DISEASES OF REGIONS. of a slight projection of the scapula, or an apparent prominence of the ihac crest — a growing out of the shoulder or of the hip, as it is popularly termed. In slight cases there may be little or no lateral deviation of the apices of the spinous processes, and the little there is may be made to disappear on suspending the patient or placing her in the prone position. In the severer cases, however, the signs are unmistakable. Thus, in the more common forms, there is usually a dorsal curv^e with its convexity to the right, and a shorter lumbar, or dorso-lumbar curve, with its convexity to the left. The right shoulder is generally elevated, and the angle of the right scapula, right iliac crest and left breast are prominent, whilst the left lumb r muscles, in consequence of the backward projection of the left lumbar transverse processes, stand out as a prominent ridge and give a greater sense of re- sistance on pressing over them than normal. In other cases the compensating curves may be so slight that there is apparently a single curve only, with its convexity either to the right or left, in- volving the whole spine or chiefly the upper dorsal or the lumbar vertebrae, and producing more or less projection of the scapula or apparent prominence of the iliac crest, etc., according to its severity and situation. Treatment. — Where there is evidence of general or muscular debility, the health and muscular tone should be improved by suitable remedies, the avoidance of late hours, fatigue and the like ; whilst the exciting cause of the curvature should be looked for and if possible removed. In slight cases, the above means, when conjoined with a judicious selection of muscular exercises and partial recumbency, will generally serve to cure or improve the curvature, or at least prevent it from gettirg worse. But in severe cases, when osseous changes are already confirmed, some form of rigid support, as a poro-plastic jacket, or a light spinal instrument, will commonly be required, Cbpeci I'y for the poorer classes of patients. In ordering such supp-jrts, however, the patient should be made to thoroughly understand that no real improvement of the curvature must be expected from them, their only aim being to relieve pain when ]jresent, to give a sense of comfort and support, to nn])rove the outward api)earance, and to prevent further deformity. In slight cases they should on no ac- count be used. The exercises that I employ are directed in part to improving the muscular tone generally, and in part to strength- ening those muscles in particular that tend to lessen or straighten the curves. For the former purpose, such exercises as swinging by the hands from a bar, forcibly stretching an elastic cord fixed to the floor, and dumb-bell exercises, should be practised. For strengthening the muscles in particular that tend to straighten the KYPHOSIS. 5 83 curve, the back should be manipulated till that posture is found in which the curves are least marked, and the patient made to hold herself in this position for as long as possible. At first she will be only able to do this for a few minutes at a time ; but by frequently assuming the posture, the muscles thus brought into play are gradually strengthened, till at last the improved posture is maintained constantly and without effort. For further improv- ing the tone of these muscles, Professor Busch and Mr. Roth recommend some such exercises as the following : — The patient's body held in the improved posture is brought over the end of a couch or table, and whilst she is prevented from falling by an as- sistant holding her legs, she alternately flexes and extends her body at the hips, the surgeon resisting her efforts. I have also ' found the use of the sloping seat, as recommended by M. Bouvier and Mr. Barwell, of considerable service in counteracting the curves. A similar effect may be obtained by wearing a thick sole on one boot, and by sitting on the off-side of the horse when riding. After the exercises, or tv/ice or thrice during the day, the patient should he on her back for half an hour to an hour, and whilst sitting her back should be supported by a rechning chair, I have had very considerable success in removing rigidity in cases where there is slight osseous deformity by applying a weight to the convexity of the curve, the patient standing with her legs straight and body horizontal and supported in this position by her elbows on a chair. Kyphosis is a general curving of the spine with its convexity backwards, or an exaggerated condition of the normal dorsal curve. It depends upon an unequal compression of the inter- vertebral cartilages and to a less extent of the vertebral bodies, which thus become wedge-shaped with their bases looking posteriorly. It is generally the ^ig. 276. result of muscular debility, rickets, slouching habits, or occupations necessitating stooping. The point of chief interest is to distinguish it from the serious angular curvature induced by caries. In children, and in adults, this is gen- erally easy ; but in rickety infants, in whom the ordinary tests for caries (see p. 586) cannot be applied, it is often very difficult. In such a case, the infant should be laid across the nurse's knees and gently extended, when the rickety curve will disappear, but the angular will remain. Author's spinal brace. The back, moreover, in caries, is rigid, and the child is uneasy in this position and tries to resist the extension by muscular effort, and draws up his legs. In rickets the back is 584 DISE.\SES OF REGIONS. flexible and there are other signs of rickets. Treatment. — In the infant, recumbency ; in growing lads and girls the correction of stooping habits by the use of muscular exercises and a spinal brace (Fig. 276), with partial recumbency, and tonics, is the treatment usually indicated. For the confirmed kyphosis of the old, noth- ing can be done. Lordosis, or curving of the spine with the convexity forwards, is a symptom rather than a disease, inasmuch as it is formed as a compensatory curve to restore the equilibrium of the spine when from any cause its normal anteroposterior curves are dis- turbed. Thus it is most common in the lumbar region, where it is merely an exaggeration of the normal curve ; and is there pro- duced to counterbalance the tilting forward of the pelvis conse- quent upon hip-disease, congenital dislocation of the hips, rickets, etc. Caries of the spjne, also called Pott's disease after the surgeon who fiist accurately described it, is characterized by the destruc- tion of one or moie of the bodies of the vertebras or intervertebral cartilages, and in consequence of this destruction is too frequently attended by the falling forward of the vertebrae above the seat of disease, and the production of angular deformity of the spine. Hence it is often spoken of as angular- ciiwature. The curve, however, is only a symptom, and a comparatively late one, of the disease, and ought not to be allowed to form. Causes. — The disease generally occurs in strumous children, and is then believed, like fungating caries in the articular ends of bone, to be due either to a low form of inflammation set up by a slight injury, or to a deposit of tubercle dependent 'upon the introduction of tubercle bacilli into the circulation in the manner already mentioned in the section on Di/wnk. It sometimes oc- curs in adults who are otherwise perfectly healthy, and can then generally be traced to some injury of the back — probably a strain of the intervertebral cartilages. Pathology. — The disease most frequently begins in the bodies of the vertebrae, less frequently in the intervertebral cartilages ; but in either case both structures soon become involved. In the bodies it generally starts as a rarefying osteitis in the actively- growing la) er of bone which exists under the epiphysial carti- lages and periosteum. The inflammatory changes that ensue are similar to those already described in rarefying osteitis of can- cellous bone. The red gelatinous inflammatory material or gran- ulation-tissue invarlcs both the l)ody of the vertebra and the inter- vertebral cartilages, and may then attack the vertebrae above and below. Not infre(|uently several of the vertebras are affected in- dependently by the disease at the same time. In this granula- CARIES OF THE SPINE. 585 tion-tissue non-vascular areas, presenting the appearance of the tubercle nodules already described, have been found, and tuber- cle bacilli have in some cases been demonstrated in them. At this stage the disease may cease, the granulation tissue become converted into bone, and no angular deformity result. More commonly, however, the granulation- tissue, having destroyed the bone-trabeculae, undergoes caseation, and breaks down into pus, producing a spinal abscess; or it may be absorbed without the formation of any pus {dij caries) ; or if the process has been very acute, large portions of the cancellous tissue may die en masse, forming sequestra, which may keep up the morbid process for years {caries necrotica). In any of these cases angular deformity will be the result, as partly by its own weight, and partly by the dragging of the abdominal muscles, the upper portion of the spine thus undermined falls forward, and nec- essarily forms an angle with the lower portion Fig. 277. at the seat of the disease. In consequence of m — J^T^ the patient's efforts to hold himself upright the ' T oi normal lumbar and cervical curves, when the disease occurs in the dorsal region, will be greatly increased ; the angular projection is thus thrown backwards (Fig. 277), and the well-known hump-back produced. When the disease occurs in the lower lumbar region there is no means of restoring the balance, and the patient is compelled to stand or walk with the body incHning forwards, and, in severe cases, nearly at right angle with the pelvis. When the disease begins in the intervertebral fibro- cartilages, it probably starts as a low form of destructive inflammation consequent upon a Caries of the spine (St. T_i . 1 ,• ii. ■ • r iU i.- Bartholomew's Hos- slight laceration or other irjuiy 01 the cnrti- pitai Museum.) lage. But however it begins, it soon involves the adjacent bones, destroying them along with the cartilage and leading to the angular deformity. The spinal cand, situated as it is in the posterior segment of the column, with the exception of being bent, undergoes but little alteration of its calibre, and the cord, as the bending of the canal occurs but slowly, conse- quently usually escapes injury. When the disease is acute and the bending consequently more rapid, some amount of temporary paralysis may occur, impairment or los- of motion being far more frequent than loss of sensation, on account of the proximity of the anterior motor columns to the diseased vertebral bodies. The cord is occasionally pressed upon by portions of bone sep- arated from the vertebrse, or by pus making its way into the canal, 586 DISEASES OF REGIONS. or by inflammaton' thickening of the membranes {pachymenin- gitis). It may sometimes undergo softening, leading to perma- nent paraplegia. Spinal abscess {psoas ajid lu??ibar). — When suppuration oc- curs, the pus collects in front of the diseased vetebrse in the angle formed by the falling forward of the upper upon the lower portion of the spine. The anterior common ligament and perios- teum, relaxed by the bending of the spine, yield to the pressure of the pus, and with the pleura or peritoneum become thickened and form the abscess wall. The pus, prevented from travelling upwards by the overhanging vertebrae, downwards in front of the column by the attachments of the anterior common ligament, and backwards by the posterior common ligament and by the ver- tebrae being less diseased behind than in front, makes its way on one or other side of the column. There it either enters the sheath of the psoas, and destroying the contained muscle, pre- sents in the iliac fossa or groin as an ihac or a psoas abscess, or passes backwards through or external to the quadratus lumborum, and points in the loin, where it is known as a lumbar abscess. In rare instances the pus may take a different course. Thus I have seen it make its way into the ischio-rectal fossa, or pass through the great sciatic foramen, or travel along the course of a rib and reach the surface near the sternum. Occasionally an abscess forms on both sides of the spine at once. In the cervical region the abscess will point in the ])harynx {posi-pharytii^eal abscess) , or m the neck. Process of cure. — Under favorable circumstances the granula- lation-tissue undergoes ossification without the production of any deformity ; but after the deformity has taken j^lace, and the ver- tebrce above and below the disease have come into contact by the falling forward of the upper portion of the spine, the destructive process, if the parts are kept at rest, may cease ; and firm osseous ankylosis, but with a permanent angular curvature, will ensue. Symptoms. — In the early stages, before the angular deformity is produced, pain is felt on percussion over the diseased vertebra, or better on the head of the rib in connection with it, or on gently pressing on the shoulders, or tapping on the head, or on applying hot sponges to the spine. Pain also is felt in the course of the intercostal nerves and hence in the case of the lower in- tercostals may be referred to the abdomen. It is increased on movement ; hence the spine is held stiffly by the muscles. The movements of the child are characteristic. If asked to pick up anything he does not bend his back, but placing his hand upon his knee to support his spine, reaches the ground by bending his legs and holding his back straight. If asked to turn around he rotates the whole body, not the back. He walks about supporting CARIES OF THE SPINE. 587 his spine by resting his hand on the various portions of furni- ture, and soon gets tired of play, and is noticed to lie about on the floor. In older patients tingUng or numbness may be com- plained of in the extremities, and a feeling as if a cord were tied tightly round the body. Later, a prominence of one or more vertebrae occurs, and the nature of the disease can no longer be doubted. If neglected, the prominence increases, and the well- known angular deformity is produced. Now, especially if the disease is high up the spine, some loss of motion in the lower ex- tremities occurs, and may progress to complete paralysis of mo- tion. Sensation is not usually affected, as the posterior columns, being remote from the disease, escape. Nor are the bladder and rectum usually implicated. If an abscess has not already formed, and especially if the disease is moderately low down, one may now present in the loin {h/mbar abscess), in the iliac fossa {iliac abscess), or in the groin {psoas abscess). The first gives rise to a fluctuating tumor between the last rib and the crest of the ilium just external to the erector spinse ; the second to a swelling in the iliac fossa. The psoas abscess may be known by the swell- ing being at first external to the femoral vessels, by the impulse on cough, and by fluctuation being detected on pressing above and below Poupart's ligament. The abscess makes its way under the femoral vessels, and then generally points at the inner and upper part of the thigh, and there breaks. After the opening of these abscesses, hectic but too frequently sets in, and the patient succumbs to the long-continned suppuration producing exhaus- tion or lardaceous disease ; or he is carried off by tubercle in the lungs or other organs. Under more favorable circumstances the abscess may heal, firm ankylosis of the spine occur, and the patient recover with a permanent hump-back. Diagnosis. — In the early stages caries must be diagnosed from neuralgia, rheumatism, lumbago, aneurysm, tumors, and hysteria ; in the later stages the angular curvature may have to be diag- nosed from the kyphotic curvature of rickets. From neuralgia, rheumatism, and lumbago it is not always easy to distinguish it. The history of the former rheumatic attack, the effect of reme- dies, and the absence of the signs given above, must then be re- lied upon. Hysteria may simulate it very closely. The absence of signs of caries, except pain ; the inconstant and more diffused character of the pain : and the presence of other signs of hysteria or of uterine disease, are the points to be attended to. A careful auscultation of the chest and examination of the abdomen will usually serve to exclude aneurysm. From tumors of the vertebral bodies leading to the breaking down of the vertebrae caries can- not at first be diagnosed, as both give rise to the same symptoms, 588 DISEASES OF REGIONS. Fig. 278. but the age of the patient and the presence of a carcinomatous growth elsewhere would lead to suspicion of cancer. The curve of rickets is more generally kyphotic, and disappears more or less completely on gently holding the child up by its arms, or extending it with its face downwards across the nurse's knees. There are, moreover, concomitant signs of rickets, and absence of those of tubercle. Treatment. — Both constitutional and local measures are re- quired. The former are those already described under Tubercle (p. 6-^,^. The chief local indication is to keep the spine at rest in order that the diseased vertebrae may be placed in the most favor- able condition for repair. This may be attempted in two ways : i. By absolute recumbency ; and 2, by the use of some form of spinal support. I. Absolute recumbency from six to twelve months in the supine or prone position on a suitably constructed couch is the best method of treatment where the patient can be properly cared for, has airy apartments, can be taken out in this position in an invalid carriage, and can reside in the country or at the sea- side. Especially is this treatment the best when the disease is situated high up in the spine, /. e., in the upper dorsal or cervical region, and it is imperatively necessary where there is paralysis. To ensure ab- solute recumbency I have lately largely employed a double Thomas's splint (Fig. 278), modified by the addition of a pelvic band, a support for the shoulders, neck and head, and two sliding foot- pieces. The two upright bars, which are pro- longed to the head support, are made after the shape of a normally formed child when in the recumbent position, and give support to both sides of the spine. Two cross-bars support the body, just below the axillae and pelvis respec- tively ; the legs are kept in position by the or- dinary circlets and foot-pieces. The splint is placed next the skin so as not to require re- moval while the child is washed, dressed, etc. It not only fixes the spine and takes off the w^eight of the head and upper limbs, but also fixes the lower limbs, and thus prevents the psoas muscles from dragging on the sj)ine. Ab- solute recumbency, when ])roijerly carried out, offers the best ])rospcct of averting serious an- gular deformity and paralysis ; as soon, however, as the acute symptoms c)uiet dcjwn, some form of spinal JUpi)ort should be applied, and the patient cautiously allowed to take a certain Double Thomas's splint for spinal caries. CARIES OF THE SPINE. 589 amount of exercise. But amongst the poor, where the children are often left to themselves during the greater part of the day, absolute recumbency can seldom be ensured ; and if it could, its advantage over other methods would be counterbalanced by the severe detriment to the health which the child would suffer in consequence of confinement to an ill-ventilated room, etc. For such patients some form of support, not only to restrain as much as possible the motions of the spine, but also to allow them to ob- tain a certain amount of fresh air, is generally necessary. 2. The supports most in use at the present day are Sayre's plaster-of Paris case and Cooking's poroplastic felt jacket, though some Surgeons still prefer steel instruments. The plaster-of- Paris case may be applied with the patient either in the upright position, suspended with his heels just off the ground by Sayre's tripod, or in the re- cumbent position by Davy's hammock apparatus. A skin-fitting vest having been previously applied, and a line drawn across the back with a pencil at the level of the axillae to indicate the upper Hmit of the jacket, crinoline bandages, impregnated with plaster- of-Paris, are wound round and round the trunk till a sufficient thickness is obtained, dry plaster being from time to time rubbed in with the hands. The case should reach from the pencil line to just below the crest of the ilium, stopping short of the great trochanter and the pubes, and may be strengthened, if necessary, in places by inserting strips of perforated tin vertically between the bandages. Before applying the bandages, a folded silk hand- kerchief should be placed over the abdomen beneath the vest, so that when afterwards withdrawn space will be left for abominal respiration {Sayre's stomach-pad). When the plaster case is dry it may be sawn through down the front, removed, and the fronts edged with leather, and perforated with eyelet-holes, so that it can be worn laced up, and be taken off from to time. To apply the poroplastic felt, the jacket, which is first made to measure, must be put in a steam oven, and when rendered throughly plastic, further moulded to the patient, who should be prepared and suspended in the same way as for applying plaster-of-Paris. Of steel instruments, that known as Taylor's is perhaps the best. In my own practice, however, I almost invariably employ the poroplastic jacket. Where the disease is in the cervical or upper dorsal region, Sayre's jury-mast may be fitted to the plaster-of- Paris case or poroplastic jacket ; or a cervical collar composed of leather or poroplastic felt may be used, or better, the combined poroplastic jacket and collar devised by the author. Should an abscess form, it should be treated in the way described under Chronic Abscess. In some cases where necrosis has been asso- ciated with caries, success has attended the removal of the seques- 59© DISEASES OF REGIONS. trum through a properly-planned incision made in the loin. In exceptional cases in which the paralysis of the lower limbs con- tinues, in spite of absolute rest and recumbency, and in which there is intractable cystitis or severe pain not relieved by ordi- nary measures, the spines and laminre of the affected vertebree may be excised for the purpose of relieving pressure on the cord. (Laminectomy.) The compression of the cord, however, would appear to more often depend on the presence of a tuberculous collection in front of the cord than on displacement of bone. Unless the tuberculous abscess, therefore, can be evacuated, the removal of the arches of the vertebrae is futile, and only tends to weaken the vertebral column. In place of laminectomy, an at- tempt may, in suitable cases, be made to reach the tuberculous collection from the front of the vertebrae. Menard has succeeded in doing this by excising the transverse processes and proximal end of the ribs corresponding to the most prominent part of the spinal curve. Through the aperture thus made he was able to scrape and wash away tuberculous material with the result that the paralysis quickly disappeared. OcciPiTO-ATLOiD, and atlo-axoid disease, are terms applied to chronic tuberculous inflammation attacking the articulations between the occipital bone and the atlas, and the atlas and the axis respectively. Hence the disease resembles in its course tuberculous disease of the joints, rather than tuberculous disease of the bodies of the vertebrae. It may begin either in the synovial membranes, or as caries of the bones forming the articular pro- cesses, and when occurring between the atlas and the axis usually affects the synovial membranes between the odontoid process and the transverse ligament on the one hand, and the tubercle of the atlas on the other. Indeed, in this situation it would appear to often begin as a caries of the odontoid process itself, and then spread to the synovial membranes. The disease is often attri- buted to a sprain of the neck, but though it may sometimes be excited by such, would appear more probably to dei)cnd on causes similar to those leading to tuberculous disease elsewhere. Symptoms. — Pain is first felt over the 'seat of the disease, and radiating in the course of the nerves emerging from the inter- vertebral foramina between the affected bones. It is increased on attempting to turn or nod the head, but is relieved by sup- porting the chin with the hand. Hence the patient often holds his head between his hands, and if asked to rotate it, turns his whole body, keeping his neck stiff and immovable the while. When the disease is chiefly limited to the articulations between the occipital bone and the atlas, the pain is principally confined to the region supplied by the suboccipital nerve, and is increased SPINA BIFIDA. 591 on nodding rather than on rotating the head. As the disease advances, the atlas, with the occipital bone, has a tendency to slip forward on the axis — directly forward if both sides are equally diseased, or more to one side if the disease is unilateral. The spine of the axis in consequence appears more prominent than natural, and the head on a plane anterior to that of the rest of the spinal column. Should an abscess form it may point at the back of the pharynx (^post-pharyngeal) or at the side of the neck. Treatment. — Absolute rest on the back, with the head between sand-bags, is imperative, as there is danger of fatal compression of the cord from the odontoid process or the tranverse hgament giving way during some sudden movement of the patient. In some cases attended with paralysis below the disease, continuous Fig. 28 Spinal meningocele. Meningo-myelocele. In the three diagrams (Figs. 279, 280, and 281) the letters have the same reference. A. Dura mater, b. Parietal, and C. visceral arachnoid. D. Pia mater. E. Cord. extension and counter-extension, with the patient in the re- cumbent position, has been successful in removing the pressure from the cord. When the acute symptoms have subsided, a moulded collar of leather or poroplastic felt, or an inflating india-rubber collar, will be required. Should an abscess form it should be opened in the neck if possible rather than through the mouth. Spina bifida "is a congenital malformation of the vertebral canal with protrusion of some of its contents in the form of a fluid tumor." It is nearly always met with in the middle line of the back, but very exceptionally the protrusion has occurred 592 DISEASES OF REGIONS. through the bodies of the vertebros instead of posteriorly through the cleft spines. It is due to an arrest of development of the laminae of the vertebrce {^mcsoblastic elements), and their conse- quent failure to unite in the middle line to form the spinous pro- cesses. This non-union may possibly be sometimes owing to an excess of cerebro-spinal fluid. A spina bifida may occur in any part of the spine, but 's most common in the lumbo-sacral region, where the laminae are the latest to unite. It may be associated with partial paraplegia or contracture, incontinence of urine and faeces, and with club-foot or other congenital deformities. Pathology. — Three chief forms of spina bifida are described : — I, spinal meningocele, 2, meningo-myelocele, 3, syringo-myelo- ele. I. In spinal meningocele the sac (Fig. 279) consists of dura mater and arachnoid blended together, and consequently communicates with the sub-arachnoid space and contains cerebro- spinal fluid. The cord and nerves remain in the spinal canal. Very rarely the sac is said to consist of dura mater only, /. e., of dura mater and so-called parietal layer of arachnoid ; it would then communicate with the subdural space instead of with the sub-arachnoid. 2. In the meningo-myelocele (Fig. 280), the most common form, the sac also consists of dura mater and arachnoid, but contains in addition to cerebro-spinal fluid the spinal cord and nerves, which are often spread out over and inti- mately blended with the posterior part of the wall of the sac. As the cord passes through the sac some of the large nerve-cords given off from it run forwards across the interior of the sac to re-enter the spinil canal. Hence those nerve.; that are given off from the cord where it is adherent to the sac wall appear to arise from the sac, and were in former times wr mg'y described as being dis- tributed to it (see Fig. 280). 3, In \}\& syringo-myelocele (Fig. 281), the most rare form, the central ca- nal of the cord is greatly distended with fluid, the expanded cord be- ing thus spread out over the sac wall, with which it is intimately blended. I'he nerves in this case pass through the walls of the sac to their destinition. yiie coverings 0/ the sac may be healthy skin; but more com- FlG. 281. Syriiigo-mycloi.cle. SPINA BIFIDA. 593 rnonly normal skin is only found at the sides, the central portion consisting of a thin bluish membrane. Sometimes a slight de- pression is seen on the lower part of the sac at the spot where the cord terminates in the wall. This is called the nmbilictes, and at its bottom the central canal of the cord has at times been seen to open. In some instances there is no protrusion, but rather a depres- sion in the situation of the cleft between the vertebra {spina bifida occulta), the cleft being occupied by the blended mem- branes, cord, and skin, and the spot covered with a tuft of hair. In obscure paraplegias, contractures and deformities of the feet the back should be examined, since this condition may be pres- ent but have been overlooked by the m-other. Symptoms. — The swelling is usually of a globular or oval shape, translucent, sessile or slightly pedunculated and flaccid, but be- comes tense and distended on coughing or crying. Pressing upon it sometimes causes the fontanelles to swell up, and may produce convulsions. When the spinal cord and large nerves are involved, there may be paralysis of the extremities or of the bladder or rectum. The gap between the laminae of the verte- brae may at times be felt on pressing on the sac. As a rule these tumors show a great tendency to enlarge, and rupture spontane- ously, in which case death usually follows from the draining away of the cerebro-spinal fluid, and septic meningitis. Death, how- ever, is sometimes due to marasmus and defective nutrition. When a spontaneous cure takes place, it is usually due to the gradual shrinking of the sac. Diagnosis. — Its congenital origin v/ill at once distinguish a spina bifida from a new growth developed subsequently to birth ; and its situation in the middle line, translucency, increase of ten- sion on straining, and the gap between the laminae, when this can be felt, will usually seive to diagnose it from other congenital tumors. Treatment. — As there are no means of accurately determining that the spinal cord is not in the sac, it has hitherto not been con- sidered safe to attempt excision or ligature, although these opera- tions have at times been attended with success. Repeated tap- pings are very fatal. The treatment usually employed, except when the spina bifida is very small or is apparently undergoing a spontaneous cure, when it should be left alone, is to inject the sac with Dr. Morton's iodo-glycerine fluid. This method when successful causes the tumor to shrink, and most closely follows the process of nature when a spontaneous cure occurs. The injection is best performed when the child is two months old ; but it may be done earher if the sac threatens to burst. "The best re- 25* 594 DISEASES OF REGIONS. suits may be expected when there is no hydrocephalus or paraly- sis, and the sac is covered by healthy skin." It is contraindi- cated when there is " advanced marasmus, great and increasing hydrocephalus, and intercurrent disease." The child should be placed on its side, and the puncture made obliquely through healthy skin on one side, and the base of the tumor, and not through the thin and imperfectly formed skin, which nearly always covers the sac in the middle line, " the object being to avoid wounding the expanded spinal cord, and the subsequent leakage of the cerebro-spinal fluid." About a drachm of the iodo-glycer- ine fluid (iodine grs. x. ; iodide of potassium, grs. xxx. ; glycer- ine, 5J.) should be injected, and the injection repeated in a fort- night if the first trial is not successful. The fluid contained in the sac should not be drawn ofl" before the injection. The advantage of Morton's fluid over tincture of iodine alone is that owing to the glycerine it contains, it becomes uniformly diffused over the sac walls. The injection of iodo-glycerine is not unattended with danger ; therefore when the sac is small and its walls are thick, and it is not increasing in size, beyond protecting it with a metal or leather shield, no further treatment should be attempted. Mayo Robson advocates excision in all cases except where there is well marked paraplegia, hydrocephalus or marasmus, or where the tumor is small and well covered by a firm pad of integument. In spinal meningocele he makes skin flaps, removes the sac, liga- tures or sutures the base, and brings the flaps together by suture. In meningo-myelocele he separates the skin from the sac, opens the sac, dissects the nerves and cord from the sac wall, returns them into the spinal canal, removes the sac, ligatures or sutures the meningeal pedicle, and brings the skin flaps together over it, taking care that the lines of suture in the meninges and skin are not placed opposite each other. SURGICAL DISEASES OF THE INTESTINES. IN'JKSTINAL ODSl RUCTION. The pathological conditions that may give rise to intestinal ob- struction are very various, and may be considered under the fol- lowing heads : I. Impaction of fteces or foreign bodies in the intestines. — Accumulation of hardened faeces may occur as the result of habit- ual or accidental constipation, and is then nearly always met with in the large bowel, and especially in the region of the caecum or in the sigmoid flexure and rectum. The impaction of gall-stones or intestinal concretions, though more rare, is also met with in the INTESTINAL OBSTRUCTION. 595 small intestines. Obstruction from these causes is more common in women than in men. 2. Internal ste angulation or internal hernia. — These terms are applied to obstruction of the intestine by some constricting agent within the abdomen. The strangulation may be effected by: I. Bands produced by the stretching of old inflammatory adhesions, the result of former peritonitis. These are more par- ticularly common about the mouths of old hernial sacs. 2. The remains of some foetal structure, as the omphalo-mesenteric duct, Meckel's diverticulum, etc. 3. A coil of intestine slipping through a hole in the mesentery or omentum. 4. A coil of intestine pass- ing into a pouch of peritoneum {^retroperitojieal hernia) as the duodeno-jejunal, the sigmoid, or one of the ileo-csecal pouches. 3. Volvulus is a twisting or kinking of a coil of intestine, so that its calibre is completely obliterated at the twisted or bent spot. Accumulation of flatus, excessive peristalsis due to gall- stones, constipation and unequal distension, have been assigned as causes. Volvulus is said to be most common in the sigmoid flex- ure ; and always to be situated towards the back of the abdominal cavity. The intestine may be — i, simply bent upon itself;' 2. twisted round its mesentery ; and 3, wound round another coil of intestine. The first form only occurs in the colon ; the second in the small intestine ; the third form usually consists of the colon wound round a coil of small intestine, the sigmoid flexure, or the caecum. 4. Intussusception (Fig. 282) is the invagination of a portion of intestine into the lumen of the intestine immediately below. The intestine thus forms three tubes, one within the other, an outer, middle, and inner (Fig. 283). The external tube is called the sheath, or intussiiscipiens, the innermost the entering tube, the middle the receding or inverted tube, the last two together being further called the intussuscepted portion, or intusstcsceptum. Thus, there are two peritoneal and two mucous surfaces of the intestine in contact (Fig. 283), and between the inner and middle tubes is a portion of the mesentery or meso-colon, which is necessarily drawn down with the intestine. The dragging of the mesentery causes the intussusceptum to assume a greater curve than its sheath, and hence to become puckered along its concavity ; it also causes the orifice of the intussusceptum to be directed towards the mesen- teric attachment and to be slit-like in shape. The intussuscep- tion nearly always increases at the expense of the lower portion of the intestine, the sheath becoming more and more infolded, so that, if the intussusception occurs at the lower part of the ileum, no more of the ileum will be involved, but the caecum and colon may be gradually drawn in. More rarely, however, the ileum is pro- 596 DISEASES OF REGIONS. truded through the ileo-caecal valve; the intussusception then increases at the expense of the upper portion of the intestine, more and more of the ileum being protruded through the valve. This variety is known as the ileo- colic, in contradistinction to the former, which is called ileo-ccecal. At first the invagination is reducible, and is not attended with any serious obstruction to the lumen of the intestine. In this condition it may remain, in chronic cases, for several weeks or months. Or the mucous membrane of the intussusceptum may become congested and swollen, rendering reduction difiicult or impossible without rup- ture or other injury of the intestine. In the majority of cases, however, especially in infants, if the intussusception is not soon reUeved, the blood-vessels of the involuted mesentery rapidly be- FlG. 28 Fig. 283. Intussusception. (.St. Bartholomew's Hospital Musium.) Diagram of intussusception. come constricted where the latter enters the sheath, causing acute obstruction to the circulation in the receding tube. As a consequence of this, the mucous membrane becomes intensely con- gested, and pours out the sanious discharge so diagnostic of the disease. In the meanwhile, the contiguous peritoneal .surfaces of the inner and middle tube become intlamed and glued together, rendering reduction imjjossible. (langrene of the intussuscej^tum now ensues, and the patient .usually dies of collapse or peritonitis in a few days. In adults, however, and in children of six or eight years and upwards, the gangrenous portion may slough off at the constricted part and be passed per anum, but in children under two years of age, the disease, unless relieved by treatment, is al- INTESTINAL OBSTRUCTION. 597 most invariably fatal. Should recovery take place in this manner the patient may subsequently succumb to stricture of the intes- tine from contraction occurring at the spot where the intestine has united. The intussusception may measure only two or three inches in length, or it may involve the whole of the large intestine and protrude at the anus. It is attributed to worms, the dragging of a polypus, an elongated mesentery, irregular peri- stalsis, diarrhoea, and external violence. Its most common situa- tion is at the ileo-csecal valve, then in the small intestine, and then in the colon. It is rare in adults, t)ut common in children, espe- cially in infants. 5. Stricture of the intestine consequent upon disease of THE intestinal WALL. — This Condition is generally due to the growth of a carcinoma or other tumor, more rarely to contractions following ulceration, the passage of gall-stones, or injury, or opera- tion on the intestine. It is most frequently met with in the large intestine, especially the rectum and lower part of the colon and caecum ; it is rare in the small intestine. 6. Contractions of the intestine consequent upon disease beginning external to the intestinal wall. — This condition may depend on chroiiic peritonitis, or on carcinoma of the omentum or mesentery. It is more common in the small than in the large intestine, and not only narrows the calibre of the bowel, but also obstructs the peristaltic action by gluing the coils of in- testine to one another and causing contraction of the mesentery. 7. Acute peritonitis and enteritis are not uncommon causes of intestinal obstruction. Peritonitis is a frequent termination of the other conditions that cause obstruction, but it is perhaps most often due to inflammation spreading from the region of the caecum (ypei'i-iyphlitis) , the bursting of a peri-typhlitic abscess into the peritoneal cavity, or to ulceration, perforation, or gangrene of the vermiform appendix. 7. Typhlitis and peri -typhlitis, or inflammation in and about the caecum, may possibly sometimes be due to the lodgment of a faecal mass in the cscum, but is much more freqnendy started by the impaction of a foreign body, as a pin or a fruit or gall-stone or little mass of hardened fjeces, in the vermiform appendix. It is apt to recur from time to time {recurrent typhlitis, ap/eiidicitis). In such cases, ulceration, perforation or gangrene of the appendix is very apt to take place and set up {a) general septic peritonitis, or {b) locahzed peritonitis. In the latter case the peritonitis may remain locahzed and terminate in a peri-typhlitic abscess, which may be either intra- or retro-peritoneal, or may spread to the general peritoneal cavity and become diffuse. 9. Mechanical pressure on the intestine by innocent or 598 DISEASES OF REGIONS. malignant growths,, hydatid cysts, enlarged glands, etc., may occasionally give rise to obstruction. 10. Congenital malformation of the intestine. — Amongst the chief of these may be mentioned imperforate anus, deficiency of the rectum, absence of the colon, termination of the colon in the bladder, etc. Obstructions from such and like causes are only met with in the infant {see Diseases of Rectum, p. 652). 11. External hernia. — All forms of external hernicC when strangulated, and generally when incarcerated or inflamed, are productive of intestinal obstruction {see Hernia, p. 6ig). Termination of intestinal obstruction. — Whatever the cause of the obstruction, the intestine above becomes sooner or later enormously distended with faecal matter (Fig. 287) and flatus, and if the obstruction be not removed the case will end fatally from exhaustion, peritonitis, ulceration or rupture, followed by collapse and peritonitis, or septic poisoning by the toxines of the bacillus coli {colibacillosis). The SYMPTOisis of intestinal obstruction vary according to the pathological conditions upon which the obstruction depends. The symptoms common to all may be said generally to be pain, vomiting, constipation, and more or less distension of the abdomen. AVhen the obstruction occurs suddenly, and is attended by stiangulation of a portion of intestine, as in i, the various forms of constriction produced by bands ; 2, a portion of intestine slipping through a hole in the mesentery or omentum ; 3, volvulus ; and 4, external strangulated hernia, the symptoms are also sudden in their onset and acute in their course, as is likewise generally the case when they depend upon intussusception, the impaction of a gall-stone or other foreign body, the sudden accumulation of faeces above a stricture, or acute enteritis or peritonitis. Thus the pain is severe and violent, and occurs suddenly in a ])erson in previously good health ; the vomiting comes on early, and may rapidly become faecal ; the constipation is complete from the first ; flatus will not pass by the anus ; the urine may be scanty or suppressed ; there is frequently hiccough or tympanites ; and the patient soon falls into a state of collapse and dies. When, on the other hand, the obstruction comes on more slowly, and a portion of intestine is obstructed, rather than strangulated, as from (1) progressive stricture of the rectum or colon; (2) the pressure of an abdominal or pelvic tumor; (3) the gluing of the intestines together by chronic peritonitis or cancer ; (4) the gradual accumulation of faeces, due to habitual constipation, and (5) chronic intussusception, the symptoms are also insidious in their onset and chronic in their course. Thus, obscure abdom- inal symptoms may have existed for some time. The pain is INTESTINAL OBSTRUCTION. 599 less severe, more diffused, and may be intermittent, but increases with the distension. Vomiting only occurs late in the course of the affection, and does not become faecal till towards the last. Constipation is not complete at first, the motions may be scybalous, and there may be a history of alternating constipation and diarrhoea. The distension of the abdomen is gradual and is, perhaps, more marked in the lumbar and epigastric regions. The abdomen appears broad, and coils of intestine may be visible, owing to increased peristalsis consequent upon hypertrophy of their muscular coat. The urine is normal. A stricture may perhaps be felt in the rectum by the finger, or in the sigmoid flexure by passing the hand. Collapse does not come on till the end. Such, broadly, may be said to be the symptoms attending acute and chronic intestinal obstruction. But it must not be for- gotten that the conditions which commonly give rise to chronic symptoms may, at any time, suddenly terminate in complete obstruction and strangulation, when the symptoms will at once become acute. Thus a slowly contracting stricture may become suddenly obstructed by the impaction of fseces, or by a portion of intestine immediately above becoming invaginated into it ; or acute peritonitis may suddenly supervene, owing to the giving way of an ulcerated portion of intestine above a stricture, etc. The DIAGNOSIS of the various pathological conditions causing obstruction or strangulation of the intestines, though sometimes comparatively easy, is often very difficult, or even impossible. Your first care, when called to a patient with signs of acute abdominal obstruction, /. e., pain, vomiting, constipation, and possibly distension of the abdomen, should be to exclude external Strangulated hernia, not merely contenting yourself with ex- amining the femoral and inguinal rings, but also making a careful search in the less common situations of hernia, as the obturator foramen and sciatic notch. Should there be any fulness, or the least suspicion of strangulation in any of these regions, an explo- ratory incision should be made. Having satisfied yourself of the absence of external hernia, you should next carefully examine the abdomen by inspection, palpation, and percussion, and explore the rectum and vagina with the finger ; whilst the former canal may, in some instances, be further examined by carefully passing a long enema tube or even by introducing the whole hand. At times something may be learnt by cautiously inflating the colon with hydrogen gas, or by slowly distending it by the fountain syringe with fluid, the patient being in the genu-pectoral position. Senn has shown that gas v.nll pass the ileo-ceecal valve, causing as it does so a distinct rushing sound with diminution of pressure, as indicated by the mercurial manometer attached to the inflating 600 DISEASES OF REGIONS. rubber-bag. If there is no obstruction the gas can be forced through the whole intestine and out at the mouth. Should a hernia be discovered exhibiting well-marked local signs of stran- gulation, or on introducing the finger into the rectum a stricture be felt or the bowel be found loaded with hardened faeces, blood and slime escape from the anus and a sausage- shaped tumor be detected in the abdomen or rectum, or a localized and tender swelling be discovered in the right iliac fossa, the diagnosis of strangulated hernia, stricture of the rectum, impaction of hard- ened faeces, intussusception, and typhlitis or peri-typhlitis re- spectively can be readily made. But when, on the other hand, the hernial rings are found free, the rectum empty, and nothing can be felt in the abdomen, the difficulty of localizing the cause of the obstruction is great, and even after the most careful ex- amination and thoughtful consideration of the symptoms, it may only be possible to arrive at an approximate guess as to the nature of the case. Thus, if the symptoms are acute, the obstruction will probably be due to some form of internal strangulation, or to a volvulus ; but it must not be lost sight of that it may be due to peri-typhlitis, acute enteritis or peritonitis, or possibly to the im- paction of a gall-stone. If the symptoms are chronic, it may be due to stricture in the upper part of the rectum or lower part of the colon, malignant disease of the omentum or intestine, or chronic peritonitis. If acute symptoms have been engrafted on chronic, it may then be caused by the impaction of faeces above a stricture, peritonitis following perforation above a stricture or impaction of a foreign body in the vermiform appendix, typhlitis, or peri-typhlitis. Although it may be impossible to make a diagnosis, the following considerations may help us. Thus, if the onset of the symptoms is sudden and the patient is an infant or a young child, the cause of the obstruction will probably be intus- susception or peritonitis. If the i)atient is elderly or middle- aged, and the symptoms are chronic, malignant stricture or im- paction of faeces is the most probable cause. In middle age intussusception is rare. The tendency to vomit is in proportion to the nearness of the obstruction to the stomach, the tightness of the constriction, and the persistence with which food or fluid has been taken by the mouth. Early vomiting implies tightness of the stricture ; violent retching or bile-vomiting points to gall- stones ; faecal vomiting only occurs when the obstruction is mod- erately low down. Vomiting may be absent in the case of ob- struction of the colon or rectum. Mnally, if peristalsis is visible, the case is almost certainly not one of acute peritonitis. I. In impacted faces there may be a history of previous con- stipation, the rectum will probably be found distended, or faeces INTESTINAL OBSTRUCTION. 6ot will be passed on the use of enemata. A swelling may be felt through the abdominal parietes, and if so will be soft, and can perhaps be indented with the fingers. In obstruction from gall- stones, there may be pain in the region of the gall-bladder, per- haps jaundice ; gall-stones may have passed, or similar attacks have been previously suffered from, and the bowels may have acted irregularly. The vomiting is gastric or bilious, and is at- tended with violent retching. In internal strangulation the attack is very sudden, and is probably attributed to a strain ; the pain is intense, and is re- ferred to one spot, or to the umbilicus ; vomiting comes on early ; the constipation is sudden ; there is no desire to defaecate ; the urine is scanty ; there is no visible peristalsis ; no tumor can be felt ; there is no haemorrhage from the bowel, and no tenesmus. There is probably a history of some affection which might pro- duce bands of adhesions, as peritonitis, typhoid fever, or a former hernia ; or there may have been previous attacks of abdominal obstruction with intervals of perfect health. 3. In volvulus, the signs are similar to the foregoing, but if anything still more severe. 4. In intussusception, when acute, there is a discharge of mucus and blood from the anus ; the abdomen is not much distended ; the abdominal parietes are usually lax, and through them a sausage-shaped tumor, doughy to the feel, hardening on handling, and perhaps changing its position from time to time, may some- times be detected ; and the invaginated bowel can possibly be felt in the rectum. Collapse soon ensues. When chronic, there may have been attacks of localized pain lasting for months before strangulation occurs, the patient having been in good health in the intervals. There is straining and tenesmus ; the constipation is not complete ; vomiting is absent or intermittent ; the disten- sion is not marked ; and collapse does not come on till the end. The tumor will have characters similar to those mentioned above. 5. In stricture the patient is usually old or middle-aged ; the symptoms come on very insidiously ; there are alternate attacks of constipation and diarrhoea ; the constipation gradually becomes more and more pronounced ; the motions are probably lumpy {scybalous) , pipe-like, or flattened ; dyspepsia is complained of; the pain is diffused and depends upon the distension of the ab- domen ; the distension comes on slowly, and is greatest in the flanks ; peristalsis is visible ; the urine is copious ; the pulse quiet ; and vomiting only occurs late in the case. Having diagnosed the case as one of stricture, the next point to determine is whether it is situated in the sigmoid flexure or rectum, and consequently that opening the sigmoid flexure in the left groin or the descending 26 6o2 DISEASFS OF REGIONS. colon in the left loin, will be well above the stricture ; or whether it is situated in the descending, transverse, or ascending colon, so as to necessitate the opening of the ascending colon or csecum. To begin with, it should be remembered that stricture is most common in the sigmoid flexure and rectum, next in the colon, then in the caecum, and is very rare in the small intestine ; indeed it is so rare in the two latter situations, that when its exact posi- tion is not known, it is generally safe to assume that right colo- tomy or typhlotomy will suffice. Again, if the stricture is in the rectum or sigmoid flexure, the distension will be equal on the two sides ; when in the descending or transverse colon, greater on the right than on the left side. The amount of distension on the two sides may be more accurately estimated by the cyrtometer than by mere inspection and palpation. If a clyster-pipe will pass for some distance, say a foot or so, and a large quantity of fluid can be injected, the stricture is probably high up ; but too much importance must not be attached to this sign, as the clyster-pipe may have bent upon itself, and the rectum and sigmoid flexure are often very capacious. Further, something may at times be learnt by ausculting the colon whilst the injection is being given, and by passing the whole hand into the rectum. The detection of a tumor in any part of the colon or caecum will, of course, set the diagnosis at rest. 6. In contractions there is pain of a paroxysmal nature of short duration and of frequent occurrence ; peristalsis may not be visi- ble on account of the matting together of the intestines, but gurglings may be heard. There is no vomiting or distension ex- cept during the attacks of pain. Constipation is not complete ; defaecation is painless ; the motions are not compressed or pipe- like as they may be in stricture ; and there is no distension in the flanks. The symptoms may at any time suddenly become acute. 7. In acute peritonitis the abdomen is distended irom the first, hard, and board-like ; peristalsis is not visible ; the pain is great and increased on the least pressure ; the pulse is small and wiry ; the temperature may or may not be raised. (See Peritonitis, p. 393.) There will jjrobably be a history of previous attacks of typhlitis or perityphlitis, or signs of gastric ulcer, or the patient is suffering from typhoid fever or has had uterine troubles, etc. 8. In typhlitis or perityphlitis there is pain in the region of the csecum coming on usually somewhat suddenly, nausea or vomiting, furred tongue, constipation and fever. At first there is in- creased resistance and tenderness in the right iliac fossa, whilst the rest of the abdomen may remain supple ; later there is a dis- tinct swelling extending inwards towards the middle line, up- wards to about the level of the umbilicus, and more or less back- INTESTINAL OBSTRUCTION. 603 wards into the loin. Still later, fluctuation in the swelling may be detected. The tenderness is often most marked at a spot two inches from the anterior superior spine of the ilium, on a line be- tween that spine and the umbilicus {McBurnefs point), i. e., over the situation of the appendix. There is probably a history of constipation or irregular action of the bowels, or of one or more previous attacks of a similar nature. 9. In mechanical pressure on the intestines by new growths, cysts, enlarged glands, etc., a tumor will probably be discovered on palpation of the abdomen or by the finger in the rectum or vagina. 10 & II. The diagnoses of congenital 7nalfo7'mation and exter- nal hernia are given under these heads respectively. Treatment. — Supposing any of the above conditions to have been diagnosed with tolerable certainty (see above), the indica- tions for treatment will be clear. Where no diagnosis, however, can be made, the treatment may at first be expectant, but no long delay is admissible if surgery is to have a fair chance of sav- ing the patient. Thus in acute cases, nothing should be given by the mouth save small pieces of ice to suck, the stomach should be emptied by irrigation with warm water with the syphon stom- ach tube, and the patient placed under the influence of morphia injected subcutaneously. An enema may be given, but purga- tives must of course be avoided. The relief, however, obtained by these means is often deceptive, and if the obstruction con- tinues it is worse thr.n useless to waste further time in giving drugs. It is better at once to open and explore the abdomen before irreparatle harm has been done. If when first seen the patient is already collapsed and his condition such that he could not bear the shock attending exploration, a small incision may be made through the abdominal wall, and the first piece of distended intestine that presents secured to the edges of the wound, and opened {Enterotomy). In chronic cases, the diet should be re- stricted, only small quantities of the most digestible food being given at a time, and as soon as a diagnosis can be made, meas- ures should of course be taken for relieving, if practicable, the obstruction. I. In impacted fcEces, when medical means and enemata have failed, the rectum may require clearing with a scoop or other suitable instiument. In ol'st/ uction from impacted gall-stones or other foreign bodies, after the UdUi.1 remedies have been unsuc- cessful, the abdomen may be cpened, and the gall-stone or for- eign body removed tlirorg'i an mcision in the intestine, or else made to pass by gentle m..nii uLition ti rough the ileo-caecal valve. The incision should be made in the longitudinal axis of the gut, 6 04 DISEASES OF REGIONS. and not opposite the impacted body where the coats may be damaged, but a few inches lower down. The gall-stone or other body may then be removed, breaking it first if necessary, and the wound be afterwards united by Lembert's suture. Or should the walls of the gut be softened by ulceration, a portion of the intes- tine may be resected, and the continuity of the tube restored by one of the methods of enterorrhaphy described at page 382. An impacted gall-stone may sometimes be broken up with a needle without opening the intestine. 2. In internal strangulation, abdominal section is the only pro- cedure of any avail, and ought, like herniotomy, to be undertaken early and not merely as a last resource (see Laparotomy^. 3. In volvulus of the sigmoid flexure, insufflation with air or hydrogen, or a large enema, will at times succeed in untwisting the intestine. If these means fail, no time should be lost in open- ing the abdomen (see Laparotomy^. If there is great distension, Treves advises that the inflated coil should be punctured through the abdominal parietes. 4. In intussusception, when acute, copious injections of warm water to empty the lower bowel, followed by insufflation of air or hydrogen with the patient inverted and thoroughly relaxed under chloroform, will often succeed in the early stages, and should be given a fair trial. In the meantime opium may be given in doses suitable to the age of the patient, food withheld, and the stomach emptied by an emetic or irrigated with warm water. These means failing, laparotomy must be performed (see Laparotomy), If the signs of strangulation are well marked, too much time should not be lost in trying injections and insufflation, lest the bowel become so damaged or the intussusceptum so adherent to the intussuscipiens as to render the prospect of success hopeless. Indeed, I have come to the conclusion thnt unless laparotomy for intussusception in an infant is undertaken within twenty-four to thirty-six hours fiom the onset of the symptoms, reduction will be found next to impossible without so injuring the intestine as to render a fatal result almost inevitable. In infants, intussuscep- tion, unless relieved by injections, inflations, etc., or by early oi)erative means, may be said to be almost invariably fatal. In chronic cases, although there is less need for early operative in- terference than in acute, as the bowel may remain incarcerated for some time before becoming strangulated, it should not be delayed too long, lest the intussuscepted portion become adherent to the sheath. Should it appear ]jrobable that this has already hap- pened, two courses are oi)en : either to open the abdomen, or to keep the patient under the influence of opium in the hope that the intussusceptum may slough off and be passed per anum. In LAPAROTOMY. 605 exceptional cases of intussusception of the sigmoid flexure the mass may be drawn out of the anus, the gut above and below united by sutures, the intussusceptum cut away, and the united gut reduced, 5. For stricture of the la^'ge intestine, left inguinal colotomy should be performed when the obstruction is in the rectum or lower part of the sigmoid flexure, and typhlotomy when in the transverse or descending colon. Should the strictured portion be readily reached in performing the operation, it may, if the disease is localized, be cut out {colectomy, typhlectomy), and the bowel secured to the wound, or better, the two portions of bowel united. In stricture of the small intestine, enterotomy may be performed as a palliative, or under suitable condidons, enterectomy with union of the intestines by one of the methods already described. 6. In contractions, where the intestines are matted together by chronic peritonitis or cancer, when medical means have failed, enterotomy may prove of temporary benefit by relieving the distension. 7. The treatment of acute peritonitis is given at page 394. 8. For an account of the early or medical treatment of typhlitis 2ind peri- typhlitis diVfoxk on Medicine must be consulted. Should, however, the inflammation terminate in suppuration and an abscess form, it should be opened and drained ; or should such an abscess burst into the general peritoneal cavity, the peritoneum should be washed out and a glass drainage tube left in the wound. The appendix, if found inflamed, plugged with a foreign body, ulcer- ated, or gangrenous, should be amputated, and the stump sutured by Lembert's method. When it appears that recurring attacks of typhlitis are due to mischief in the appendix {recurring appendi- citis), the question of removing the appendix after the acute at- tack has subsided may be raised. The chief indications for this measure are {a) incapacity of the patient from the frequency of the attacks, {b) increasing severity of the attacks, (r) extreme danger of last attack, and \d) signs of local suppuration about the appendix. The incision should be made about two inches from the anterior superior spine of the ilium, at right angles to a line drawn from the iUac spine to the umbilicus, or over the appendix, if this structure, as is often the case when swollen and thickened, can be felt. The anterior muscular band of the caecum is at times a good guide to the appendix. Adhesions having been carefully separated, the appendix is removed, and the stump sutured and covered by a peritoneal or omental graft. Laparotomy, abdominal section, or opening the abdomen, is an operation that may be required for the purpose of exploration in doubtful cases of intestinal obstruction or for the relief of 6o6 DISEASES OF REGIONS. Fig. 284. volvulus, Strangulation of the in testines by bands or diverticula, in- tussusception, reduction of hernia en tnasse, etc. The room should be at a temperature between 70° and 80° Fahr., and the patient, with the limbs wrapped in cotton-wool bandages, placed on a rubber bed filled with hot water. The greatest care should be taken that nothing septic comes in contact with the wound or peri- toneal cavity. The stomach may be irrigated with warm water before giving the anjesthetic. This prevents vomiting, and may remove some of the contents of the upper part of the intestine and relieve distension. Some Surgeons give a hypodermic injec- tion of Tsoth of a grain of atropine and a rectal enema of brandy to increase the heart's action. Having thoroughly cleansed the skin with soap and water, and afterwards well sponged it with car- boHc lotion (i in 20) or perchloride of mercury lotion (i in 1000), make an incision in the middle line of the abdomen, midway between the pubes and umbilicus (Fig. 284, a), and having rapidly exposed the peri- toncm and stopped all haemorrhage, carefullv open the peritoneal cavity on a director. Some Surgeons ad- vise that the incision should be limited, and only long enough to at first admit one or two fingers. I prefer myself for the purpose of sav- ing time to make it long enough to at once admit the whole hand if found necessary. If a distended loop presents in the wound, the ob- struction is in the large or lower por- tion of the small intestine ; if this loop contains fluid, feeces, or gas, it is probably near the obstruction ; if only gas, some distance off. Pass one or two fingers or the whole hand into the abdominal cavity and first explore the hernial rings from within, and if these are free the region of the csecu-n, taking care to prevent the intestines from protruding by plarins: over them a warm flat aseptic sponge. If the Ccccum is found distended, the obstruction must be in the large intestine. Cairv your fingers or hand, therefore, along the course of the colon until the obstruc- tion is met with. If, on the other hand, the crecum is empty, the obstruction must be in the small intestine. Pass your fingers or hand in this case into the pelvis, and search for an empty loop of I^ines of incision in certain operations on the abdomen, a. Laparotomy, Ovariotomy, b. Supra-pubic cyst- otomy, c. Ligature of external iliac artery, d. Inguinal colotomy. e (jastrostomy. f. Cholccystotomy. LAPAROTOMY. 607 Fig. 285. intestine below the obstruction, and follow the intestine by pass- ing it through the fingers piece by piece till the obstruction is discovered. If after a search of some minutes the obstruction is not found, enlarge the wound and allow the intestines to prolapse, keeping them warm by the continual application of aseptic gauze wrung out of hot water. When the intestines are much distended Mr. Greig Smith advises that the distended loop should be drawn into the wound, punctured with a Spencer Wells ascites needle connected with an aspirator bottle, the distension relieved, and the Httle wound sutured, the Surgeon waiting for hours at the bedside if necessary, and aspirating occasionally till the distension is relieved. The gut in the meantime may be kept in contact with the wound by a skewer passed under it through the mesentery. In draining the bowel a Paul's tube (Fig. 285) may be used. The gut having been drawn into the wound and packed round with aseptic gauze^ an incision large enough to admit the tube should be made, the tube (previously plugged with wool) inserted, and fixed by a ligature passed round the flange. The plug of wool is then removed and rubber tubing fixed to the distal end of the tube to convey away the faeces. After the distension is re- lieved the case must be treated as cir- cumstances suggest. (a) If a loop of intestine is found strangulated in one of the hernial rings, or in a hole in the mesentery, it must be released from within the abdomen, dividing any stricture if necessary, {d) If a volvulus is discovered an attempt must be made to untwist it, and as a prophylactic against retwisting, the mesentery may be shortened by folding it upon itself parallel to the intestine, and fixing with sutures. If the volvulus cannot be reduced, the con- tents may be let out, the wound sutured, and another attempt made. This failing, the volvulus may be excised and the intes- tine restored by one of the methods of enterorrhaphy (page 382). If the patient is too collapsed to admit of excision, the volvulus may be left, and the intestine short-circuited by means of Senn's plates, etc. If gangrene has occurred, the volvulus must be ex- cised and circular enterorrhaphy or lateral approximation per- formed, (c) If a band is met with it must be divided. (^/) If a large diverticulum is the cause of the obstruction it must be cut across, and the bowel end closed by Lembert's suture, (e) If a small diverticulum is producing the constriction it must be severed Paul's glass tubes for draining the intestine. The end with the double flange is inserted and tied in the gut. (After Paul.) 6o8 DISEASES OF REGIONS. Fig. 286. and the two ends ligatured. Should the intestine give way in di- viding the obstructing band, etc., or have already given way — if the perforation is small and the coats are in a fairly healthy condi- tion, the wound in the intestine may be closed by sutures in the way described under wounds of the intestine. But if the coats are in an inflamed or sloughy condition, or gangrenous, the diseased portion may be excised, and the upper and lower portions of the intestine united in one or other of the ways already mentioned (page 382). Only when the patient is much collapsed should the ends of the bcwel be iixed to the external wound and an artificial anus made. Before uniting the intestine, however, it may be well in some cases to fix the intestine temporarily in the wound and let the contents of the distended por- tion drain away for several hours, or even dajs. (/) If an intussus- ception is discovered, first squeeze out some of the inflammatory oedema by steady, uninterrupted manual compression with an asep- tic sponge, and endeavor to reduce the intussusception by gentle trac- tion on the bowel just above the neck of the intussuscepiens and by counter- traction just below the apex of the intussusceptum ; or better, try to squeeze out the in- tussusceptum by kneading and pressure from below. Reduction may possibly be aided by insuffla- tion of the rectum with air or hy- drogen. If adhesions have formed, try to break them down by gently insinuating a probe between the contiguous serous surfaces. After reduction search for any rent in the peritoneal coat and bring it together by suture and seal with an omentum graft. Reduction failirg, the following courses are open: i. Exclusion of the intussusception by leaving it in situ and short circuiting the intestine (Fig. 286) by forming a com- munication between the bowel above and below the intussuscep- tion by means of Senn's and Murphy's method. 2. Complete or partial excision of the intussusception and restoration'of the bowel by circular enterorrhaj hy, lateral af^proximation. Murphy's but- ton, etc. Complete excision is a most serious operation, espe- cially when a long length of bowel is involved. In such a case, Diagram of the method of short-circuiting the intestine for irreducible intussus- ception. A c. Ascending colon, c. Caicum. 1. Ileum. ENTEROTOMV, OR NELATON's OPERATION. 609 if there is no sign of gangrene the sheath may be opened, the in- tussusceptum excised just below its neck, the stump ligatured, and the continuity of the intestine restored by lateral approximation by bone-plates or lateral implantation. When gangrene has occurred, the whole intussusception must be excised. Since the introduction of the more rapid methods of restoring the continu- ity of the intestine, the need of making an artificial anus should seldom occur. After any of the above operations, carefully cleanse the abdo- men from blood by gentle sponging and close the wound in the parietes, with the two surfaces of the peritoneum in contact, by sutures passed through the skin and peritoneum. If in spite of all care the peritoneum has been soiled by faecal matter, or septic changes have already started, flush out the peritoneal cavity with gallons of hot water to which, some antiseptic as salicyhc acid (5 per cent.) or boracic acid (2 per cent.) may be added. In flushing out pass the irrigating tube amongst the intestines to the back of the abdominal cavity and into the pelvis so that the water may flow outwards. If the intestines have been allowed to pro- lapse there may be some difficulty in getting them back. Cover them with antiseptic gauze wrung out of hot water, tucking the margins of the gauze beneath the edges of the wound. Introduce the sutures, and when they are all in situ make uniform pressure on the gauze as the sutures are tightened and tied from above downwards. Withdraw the gauze before the last sutures are tied. Drawing forward the edges of the wound with retractors will materially aid the replacement of the intestine. If they cannot be replaced, draw a distended loop away from the wound, aspirate or open it, evacuate as much of the contents as possible, suture the wound by Lembert's method, and again endeavor to replace the prolapsed intestine. When fgecal soihng or septic changes have occurred, place a glass drainage tube in the wound (see Ovariotomy) . (g) If the obstruction is found to depend on a perityphlitic abscess or acute peritonitis, a rubber or glass drainage tube should be placed in the wound in the abdominal parietes, after the ab- scess or peritoneal cavity has been washed out. Enterotomy, or Nelaton's operation, consists in opening the abdomen by a short incision in the middle line or in the right or left groin, seizing the first piece of distended intestine that pre- sents, and securing it to the wound by sutures and then opening it. This operation is employed in cases where the obstruction is believed to be in the small intestine, though the diagnosis of the situation is uncertain, and where the patient's condition is such that the severe shock and the prolonged manipulation that neces- 6ro DISEASES OF REGIONS. Fig. 287. sarily attends laparotomy (the operation otherwise indicated) would probably be fatal. It may also be employed in cases ot obstruction due to contractions consequent upon the matting together of the small intestines from chronic inflammation, cancer, etc. It should be thoroughly understood, however, that the operation is only Intended to relieve the distension of the in- testines and prevent their rupture. It does not attack the seat of obstruction. But by relieving the acute symptoms it may give time for a diagnosis in doubtful cases to be arrived at ; and the patient's condition after it may so far improve as to allow of a more radical course of treatment being undertaken on a future occasion. The method of Greig Smith (p. 607) is likely to re- place to a great extent the above operation. Enterectomy consists in opening the abdomen and excising a portion of the intestine. It may be required for irreducible intus- susception, carcinomatous strict- ure, gangrene from strangulation by bands, the closure of frecal fistulse, wounds of the intestine, etc. Open the abdomen as in laparotomy ; draw the portion of intestine to be removed well out of the wound, and pack it round with moist antiseptic gauze ; clamp the intestine with a rubber tube passed through a small incision in the mesentery above and below, to prevent the escape of faeces ; cut out the diseased or damaged part ; tie all bleeding vessels ; and then unite the intestine by one of the methods already described (p. 382). Or if the intestine is much distended and the patient in a state of extreme collapse, secure both the proximal and distal portions of the intestine to the woimd in the abdominal par- ietcs by sutures. After the con- tents of the over-distended bowel have been evacuated and the gut has regained its tone, the two portions may be united and returned into the abdomen. Fig. 287 represents a distended caecum and lower portion of the ascending colon which was re- moved for carcinomatous stricture by my colleague, Mr. Langton. The csecum, with part of the ascending colon and the end of the ileum removed for cancer of the ascending colon. The cEKCum was greatly distended. (St. liartholomcw's Hospital Museum.) INGQINAL COLOTOMY. 6ll The gut was united above and below the excised portion by Senn's plates, and the patient made an excellent recovery. For the removal of the caecum the incision should be made in the right iliac fossa (p. 605). According to whether small intestine, colon, or caecum is ex- cised the operation is spoken of as enterectomy, colectomy, and typhlectomy. Inguinal colotomy is the operation of opening the sigmoid flexure of the colon in the left groin {Littre's operation). It has been much employed of late in place of lumbar colotomy, especi- ally for carcinoma of the rectum before distension of the colon consequent on the stricture has occurred. Its chief advantages over the lumbar operation are : i, that there is less difficulty in finding the gut ; 2, that there is le^s danger of peritonids, in that, as the peritoneum has to be opened, all proper precautions can be taken ; 3, that the wound is more superficial, and consequently there is less risk of infiltration of the tissues and septic poisoning ; and 4, that the groin is a more convenient situation for an anus than the loin. An oblique incision (Fig. 284, d) about two inches long is made one inch from the anterior superior iliac spine, at right angles to a line drawn from the umbihcus to the iUac spine, one inch of the incision being below and one inch above the Hne. Divide the skin, superficial and deep fascia, muscles, fascia transversalis, and the peritoneum on a director. If the gut does not present in the wound carefully search for it with the fingers. It may be known by the longitudinal bands of muscular fibres, by the appendices epiploicae, and by its mesen- tery running to the left, whereas that of the small intestine runs to the right. Having found the colon, introduce a flat sponge into the wound to prevent the entrance of blood, and stitch the parietal peritoneum to the skin with four sutures. Remove the sponge and draw down the colon until the meso-colon is taut, so as to avoid prolapse of the bowel subsequent to the operation. Draw the bowel well into the wound, pass a piece of glass rod beneath it through the meso-colon so as to produce a good spur, and thus prevent the faeces going down the distal end of the in- testine, and secure the gut to the parietal peritoneum by sutures passed through only the peritoneal and muscular coats. Apply an antiseptic dressing with a piece of protective next the bowel to prevent its adhering to the gauze, and at the end of three to five days, when adhesions have had time to form, cautiously open the gut by cutting through it on to the glass rod. Some Surgeons, for the purpose of forming a spur, draw the gut forward by a liga- ture passed through the mesentery. Others, with the same aim in view, divide the colon and secure both open ends to the 6l2 DISEASES OF REGIONS. wound ; whilst others again close the lower end by means of Lembert's sutures, and drop it back into the peritoneal cavity. These procedures, in my opinion, add to the risks of the opera- tion, and are, I think, unnecessary if the bowel is drawn well into the wound and a piece of glass rod passed through the meso- colon in the way above described. No food should be given by the mouth for the first twelve or twenty-four hours and then slop diet until the gut is opened. If the bowel is greatly distended at the time of operation and threatening to burst, it may be opened at once ; or should vomiting and distension come on after the operation, it may be opened before the usual four or five days have elapsed. Some Surgeons give opium as a routine practice, others withhold it unless there is pain or restlessness. If the bowel does not act spontaneously after the gut has been opened, a gentle saline purge or an enema may later become necessary. The bowel below the wound may also require washing out by an enema. Lumbar colotomy is the opening of the colon in the left lum- bar region (yCalliseti's operation), ox xw the right {Amussafs oper- ation). The former should be chosen when the disease is in the rectum or lower part of the sigmoid flexure ; the latter when there is any doubt whether it may not be in the transverse colon. That on the left side, the common operation, need only be described. Place the patient on his right side, slightly inclining towards his face, with pillows under his abdomen, or beneath his loin, in order to make his left side prominent. The outer border of the quad- ratus lumborum, the guide to the colon, should then be marked; it is situated half an inch posterior to a line drawn vertically up- wards from a point midway between the anterior superior and posterior superior spines of the ilium. Then make an incision about four inches long between the last rib and crest of the ilium from the erector spinae obliquely outwards and downwards. Divide the skin, fascia, and various layers of muscles, viz., the latissimus dorsi, external oblique, internal oblique, and transver- salis, and the transversalis fascia on a director (Fig. 288), and the quadratus lumborum will now be exposed at the inner part of the wound, and may be known by its fibres running upwards and in- wards. When the colon is distended it will bulge in the wound ; when contracted, however, it may be sought in the wound by carefully scratching through the fatty tissue covering it with two pairs of dissecting forceps. If there is much difficultly in finding it, pass per rectum a small catheter, if practicable, through the stricture, and inflate the colon. The colon may be distinguished from the peritoneum, which sometimes presents in the wound, by its situation immediately external to the (juadratus lumborum and ASPIRATION OF THE LIVER. 613 Diagram of parts divided in left lumbar colotomy. below the kidney ; by the presence of the longitudinal bands of muscular fibres ; by the thickness of its coats on nipping it up by the fingers ; and, at times, by in this way feeling scybalous masses of faeces in its interior. The peritoneum, on the other hand, may generally be known by the absence of the above characters, and, if it is nipped up, by the intestine being felt to sUp away from between the fingers. Hav- ing found the colon, secure it to the skin. This is usually done by passing a silk suture by means of a curved needle on a handle, first through the skin, then through the bowel, and then through the skin on the opposite side of the wound, and repeating the procedure at the other end of the wound. The bowel is then opened in a longitudinal direction, the loops of suture by which it is transfixed hooked out by the finger and divided, and the bowel secured to the integu- ment by the four sutures thus formed. A better and more convenient way of passing the sutures, which should then be of wire, is by Smith's cleft- palate needle. If this is used a series of sutures are passed, first through the skin, and then through the wall of the bowel, and tied before the bowel is opened. Should the peritoneal cavity be opened by mistake, it must be carefully closed by suture before the incision is made into the colon. Some perform lumbar colotomy in two stages, like gastrostomy ; but if the operation is carefully done in the way described above, such is hardly necessary. The bowel beyond the wound may sub- sequently require clearing with an enema. Indeed, it has been proposed to close completely this part of the bowel by operation so as to prevent faeces passing down it. OPERATIONS ON THE LIVER, GALL-BLADDER, STOMACH, SPLEEN, AND PANCREAS. Aspiration of the liver is sometimes performed for the purpose of diagnosis in the case of a suspected hydatid cyst or abscess in the liver, or for the removal of the fluid from an hydatid cyst. Having thoroughly cleansed the skin with an antiseptic and placed the patient, if nervous, under an anaesthetic, introduce the aspirating needle at the most prominent part of the swelling, taking care to avoid the colon and intestines. When operating for hydatids stop the aspiration if blood escapes, if the patient becomes faint, or if violent cough comes on. Otherwise continue the aspiration till the cyst is emptied. On the removal of the 6 14 DISEASES OF REGIONS. needle, place an antiseptic pad over the wound. The operation is not free from danger, several patients having died suddenly on the introduction of the needle, apparently in some cases from plugging of the pulmonary vein by a portion of an hydatid that has escaped into the circulation through a wound of one of the hepatic veins ; and general infection of the peritoneal cavity with hydatids has sometimes happened. It is better, therefore, for the purpose of diagnosis, to make an exploratory incision and to evacuate the hydatid or abscess in the way described below. Incision of the liver may be required for evacuating an hydatid cyst, or abscess. Make an incision over the most prom- inent part of the swelling, and having divided the abdominal parietes and stopped all bleeding, open the peritoneal cavity. If the liver is adherent to the abdominal walls, carefully incise it, first introducing an aspirating-needle to determine the situation of the cyst or abscess. If non-adherent the liver may be stitched to the abdominal wall, or the prominent part well packed round with sponges so as to cut off the general peritoneal cavity ; an aspirator may then be introduced to determine the situation of the cyst or abscess, and the liver substance incised. Or the opening of the cyst or abscess may be delayed till the liver has become adherent to the parietes. Great care should be taken, if the cyst or abscess is opened at once, to prevent any fluid or pus escaping into the peritoneal cavity, and the strictest antiseptic precautions should of course be observed. In the case oi a>i hydatid €}">(, after most of the fluid contents have been evacuated by the aspirator the cyst should be opened, the daughter cyst removed, and the lining membrane shelled off the fibrous capsule {jna^supialised), Xhe. edges of the wound in the liver sutured to the abdominal wall, and the cavity in the liver drained. If the cyst has suppurated or an abscess is being dealt with, should adhesion not have oc- curred suture the edges of the wound in the liver to the ab- dominal walls, and place a drain tube in the wound and ajiply antiseptic dressings. If the abscess has already ruptured into the peritoneum, that cavity should be thoroughly washed out with hot boric acid lotion and drained. Tapping the abdomen for ascites should be done in the linea alba, midway between the umbilicus and the pubes (Fig. 284, a.). The bladder having been emptied, a small incision should be made through the skin, and the trocar and cannula, with a tube attached to convey the fluid into a vessel, should be thrust into the abdomen. The fluid should be drawn off slowly, and a many- tailed bandage, previously passed round the body, gradually tightened as the fluid flows, in order to keep up pressure on the abdominal vessels, and so prevent syncope. Or the fluid may be CHOLECYSTO-ENTEROSTOMY. 6 1 5 drawn off with a Southey's trocar and cannula. When this is used a skin incision is not necessary, nor is the many-tailed bandage, since the abdomen takes many hours to empty on account of the small size of the cannula, and there is thus no fear of syncope. Cholecystotomy is the opening and draining of the gall- bladder, consequent upon the impaction of a calculus in the cystic duct. Make a vertical incision in the liner semilunaris, begin- ning just below the ninth costal cartilage, or over the tumor when the gall-bladder is distended (Fig. 284, f). Having divided the abdominal parietes and stopped all bleeding, open the peritoneum. Search for the gall-bladder with the finger beneath the liver if it does not present in the wound, and bring it to the surface if prac- ticable. Pack the wound with sponges to prevent any fluid escaping into the peritoneal cavity, and introduce an aspirator- needle into the gall-bladder, which, as the fluid escapes, should be well drawn into the wound. Enlarge the opening in the gall- bladder and remove any gall-stones found loose. If a stone is found impacted in the cystic duct, extract it, if possible, by for- ceps, by gentle manipulation with the fingers in the abdomen, by careful crushing with padded forceps, by breaking it with a needle passed through the wall of the duct, or by chipping off fragments as it hes in the duct. Secure the edges of the aperture in the gall-bladder to the abdominal wall by sutures, with its peritoneal coat well in contact with the parietal peritoneum ; leave a drain- tube in the gall-bladder ; and close the rest of the abdominal wound in the way already described. The biliary fistula thus left will generally close in a few weeks if the cystic duct has been cleared. Cholecysteciomy, or extirpation of the gall-bladder, may be required : i, where perforation following suppuration and ulcera- tion has occurred, and the coats are found too softened to admit of suture ; and 2, where cholecystotomy is indicated, but on opening the abdomen the gall-bladder is found so contracted that its fundus cannot be drawn into contact with the abdominal walls without tearing it. Make an incision similar to that for chole- cystotomy, prolonging it or dividing the muscles transversely a httle below the ribs if more room is required. Having well packed the wound with sponges to prevent blood escaping into the general peritoneal cavity, dissect the gall-bladder from the liver, clamping or tying any bleeding vessels, divide the cystic duct between two ligatures, cleanse the wound, remove the sponges, and unite the abdominal walls in the usual way. Cholecvsto-enterostoimy, or the establishment of an opening between the gall-bladder and the intestine, may occasionally be required for immovable obstruction of the common bile-duct, as 6i6 DISEASES OF REGIONS. from cancer about the head of the pancreas, duodenum, etc., involving the duct. Hiving opened the abdomen as in other operations on the gall-bladder, draw the gall-bladder and duode- num into the wound, and having mide an incision into each, unite them by sutuie, cr better, by Murphy's button. When the latter method is emploved a ruining thread is first passed, as shown in Fig. 289, through all the coats of the duodenum, and Fig, 2 Method of insetting the silk ligature to lorm the running thread for fixing Murphy's button in the lateral wall of the intestine. The incision for the button is seen within the loop of the thread. (After Murphy.) then another thread in like manner through all the coats of the gall-bladder. An incision is next made into the duodenum within the running thread (see Fig. 289) two-thirds of the length of the diameter of the button to be used, the button slipped in, and the thread tightly tied round the central cylinder (see p, 390). A similar incision is made in the gall-bladder, its contents evacuated, the other half of the button inserted and secured by the running thread in a similar way. The two halves of the but- ton, held by the fingers in the way shown in Fig. 290, are now pressed together, thu:s fixing the serous surfaces in contact. The spring in the button produces pressure atrophy of the tissues embraced by it, leaving an opening as large as the button, which, thus freed, is passed per anum. Pylorpxtomy, or removing the pylorus for carcinoma, was for- merly done by uniting the severed duodenum to the stomach by sutures. Now the cut ends of the stomach and duodenum are usually sewn up by a continuous Lembert suture, and the stom- ach united to the duodenum or the jejunum by Senn's plates {V\g. 292), Murphy's button, or some other method of lateral approximation. Gastro-kntkros'iomy or forming a fistula between the stomach and small intestine to allow fluids to pass out of the stomach, is employed (a) where the disease of the pylorus is too extensive for removal; (h) after excision of the pylorus, to save the time required to sew the stomach to the duodenum, and (c) in fibrous GAS! RO-ENTEROSTOi\] Y. 617 Stricture of the pylorus leading to dilatation of the stomach. It may be done by placing one of Senn's plates in the stomach and Fig. 2qo. Male and female half of Murphy's button, fixed in situ and ready for pressing together. (After Murphy.) Fig. 291. Dilatation of the stomach from carcinomatous stricture of the pylorus. The stomach held ten pints. (St. Bartholomew's Hospital Museum, No. 1923^.) the other in the termination of the duodenum or commencement of the jejunum, in the way shown in Fig. 292. A reaction, 26* 6i8 DISEASES OF REGIONS. however, seems setting in against the use of Senn's plates, since it is thought by some that they favor regurgitation of the contents of the intestine into the stomach, and that after their use there is a tendency for the aperture between the viscera to contract. By Postnikow the jejunum is attached to the front of the stomach by a row of sutures passing only through the serous and muscular Fig. 292. Part of the stomach and jejunum from a case of gastroenterostomy for malignant growth at thepylorus. A. Stomach. B. Jejunum. The bone plates are still i>i situ. The plate in the jejunum is seen. (St. Bartholomew's Hospital ftluseum.) coats ; then in front of the line of sutures oval portions of the serous coat of each viscus are removed ; the exposed muscular coat and underlying mucosa of each viscus are next pinched up and tightly ligatured so as to cause them to slough, and the raw edges of the serous coats united each to each by non-penetrating sutures. Another row of stitches are finally inserted in front. DuODENOSTOMY AND JEJUNOSTOMV, OX the Operations for forming an artificial opening into these portions of the small intestine re- spectively, are so rarely required that they are not here described. Neither is the operation of opening the stomach, securing it to the abdominal walls, and then scraping away with a curette por- tions of the carcinoma blocking the pylorus. Indeed, gastro- enterostomy by the improved methods has practically replaced these operations. The nefcessity for the large number of Lam- bert's sutures formerly employed in gastro-enterostomy is now done away with, and the operation can consequently be performed in a very much shorter time, ancl hence with much less shock. Many successful cases have been recorded. Dilatation of the caroiac and i-viokic ends of the stomach FOR SIMPLE fibrous S'lKiCJURE (Loic/d^i flpera/ton) consists in opening the stomach and then dilating the cardiac or pyloric end, HERNIA. 619 as the case may be, with the finger. The wound in the stomach is then closed by Lembert's suture, and the abdominal parietes united, as after ovariotomy. The strictest antiseptic precautions must of course be taken. In the successful operations there has been no return of the stricture at present. Pyloroplasty, which has been successfully employed for non- mahgnant stricture, consists in dividing the pylorus longitudinally, widely retracting the margins of the wound, and then uniting them by suture in such a way as to leave the incision transverse. Splenectomy, or extirpation of the spleen, may be required for rupture of the viscus, and for some cases of hypertrophy. An in- cision is made either in the linea alba, the linea semilunaris, or still further to the left, and the spleen having been thoroughly ex- posed, adhesions carefully broken down, and the organ, if en- larged, drawn out of the wound, the pedicle is transfixed in several places, and the ligatures interlocked and tied. The pedi- cle is next severed well to the splenic side of the ligatures, the organ removed, the peritoneum thoroughly cleansed, and the ab- dominal wound united and drained. Great care should be taken not to tear the splenic substance, an accident attended with fear- ful haemorrhage. Drainage of pancreatic cysts due to obstruction of the duct or to injury may be required. These cysts give rise to a tumor in the epigastrium, which is often attended with severe neuralgic pain, and from which may be obtained on aspiration an alkaline fluid having the properties of turning starch into sugar and of emulsifying fats. Fat may be present in the faeces and sugar in the urine. The abdomen should be opened and the cyst stitched to the abdominal wall and drained. Lloyd beheves that many of these so-called cysts are due to haemorrhage into the lesser sac of the peritoneum, the result of injury, whilst Swain attributes them to rupture of a retention-cyst of the pancreas into the lesser sac. The term Hernia, though often used in conjunction with other terms to signify the protrusion of any viscus from its containing cavity, as '^'^ Hernia cerebri,''' or "Hernia testis,'' when employed alone is applied only to such a protrusion from the abdomen or pelvis, and is equivalent in this sense to the term rupture, the name by which the affection is popularly known. Description of hernia in general. — A hernia may occur at almost any situation, but is most common at the inguinal and femoral rings, spots at which the abdominal parietes are naturally weaker than elsewhere. It generally consists of intestine, or of 620 DISEASES OF REGIONS. omentum, or of both ; but almost every one of the abdominal or pelvic viscera have at times formed the protrusion. The causes of hernia are predisposing and exciting. The p?rdisposing m^-j ht divided into: i. Hereditary and congenital malformations, such as an elongated condition of the mesentery, a patency of the funicular portion of the tunica vaginalis or canal of Nuck, and congenital defects of the abdominal parietes. 2. Acquired elongation or downward displacement of the attach- ment of the mesentery. 3. A relaxed condition of the abdominal muscles, such as is induced by pregnancy, and by rapid emacia- tion in persons previously stout. 4. The rapid formation of fat in the omentum or mesentery. 5. Any injury or operation that has weakened the abdominal walls. 6. Occupations involving severe muscular exertion ; and 7. The male sex, inasmuch as men are more subject to the exciting causes. The exciting causes are such as produce a diminution in the size of the abdominal cavity by the contraction of the muscles forming its walls and the consequent compression of the contained viscera. They may be divided into those that act suddenly, and those that act slowly. Amongst the former may be mentioned sudden and violent exertions, straining at stool, lifting heavy weights, etc. x'\mongst the latter, continual straining, as from stricture of the urethra, enlarged prostate, phimosis, or a narrow meatus, constant cough- ing occasioned by chronic bronchitis and emphysema, etc. Anatomy of hernia. — As the viscus is protruded through the abdominal or pelvic parietes, whether at one of the so-called rings or elsewhere, it generally forces that portion of the parietal peritoneum which lies over the aperture, before it in the form of a pouch. When it escapes at the internal inguinal ring, how- ever, instead of thus protruding the peritoneum in front of it, it may pass into the tubular prolongation of peritoneum which naturally descends in front of the testicle in the foetus, and which from some cause has ren)ained unobliterated. The pouch of peritoneum in which the protruded viscus is thus enclosed is called the sac. In the former case it is spoken of as an acquired, in the latter as a co7igeniial sac. In some forms of caecal hernia the sac may be incomplete, /. e., the viscus may be only covered by peritoneum m front, and in contact with the tissues behind ; and in diaphragmatic hernia, and in hernia following a wound of the abdominal walls where there is no parietal peritoneum cover- ing the aperture, there will be no sac. The protruded viscus enclosed in its peritoneal sac forms a swelling surrounded by the tissues of the part into which it has escaped. The tissues super- ficial to it, i. e., between the sac and the skin, form what are called its coverings. We have to consider, therefore, i, the sac, 2, its contents, and 3, its coverings. REDUCIBLE HERKIA. 62 1 1. The sac is said to consist of a body, neck and mouth, terms which sufficiently explain themselves. It is at first thin and membraneous, resembling the peritoneum ; but in old herni^e may become thickened and indiur.ttd, cr else, as for example in um- bilical hernia, attenuated or in plue.s absorbed. It is usually globular or pyriform, but may take almost any shape. Thus it may be fusiform, hour-glass-like, or divided by adhesions into two parts, the lower part, perhaps, containing fluid and forming what is known as a hydrocele of the sac. The neck is at first generally slightly puckered, but as the result of inflammatory con- solidation becomes in old hernise smooth, thickened, and often indurated. The mouth may be wide and expanded, or, in the case of congenital herniae, in which the neck is frequently elon- gated, narrow and contracted. 2. The contents of the sac may be intestine alone {etitej'ocele) ; or omentum alone {epiplocele) ; or both, the omentum then gen- erally descending in front of the intestine {entero-epiplocele^ , or more rarely the intestine in front of the omentum i^epiplo-ente7-o- cele). In exceptional instances the bladder, the ovaries, and other of the abdominal or pelvic viscera, have been met with in the sac. The small intestine, and especially a portion of the lower three feet of the ileum, most frequently descends. When the large intestine descends it is generally the caecum ; but any portion of the small or large may do so. There may be but a small knuckle of intestine in the sac, or a part only of its calibre ; but when once a portion has escaped there is generally a tendency for more to follow, and in old hernise to the extent of several inches or even feet. The protruded intestine and mesentery in long-standing cases become hypervascular and thickened, and the omentum hypertrophied and matted together. A small quantity of serous fluid is also generally found in the sac, and in rare in- stances loose or attached fibrinous bodies somewhat similar to those met with in bursse. Where the neck of the sac has become obhterated by the long wearing of a truss, the sac has been found filled entirely with serous fluid, thus forming a cyst. 3. The coverings of the sac necessarily vary according to the situation of the hernia. They will be enumerated under each special form, and little more need be said about them here further than that they often become thickened, blended together, thinned, or absorbed, so that in actual practice they can seldom be demonstrated. The conditions of a hernia. — A hernia may be : ( i ) re- ducible ; (2) irreducible; (3) strangulated; (4) incarcerated, and (5) inflamed. I. A reducible hernia is one that can be returned into the 62 2 DISEASES OF REGIONS. abdominal cavaty ; /. e., it either goes back when the patient Hes down ; or it can be made to do so by the patient himself, or by the Surgeon making pressure upon it in a suitable direction. The sac, except perhaps in quite recent cases, cannot be put back into the abdomen in consequence of its adhesions to the surrounding tissues, but remains empty /// situ. Symptoms. — At first there may be a mere fulness or protrusion, commonly at one of the abdominal rings ; the protrusion becomes more prominent when the patient stands up, strains, or coughs, but it completely disappears on his lying down. If neglected it gradually increases in size, forming a prominent non-translucent swelling, in which a distinct impulse is felt on coughing. If the hernia contains intestine {enterocele), it will be tense and elastic, and resonant on percussion ; whilst a peculiar gurgling is heard from the displacement of gas and fluid on returning it into the abdomen. If, on the contrary, it contains omentum {epip/ocele) , it will be dull to percussion, doughy and inelastic, or hard and resisting, and lobulated, whilst the characteristic gurgUng is not heard on returning it into the abdomen. The diagnosis will be given under the head of Special Hernice, as it is from other diseases of each special region that a diagnosis has to be made. The treatment may be palliative or radical. The palliative treatment consists in reducing the hernia and applying some form of truss. A pad and spica bandage should be applied (Fig. 293), till a truss can be procured. The form of truss will vary accord- ing to the position, size, etc., of the hernia. Fig. 294 is an inguinal truss of the ordinary shape, and may be distinguished from a femoral (Fig. 295), by the pad of the latter being placed more vertically. Fig. 296 is an umbilical truss. In measuring for a truss the following notes should be taken and sent to the maker: — i. The dimensions round the pelvis midway between the crest of the ilium and the great trochanter. 2. The kind of hernia. 3 The side on which it is situated. 4. The size of the ring. 5. The age and sex of the patient. 6. The strength of the spring required. The truss should be worn constantly, and never on any excuse be left off. A lighter truss may be provided for the night, and one covered with India rubber or made of vulcanite for the bath. The /'a^-Z/Vrt;/ treatment consists in reducing the hernia, and in some way obliterating the sac and closing the canal and ring. In young children the removal of the cause, as phimosis, etc., and the wearing of a truss may do this ; but in older children, and in adults, the ring is usually too large and otherwise altered for the hernia to be thus cured, and some further procedure, if thought advisable, must be undertaken. REDUCIBLE HERNIA. 623 Radical Ctire of Hernia. — The methods that have been prac- tised for the radical cure of hernia are very numerous. Some of them, as Wood's, Spanton's, Warren's and Heaton's are practically obsolete, and will be here no longer described. The more Fig. 293. Fig. 294. Inguinal truss. Spica bandage for the groin. (Brj-- ant's Surgery.) Fig. 295. Fig. 2q5. Umbilical truss. Femoral truss. modern methods are all founded, to a greater or less extent, on Banks' operation, which consists in cutting away the sac after ligature of its neck and sewing up the ring. This simple pro- cedure, though often sufficient to insure a radical cure, is some- times followed by a return of the hernia ; hence more elaborate operations have been introduced. Most of them are only appli- 624 DISEASES OF REGIONS. cable to inguinal hernia. Sufificient time has hardly elapsed to enable one to say which of the methods are the most efficient, or to what special form of inguinal hernia the one or the other method may be best adapted. The methods I have employed myself of late are a modified Banks' operation for simple cases, and a modified Bassini's for cases in which the external ring is very large and the canal more or less obliterated. (i) Macewen's Method. — Macewen dissects up the sac and frees it as far as the internal abdominal ring by introducing his finger along the inguinal canal. The internal ring having been reached, the peritoneum is separated for '^i'^- =9-- about half an inch from the whole of the abdominal aspect of the circumference of the ring. The external oblique is not divided. A stitch is firmly secured to the distal extremity of the sac and a needle carrying the silk is passed in a proximal direction several times through both layers S of the sac, so that when pulled upon the sac Method of folding up the sac bccomes folded upou itself like a curtain in Macewen's method of /t-.- \ n-.! ji • ii -u 1 i. radical cure of hernia, s. (Fig. 297). The nccdlc IS then brought Sac. R. Internal abdom- q^j through the anterior abdominal wall inal ring, p, P. Parietal . ° . . 1 1 r i 1 1 peritoneum. just abovc the mtcmal rmg, and the folded sac having been pushed through the ring in the transversalis fascia is secured there by the silk suture. The external abdominal ring is then laced up and the skin-incision closed in the usual way. (2) Stanmore Bishop's Method. — Stanmore Bishop dissects up the sac and frees it from the surrounding structures as far as the internal abdominal ring. The parietal peritoneum is then sepa- rated for about half an inch from the whole of the abdominal aspect of the circumference of the ring. A stout piece of aseptic silk armed at either end with a large curved Hagedorn's needle is taken, and commencing at the distal extremity of the sac, one needle is made to pass in a proximal direction along the outer side of the wall of the sac, after the fashion of hemming, as far as the internal ring, and the other needle utilized in a like manner on the inner side (Fig. 298). Both needles are then brought out through the abdominal wall, on the outer and inner sides of the ring respectively. In this way the sac is completely hemmed round with a thread of silk, and when traction is made on the ends of the silk the sac is puckered up in a mass (Fig. 299). Having done this, the sac is invaginated with the tip of the index finger and pushed through the internal ring while traction is still being made. The silk is then tied, the internal ring thereby being closed and REDUCIBLE HERNIA. 625 the puckered invaginated sac forming a button-like projection on the abdominal aspect of the ring (Fig. 300). Fig. 299. Fig. 298. Method of treating the sac in Bishop's Method for Radical Cure of Hernia, s. Sac. R. In- ternal abdominal ring. P p. Parietal peritoneum. In Fig. 298 the sac is hemmed round with a silk ligature. In Fig. 299 the sac is puckered upon outer side of ring. In Fig. 300 the puckered sac is invaginated, and forms a button-like projection on abdominal aspect of ring. The silk ligature in all three figures has a needle at each end. (3) Barker's Method. — Barker dissects out only the neck of the sac, ligatures it, and cuts it through half an inch below the ligature. The scrotal portion of the sac is left /;? situ. The neck of the sac is fixed to the abdominal wall by the same ligature that closes the internal ring. The external abdominal ring is next laced up as usual. (4) BalPs Method. — Ball, of Dublin, after dissecting out the sac, recommends torsion or twisting before ligaturing the neck and cutting off the body of the sac. (5) Halsted's Method. — Halsted, of Baltimore, makes an inci- sion parallel to Poupart's hgament from the anterior superior spine of the iliam to the pubic spine. He divides the aponeiirosis of the external oblique the whole length of the skin incision. The sac is then dissected up and sutured by quilted sutures at as high a level as possible, and then the lower portion is cut away. The spermatic cord is now transplanted to the outer angle of the wound in the external oblique, and the rent in the aponeurosis sutured in its entire extent beneath the cord. In this way the cord takes a subcutaneous course and a new inguinal canal has been fashioned, which passes outwards and upwards from the internal abdominal ring. 27 d26 DISEASES OF REGIONS. Fig. 301. (6) McBurnefs Method. — McBurney, of New York, treats the wound by open incision after dissecting out and ligaturing the sac. He endeavors to keep the wound an open one by turning in the integument and suturingit to the deep fascia. He then packs it with iodoform gauze and allows the wound to granulate. The wound takes from three to six weeks to heal, but the firm scar left completely obliterates the inguinal canal. (7 ) Bassi?ii's Method {s/ightly modified). — An incision is made from the internal to the exter- nal ring parallel to and about ^-inch above Poupart's liga- ment. The external ring having been defined, the aponeurosis of the external oblique is divided from the apex of the ring the whole length of the skin- incision. The sac is next defined, cleared with the finger as high as the internal ring, the neck ligatured and the body cut away. The cord is now lifted out of the inguinal canal and held aside by a silk ligature passed lightly beneath it (Fig. 301, b). The internal oblique, with the transversalis and trans- versalis fascia, is next separated from the aponeurosis of the ex- ternal oblique and from the peritoneum, and sewn by four or five silk sutures to the deep internal surface of Poupart's ligament, which should have been previously defined. In PMg. 301 two of the sutures (d, e) are seen in situ. When all the sutures have been passed they are tied beneath the cord and thus ]nill the conjoined tendon of the internal oblicjue and transversalis with- the transversalis fascia firmly downwards and outwards, and thus form a firm pos- terior wall to the inguinal canal. The aponeurosis is now united by a continuous suture (Fig. 301, H),and the skin-wound closed. (8) Radical Cure of Fc7noi-al Hernia. — Make an incision over the hernia from a little above Poupart's ligament vertically down- wards about 2j/ inches. Having freed the sac, opened it, and Method of applying the sutures in the radical cure of hernia by the modified . Bassini Method. A. Aponeurosis of external ob- lique turned down, n. .Silkligature holding spermatic cord F aside, c. Director re- tracting the upper margin of the divided aponeurosis of the external oblique. D and E. Two of the deep sutures passed through the deep internal surface of Poupart's liga- ment and conjoined tendon, c. The con- joined tendon of the internal oblique and transversalis and transversalis fascia. H. Continuous suture for sewing up ihe divided aponeurosis of the external oblique. I, i. The skin, in which some of the spots are in- dicated at which the skin sutures should be passed. • IRREDUCIBLE HERNIA. 627 returned its contents, clear the neck with the finger passed up the femoral canal Ligature the neck ; cut away the body of the sac, and with the aid of Macewen's needles carry the two ends of the ligature which has been tied round the neck up the femoral canal anterior to the peritoneum, and make them emerge through the abdominal wall just above the round ligament or spermatic cord, about yl of an inch apart. On tying the two ends of the liga- ture the sac will be drawn well behind the abdominal parietes. Whilst passing the ligatures protect the femoral vein with the finger, and draw up the skin incision that the needles may emerge in the wound. On letting go the skin, the knot of the hgature will be covered by it. Next sew Hey's ligament to Cooper's liga- ment (a band of strong ligamentous fibres running along the pec- tineal ridge of the pubes) by one or two silk sutures, thus closing the femoral canal. (9) The radical cu7-e of U77ibilical hernia may be done by re- moving the sac, refreshing the edges of the ring, and bringing the wound together with the peritoneal surfaces in contact ; or if the ring is very large and its margins are dense, then a large flange stitch may be used (Fig. 302), as practised by Greig Sm.ith. The cicatricial tissue is divided all round the ring at its free margin, down to the rectus muscle, and the sutures passed first through the upper fibrous edge, then through the rectus, then through the lower fibrous edge on one side of the wound, and then in the re- verse order through the tissues on the other side. 2. An IRREDUCIBLE HERNIA is ouc that cannot be returned into the abdomen. The causes of the irreducibility, which are many, may be con- veniently classified according as the impediment to the return of the contents of the sac exists : i. Outside the sac, from inflamma- tory thickening and contraction of the tissues forming the ring or other aperture through which the hernia has escaped. 2. In the sac walls, from the inflammatory thickening and contraction, and from elongation of the neck of the sac. 3. Inside the sac, from («) the great bulk of the intestine or omentum due to increased growth subsequent to their descent ; {b) constriction of the omentum at the situation of the ring and expansion of the lower part ; (r) adhesion of the intestine or omentum to the sac, or to one another ; (<•/) bands of adhesions stretching across the sac, and so confining a loop of intestine or knuckle of omentum ; (^) a collection of fluid in the sac; (/) a portion of intestine (as the caecum) having descended uncovered with peritoneum on one aspect, the uncovered portion forming adhesions with the tissues around it where the sac is absent. The symptoms are similar to those of the reducible form, save 628 DISEASE? OF REGIONS. that the hernia cannot be completely reduced. Thus, there is impulse on coughing, non-translucency, and when it contains in- testine, gurgling on handling, and resonance on percussion. It Fig. 302. Greig Smith's method of performing the radical cure ol umbilical hernia. A. Tran.sverse sec- tion through hernia and parietcs, showing sac, contents, ring, and lines of incision, i N. Intestine, o M. Omentum, s K. Skin. F. Fascia, thickened at margin of ring. M. Rec- tus muscle, p. Peritoneum, i. Incision through the skin of sac, which is continued along the subperitoneal tissue to margin of rmg. 2. Same on opposite side. Between i and 2 skin and sac are removed on free surface, and sac on deep aspect. 3 and 4. Incisions car- ried deeply through thickened fascia round umbilical ring 10 expose recti. H. Gut returned, omentum removed, superfluous skin and sac removed, sutures placed, incisions in fascia opened up and recti exposed. References same as in A. C. Sutures tied, .skin .suture to one side of parietal line of junction. D. Bird's-eye-view showing double set of sutures around umbilical ring and cutaneous wound. I, From a drawing by .Mr. Greig Smith.) i.s, moreover, often attended with dragging or colicky pains and dyspeptic symptoms. When its contents are both intestine and omentum, the intestine can sometimes be returned. A consid- eration of the above signs should serve to distinguish it from a hydrocele extending high up the cord, with which it is perhaps STRAJS'GULATED HERNIA. ' 629 most likely to be confounded. An irreducible hernia often attains a large size, and is not only on this account a constant source of annoyance to the patient, but is also one of danger, as there is al- ways a risk of its becoming obstructed, strangulated, or inflamed, or ruptured by accidental blows, etc. The treatment may be directed to one of two ends : i, to protect the hernia from injury and prevent it from getting bigger by the descent of more intes- tine or omentum ; and 2, if possible, to render it reducible, or better, if the patient's general state of health is favorable, to cure it, by one of the radical o|)erations already described. For the first purpose the patient should wear a bag truss (Fig. 303), or the lace-up Fig. 30^!. truss. Trusses are often difficult to ad- just. Under such circumstances a cast of the parts should be taken in plaster- of-Faris, and to this any instrument- maker can then accurately mould the truss. When the patient will submit, an attempt may be made to convert the hernia into a reducible one ; and if per- \ severed in will frequently, especially in Bag truss for irreducible hernia. recent hernige, be successful. The patient should maintain the horizontal position, the diet should be re- stricted, saline purgatives given, and ice occasionally applied to the part, or continuous pressure may be kept on the hernia by means of the hinge- cup truss. This treatment will, of course, only be successful when the irreducibility depends upon remov- able causes, such as an increase in the bulk of the omentum or intestine. When due to adhesions and the like, it cannot be thus overcome, though with the use of the hinge-cup truss ad- hesions if not too firni may gradually elongate and disappear. Seeing, however, that strangulation may occur notwithstanding the use of a truss, other things being equal, I always myself advise a radical cure. 3. Str-angulated hernia. — This form of hernia is one in which the protruded portion of intestine or omentum is so tightly gripped, that not only is its return into the abdomen prevented, but the circulation through its blood-vessels is so impeded that congestion, followed by inflammation and gangrene, speedily en- sues, if the strangulation is not soon relieved. Causes. — I. The sudden forcing of intestine or omentum through a ring or aperture so small that it is tightly gripped from the moment of its descent. This is usually the cause of strangu- lation in a recent hernia or in an old hernia which has suddenly descended through the patient's neglect to put on his truss. 2. 630 DISEASES OF REGIONS. The increase of bulk in the hernia subsequent to its descent, and its consequent constriction where it passes through the aperture or ring. This is usually the cause of strangulation in irreducible herniae, or in hernife that have not been kept up by a truss. Such an increase in bulk may be induced by: {a) the sudden pro- trusion of a fresh portion of omentum or intestine on the top of that already down ; (^) the swelling of the intestine from catarrhal inflammation of the mucous membrane, or from its becoming ob- structed by faeces or flatus ; and (r) congestion and inflammation of the omentum. The sea/ of constriction, or as it is technically called the stricture, is generally either (i) outside the sac, i. e., at one of the tendinous rings, or other aperture through which the hernia has passed^ or (2) i?i the neck of the sack itself; whilst (3) in very rare instances, it may be inside the sac, the intestine having slipped through a hole in the omentum, or become entangled by a band of adhesions. Mechanism of strangulation. — The compression of the veins at the seat of stricture impedes the return of venous blood from the protruding portion of intestine or omentum, and the congestion, causing compression of the arteries, ultimately leads to the com- plete arrest of the circulation, and gangrene finally ensues. The congestion, moreover, induces paralysis of the muscular coat and consequent cessation of its peristaltic action and the onward flow of the intestinal contents. For strangulation to occur it is not necessary for the whole circumference of the bowel to be included in the stricture. An inclusion of only a small portion of its cir- cumference (Richter's hernia, sometimes incorrectly called Littre's hernia), in consequence of the venous congestion and subsequent inflammation which it induces, is sufficient. Indeed, symptoms of strangulation are said to occur when omentum only is contained in the hernia, a fact somewhat difficult to explain, as constriction of omentum by a tight ligature certainly gives rise to no symp- toms. It is possible that in these cases the signs of strangulation have depended on reflex irritation of the omental nerves, or on a small knuckle of intestine having been strangulated at the neck of the sac and slipped back unperceived. That strangulation may produce a severe impression on the nerves is evidenced by the pain reflected to the umbilicus, and by the general nervous symptoms. Patholoi^ical condition (f the strangulated part. — When the con- striction is very tight the circulation may be completely arrested, and gangrene ensue in a few hours, liut as a rule the arrest is only partial, and the gangrene is preceded by congestion and inflammation. 'I'he intestine at first appears red and, perhaps. STRANGULATED HERNIA. 63 1 slightly swollen, but not otherwise altered, whilst clear serous fluid in greater or less quantity is poured out between it and the sac. It next assumes a mulberry color, and as the congestion increases it becomes darker and darker, and finally black or ash- gray. At the same time it becomes more swollen, and loses its bright shining appearance, becoming sticky, then doughy in con- sistency, and pitting on pressure, whilst the fluid gets darker and turbid, and feculent in odor ; finally the intestine sloughs, and its contents are extravasated into the sac. Sloughing or ulceration frequently begins at the seat of stricture, and in the mucous coat, where, even at an early stage, an impression of the stricture is often seen. The omentum undergoes similar changes, passing gradually into a state of gangrene. The intestine above the stran- gulated portion for a variable distance is congested and distended with faecal matter, whilst that below is empty and contracted, but otherwise natural. Simultaneously with these changes a local peritonitis is set up about the neck of the sac, gluing the intestine to the peritoneum, so that as a rule there is no extravasation into the peritoneal cavity. The sac becomes inflamed, a faecal abscess is formed, and, if the patient survives, opens on the surface, leav- ing him with a faecal fistula. In other cases general peritonitis supervenes, or the mtestine gives way above the stricture, and so peritonitis results. The symptoms are local and general. Local symptoms. — The hernia, if previously reducible, is no longer so ; it becomes tender or painful on handling, tense, and often tympanitic ; and the im- pulse 071 coughing is lost. Pain may be present in the hernia, but is generally referred to the region of the umbilicus. The skin is usually natural, but where gangrene has occurred it may become mottled, or brick-dust red, and emphysematous, and exhale a faecal odor. Cessation of pain may then occur, but is a delusive sign. The general symptoms are those of intestinal obstruction, the two chief being vomiting and constipation. The vomiting is of a peculiar gushing character, with httle or no retching. The vomit at first consists of the contents of the stomach, but soon becomes bile-stained, and finally fascal, /. '.) Uric acid crystals. (Bryant's Surgery.) of the presence of uric acid, as well as of the urates, are : i. Rapid tissue waste, as in fevers; 2. Over-indulgence in animal Fig. 324. Fig. 325. Crystals of oxalate of lime. (Bryant's Surgery.) Phosphate of lime. (Br>'ant's Surgery.) food; 3. Dyspepsia ; 4. Congestion of the kidney ; 5. Gout ; and 6. Deficient action of the skin. 676 DISEASES OF REGIONS. 3. The oxalate of lime is a crystalline deposit and assumes two forms, the octahedral and the dumb-bell crystals (Fig. 324). On holding the urine up to the light the crystals as minute shining particles are seen in it. The causes are : i. Nervous exhaustion from overwork or sexual excesses. 2. Dyspepsia induced by sac- charine food, excess of alcohol, or vegetable diet. 4. Phosphatic deposits occur in three forms, {a) phosphate of lime, {b) phosphate of ammonia and magnesia, or triple phos- phates, {c) the two former mixed, or the fusible phosphates, i^d) Phosphate of lime forms a white cloud or amorphous deposit of pale granules or spheroids, two of which adhering form the so-called false dumb-bell; or a crystalline deposit of six-sided prisms col- lected into sheaths or bundles (Fig. 325). It may be mistaken for albumen, or when in considerable quantites for pus or mucus. The urine is usually alkaline, but may be neutral or even feebly acid. (^) The ammo- '^'<^- 326. nio-maguesiiim phosphates occur in the form of large triangular prisms with truncated extremities ; as four-sided prisms; as six- sided plates ; and as foli- aceous stellar prisms on adding ammonia (Fig. 326). The urine is nat- ural in color, neutral or alkaline, with a foetid am- moniacal odor. Causes. — Phosphatic deposits are due to local disease or in- jury of the urinary or- gans, such as may be in- duced by spinal mischief, a foreign body in the bladder, etc. The mu- cus or bacteria in the bladder decomposes the urea into carbonate of ammonia, which converts the soluble acid phosphates into insoluble alkaline phosphates. Carbonate of lime, cystic oxide, and itric oxide, are too rare to require description. B. 7he organized deposits. — To these belong pus, blood, mucus, epithelium, renal casts, spermatozoa, and fungi. P//s occurs as a thick sediment, and may be recognized by the urine containing albumen, and by the microscopical api)earance of the pus-corpus- cles (p. 37). It may be due to cystitis, pyelitis, gonorrhoea, leu- Phosphates of ammonia and magnesia (triple phos phalesj. (Bryant's Surgery.) THE OXALATE OF LIME, OR MULBERRV CALCULL 677 corrhoea, and abscess in any part of the urinary tract. Urine containing 7uucus becomes gelatinous and ropy on adding liquor potassse. Blood may be recognized by the urine being smoky or red, by the ozonic ether test, and by the microscope and spectro- scope. See Hcematuria (p. 69S). Epithelium, renal casts, sper- matozoa, diudi fungi may be detected by the microscope. Urinary calculi are commonly spoken of as renal, vesical and prostatic, according as they occur in the kidney, bladder or pros- tate. Renal calculi are formed in the kidney, and hav^e already been described (p. 670). Prostatic calculi are formed in the racemose glands of the prostate, and will be further referred to under diseases of that organ (p. 702). Vesical calculi may originate in the bladder, or, as is more commonly the case, in the kidney, whence they pass into the bladder, and there increase in size by the excessive deposit upon them of the same or other of the urinary salts. The calculi most frequently met with in this situation are (i) the uric acid, (2) the oxalate of lime, and (3) the fusible or mixed phosphates. The rarer forms are (4) the urate of ammonia ; (5) the cystic oxide, or cystine ; (6) the phos- phate of lime ; (7) the phosphate of ammonia and magnesia, or triple phosphate; (8) the carbonate of lime; (9) the xanthic or uric oxide ; ( 1 o) the fibrinous ; ( 1 1 ) the blood ; (12) the uro- stealith; and (13) the silicious. The last seven being exceedingly rare, are not described. 1. The uric acid calculi are the most common. They are gen- erally of moderate size, oval, and laterally compressed, of a nut- brown color, smooth or finely granular, moderately heavy and hard, and laminated on section. They are completely destroyed in the blow-pipe flame, giving off a smell of burnt feathers. They are insoluble in weak hydrochloric acid, but soluble in warm alkahes. When treated by nitric acid and evaporated to dryness, on the addition of a drop of ammonia a purple color is pro- duced {murexide test). The nucleus is generally composed of uric acid, sometimes of oxalate of lime, and is generally formed in the kidney. These calcuh occur most frequently m youth and middle age. 2. The oxalate of lime, or mulberry calculi (Figs. 327, 328), as they are often called from their resemblance, when first re- moved, covered with blood from the bladder, to a mulberr}% are generally of moderate size, globular in shape, usually of a dark- brown or mahogany color, rough and tuberculated, very hard and heavy, and crystalline on section. They are only partially de- stroyed in the blow-pipe flame, the residue being alkaline and effervescing with an acid. They are insoluble in acetic acid, but soluble in hydrochloric acid. The nucleus is generally composed 678 DISEASES OF REGIONS. Oxalate of lime calculus. Fig. 328. of oxalate of lime, but may consist of uric acid or urate of am- monia. The nucleus is usually formed in the kidney. These cal- culi are most frequent in middle a^e. 3. The phosphatic calculi are of three kinds : (a) the phos- phate of lime or earthy phosphate ; (^) the ammonio-magnesian or triple phosphate, and (r) the phos- phate of lime with the ammonio-magne- sian phosphate, the mixed or fusible phosphate. Of these the last is the only common form. It is usually of large size and of white color, smooth, soft, friable, earthy and laminated on section, and of irregular shape, taking that of the nucleus on which it is formed ; it fuses when heated in the blow-pipe flame ; is insolu- ble in warm alkalies, but is soluble in ace- tic acid. The nucleus is composed of uric acid, oxalate of lime, or of some for- eign body other than a calculus, as a piece of catheter, hair-pin, blood or fibrin. It occurs most frequently in the later p>er!ods of life, and is then generally pro- duced as follows : A calculus or other for- eign body irritates the mucous membrane of the bladder, and a secretion of mucus is, in consequence, poured out. This mucus decomposes the urea contained in the urine into carbonate of ammonia and water. The carbonate of ammonia unites with the acid phosphates, and an insoluble mixed phosphate of ammonia magnesia and lime is thrown down and deposited on the foreign body. Hence these calculi are only met with in alkaline conditions of the urine. Although calculi may be chiefly composed of one constituent, they are more often composed of several, which may be arranged in alternate layers {allernatini:^ calculus). The formation of these layers is due to the varying state of the patient's health and of the condition of the mucous membrane of the bladder. Section of o.xalate of lime calculus. DISEASES OF THE H LADDER. Extroversion or ectopia vesic/e is the mnlformation in which, in consequence of an arrest in the develoi)ment of the anterior wall of the bladder and the corresponding part of the abdominal parietes, the posterior wall of the bladder is pushed forward by the pressure of the abdominal viscera, and protrudes as a red ACUTE CYSTITIS. 679 velvety tumor. It is associated with epispadias or absence of the upper wall of the urethra, and with failure of union of the pubic bones at the symphysis. The testicles are frequently retained in folds like the labia on either side. It is attended with extreme discomfort from the constant dribbling away of the urine from the mouths of the ureters, which can be seen on the surface of the tumor. Treatment. — Many operations having for their object the closing in of the bladder by flaps of skin taken from the adjacent abdominal wall, have been performed for the relief or cure of the deformity. Various attempts have also been made to turn the ureters into the colon or rectum, but without success. Recently Trendelenberg has succeeded in reducing the gap between the pubic bones by separating the sacro-iliac synchondroses, so that he was enabled at a subsequent sitting to bring the margins of the mucous surface of the bladder in contact, and then unite them by a plastic operation. The newly-formed bladder is in this way lined with mucous membrane instead of having its front wall closed in by skin. The objection to the skin flap is the growth of hair into the bladder at puberty and its incrustation with phos- phates. If no operation is undertaken a properly-shaped urinal must be worn. Cystitis, or Inflammation of the Bladder, may vary from the mildest catarrh to the most intense inflammation, involving not only the mucous membrane but the other coats of the organ as well. For the purpose of description, however, it may be divided into the Acute and Chronic. Acute cystitis. Causes. — In its most intense form it is nearly always the result of injury or operation, as the passage of instru- ments, irritation of sharp fragments of a crushed calculus, etc. In its milder forms it may be due to the extension of inflammation from the urethra as in gonorrhoea, or from the ureters in cal- culous pyelitis ; to the exhibition of certain medicines, as cantharides ; and occasionally in gouty subjects to exposure to cold. Symptoms. — In the acutest forms there is intense pain, and strangury, /. e., a continual desire to void urine, which is passed drop by drop in a spasmodic manner; whilst there is high fever, rapidly running into a typhoid type. In the less acute or more common forms micturition is still very frequent, with increased pain, as soon as a little urine has collected in the bladder, in con- sequence of the stretching of the inflamed mucous membrane. The urine is scanty, high-colored, often blood-stained, and mixed with mucus and pus. The fever, though generally high, is less marked than in the acuter cases, and may be of a mere transitory character. 68o DISEASES OF REGIONS. Pathology. — In the milder forms the inflammation is limited to the neck of the bladder and to the mucous membrane only. In the worst forms it involves the whole bladder, and extends to the muscular or even the peritoneal coat. It may terminate in i, resolution ; 2, chronic cystitis ; 3, ulceration or gangrene of the m.ucous membrane ; 4, abscess in the walls of the bladder ; 5, in- flammation of the kidneys, or more rarely of the peritoneum ; and 6, sapr^emia, produced by the absorption of the products of the decomposing urine. Treatvient. — The cause, if possible, should be removed. Thus, if there are fragments of calculus in the bladder, they should at once be extracted by the large evacuating catheter, any that can- not be got away being crushed ; or perhaps better, the bladder may be opened by a median incision in the perineum and thor- oughly washed out. If a catheter has been tied in, it should at once be withdrawn. Hot sitz-baths should be given night and morning, leeches applied to the perineum, suppositories of morphia placed in the rectum, and salicylate of soda, hyoscyamus, and alkalies if the urine be acid, administered to relieve strang- ury. AH stimulants should be avoided, the diet restricted to milk, and the bladder washed out with hot water, or when the urine is decomposed, with a weak antiseptic lotion as boric acid, salol, etc. If washing out increases the irritation, the blad- der in severe cases should be drained by an incision in the peri- neum. Chronic cystitis is much more frequent than the acute variety, and in its mildest form is known as catarrh of the bladder. Causes. — It may be a sequel to an acute attack ; or it may be chronic from the commencement, and may then be due to a stone or other foreign body or a growth in the bladder, obstruction to the urinary outflow, as from an enlarged prostate or stricture of the urethra, the extension of gonorrhoea, paralysis, over-distension or atony of the bladder, or the spread of inflammation from the neighboring organs. Ihe symptoms are similar to those of acute cystitis, but are much milder in intensity. Thus, there is increased frequency of micturition, the patient, perhaps, having to make water every hour or half-hour, the desire to do so being generally so urgent that he is unable to control it. This, as in the acute variety, is due to the stretching of the inflamed mucous membrane as soon as a few ounces of urine collect. The pain usually ceases immediately the bladder is relieved. The urine is characteristic ; it generally contains large quantities of ropy mucus and pus, which form, on standing, a distinct layer at the bottom of the containing vessel. It is often alkaline, and sometimes highly ammoniacal and offen- ANTONY AND PARALYSIS OF THE BLADDER. 68 1 sive from the decomposition of the urea into carbonate of ammo- nia. This decomposition is brought about by fermentation, prob- ably set up by the presence of micro-organisms {micrococcus uircz) that have gained admission either by the use of a contaminated catheter, or by making their way along the stringy mucus that may hang about the urethra. Pathology. — The mucous membrane is thickened, velvety, mottled with patches of a dark slate or red color, and may be covered with muco-pus and sometimes with a deposit of phosphates, or it may even, in places, be destroyed by ulceration. The muscular coat, where there has been obstruction to the outflow, becomes thickened and fasciculated, the hyper- trophied fibres giving the interior of the bladder a columnar and rugose appearance. In places the mucous membrane may pro- trude between the fasciculi of the muscular coat, forming sacculi which may become receptacles for urine, and in which calculi may form. If the cystitis is allowed to continue the kidneys may sub- sequently become affected. Treatment. — As in the acute form the cause, as stricture, stone, etc., must first be removed, as where this is impracticable the treat- ment at best can only be palliative. The diet should be unstim- ulating, and alcohol in any form, as a rule, forbidden. A purely milk diet is at times most successful. Internally such medicines as buchu, uva ursi, balsam of copaiva, salol and chlorate of potash should be given where thick ropy mucus is passed with the urine ; and benzoic acid, which in its passage through the system is con- verted into hippuric acid, may be tried when the urine is alkaline. Locally, the bladder should be washed out twice a day with some antiseptic solution, as boric acid, nitric acid, corrosive sublimate, quinine, etc. The best results are sometimes obtained from water as hot as can be borne. Great care should be taken that all instruments are rendered thoroughly aseptic before use. In severe cases, where other means have failed, the bladder should be placed at rest by perineal cystotomy and subsequent drainage for some weeks. Irritaf.iiity of the bladder, by which is meant a too frequent passing of water, is often spoken of as a disease ; but is no more so than is pain, since it is is only a symptom either of disease of the urinary organs, or of some general state of the system, as hysteria, Bright's disease, etc. The cause should be sought and treated. Inversion of the bladder, and hernia of the bladder, are both very rare, and are not here described. Atony and paralysis of the bladder. Both these terms are applied to a want of sufficient contractile power in the muscular coat to expel the contents of the bladder ; but in atony the want of 682 DISE.ASES OF REGIONS. power is the result of loss of tone in the muscular fibres, while paj-alysis is due to the failure of nervous influence. Eoth condi- tions must be distmguished from the mere inability of the blad- der to empty itself on account of obstruction to its outlet. (See Retention,') Atony may be due to — i. Simple over-distension, consequent upon the patient having voluntarily or compulsorily held his urine for too long a period, whereby the muscular fibres are over- stretched and unable to recover themselves. 2. It may be the result of gradual distension owing to enlarged prostate or stric- ture. In consequence of the obstruction, the bladder does not empty itself, but some urine remains after every act of micturi- tion ; the amount retained gradually increases, the bladder be- comes distended, and its fibres, if the patient is old, become stretched, and lose their tone, instead of becoming hypertrophied, as commonly happens in a young and healthy person. 3. Again, atony may be due to cystitis, owing to the inflammation having spread to the muscular coat, which then undergoes fibroid or fatty changes. Symptoms. — The patient complains of inability to hold his urine, or that it constantly dribbles away, or that he has to pass it very frequently. The involuntary flow occurs at first during sleep ; afterwards on any exertion causing contraction of the abdominal muscles. These symptoms, although often improperly spoken of as incontinence, are really those of retention, the blad- der being fully distended, but unable to empty itself, and the ex- cess flowing involuntarily away. The treatment consists in passing a catheter at regular inter- vals, and as often as may be necessary to completely empty the bladder; whilst, in the meantime, the condition leading to the atony must be treated by appropriate means. Thus, if the result of over-distension, strychnine and galvanism may be tried ; if the result of gradual distension from enlarged prostate or stricture, these conditions must be treated in the way mentioned under their respective heads. In both paralysis and atony, cystitis, dilatation of the ureters, pyelitis and disorganization of the kidney rapidly ensue if the cause of the bladder trouble cannot be relieved. True paralysis of the bladder is nearly always the result of disease or injury of the brain or spinal cord, and is not met with except in general paralysis. 'J'he bladder being paralyzed cannot empty itself, and becomes distended as in atony ; and when it can hold no more, the excess overflows through the sphincter, which is also j)aralyzecl. Rejlex paralysis, however, often occurs after an injury or surgical operation, especially that THE TUMORS MET IN THE BLADDER. 683 for haemorrhoids. The local treaiment consists in the regular passage of a catheter two or three times daily. Tubercle of the bladder is rare, and is nearly always secondary to tubercle in other parts of the genito-urinary tract. There is pain, haemorrhage, and other signs of chronic cystitis ; but the diagnosis will depend rather on the exclusion of other diseases such as stone, tumors, etc., and the presence of tubercle in other organs. Treatment. — The general constitutional reme- dies for tubercle should be employed ; together with such local remedies as are indicated for cystitis, and for the assuaging of the pain. These failing to relieve, suprapubic cystotomy may be done and the bladder washed out, and such caseous masses of tubercle as permit of it scraped away. Vesico-intestfnal fistula may be known by the occasional passage of faecal matter and gas by the urethra, and is usually a source of great discomfort. It commonly depends on inflammatory or other form of ulceration of the intestine involving the bladder. Treatment. — When the fistula is thought to be low down the intestine the abdomen may be explored, and the colon above the fistula united to the abdominal wall and then opened. The tumors that may be met with in the bladder are : — i. Thefihi-ous. 2. The mucous. 3. The villous or papillomatous. 4. The tjialignant. The fibrous and mucous spring from the sub- mucous coat, and protruding the mucous membrane in front of them assume a polypoid or warty shape. They are very rare. The villous or papillomatous spring from the mucous membrane, and appear as soft, flocculent growths resembling the villi of the chorion. They are the most common of the innocent growths. The malignant either spring from the mucous or the sub- mucous coat, and may form a large mass often nearly filling the bladder, or assume a villous appearance, or merely infiltrate the walls. They have either a carcinomatous or sarcomatous structure. The symptoms common to all are those of a foreign body in the bladder, with haematuria and absence on sounding of stone. In Xhtfil^rous there are signs of obstruction to the urinary outlet, but little or no haematuria, and the tumor may sometimes be felt with the sound. In the villous (Fig. 329) there is usually more or less continuous haemorrhage, without any other cause being discoverable to account for it ; there is seldom any marked ob- struction to the urinary outflow ; and shreds of the growth may come away spontaneously or in the eye of the catheter. In the malignant there are usually sudden attacks of severe haemorrhage from time to time ; and a growth may be felt by the sound, or by the finger in the rectum, or by palpation above the pubes. There are commonly moreover other signs of malignancy, as rapid 684 DISEASES OF REGIONS. growth of the tumor, cachexia, etc. Tumors of the bladder, however, especially the villous, are often difficult to diagnose ; some aid, it is tnie, may at times be gained by the electric cystoscope, but a diagnosis cannot always be made without a digital exploration of the bladder, which should be undertaken where symptoms such as the above are persistent unless they point to a malignant growth. In using the cystoscope a meas- ured quantity of fluid should be left in the bladder, which should be previously irrigated if F'G- 329. the urine contains blood or pus till the fluid returns clear. Treatment. — The removal of the tumor, except it is malignant, should generally be attempted. In the fe- male the urethera may be dilated for this purpose. In the male the incision into the bladder should be made above the pubes, and the site of the tumor lighted up by passing a large glass vaginal speculum into the bladder so that the tumor may lie included in its lumen. If more light is required a small electric lamp on a slender handle can be passed down the speculum. The growth may be then removed by the cold wire or galvano-cautery loop, or by forceps, or be burned off by the actual or galvano-cautery. If a villous tumor is simply torn off by forceps, severe haemorrhage, which I have known to prove uncontrollable and end fatally, may ensue. Tumors infiltrating the anterior wall, if not too large, may be removed by raising the peritoneum, excising the growth with the infiltrated wall, and uniting the edges of the wound with sutures. When removal is contra-indicated, relief where there is obstruction to the urinary outlet may be obtained by suprapubic puncture ; haemorrhage should be restrained by astringents ; and pain assuaged by opium. SiON'E IN THK lii.ADDKR may occur at any age, but it is said to be most frequent between the ages of fifty and seventy ; next, be- tween the ages of two and six ; whilst between the ages of twenty-six and thirty-six it is rare. It may occur in both males and females, but is decidedly more common in tlie former. Villous tumor of the bladder. (St. Biinhnlo mew's Hospital Museum.) STONE IN THE BLADDER. 685 The causes are not altogether known ; but residence in certain districts or countries, poor living, abuse of alcohol, especially in the form of malt liquor, excess of nitrogenuous food, want of suf- ficient exercise, and anything that induces the excessive formation of uric or oxahc acid in the urine, are regarded as predisposing causes. Retention of urine from prostatic enlargement and the presence of a foreign body in the bladder are exciting causes. In a few cases a nucleus has been formed for a calculus by a piece of necrosed bone which has reached the bladder from a fractured pelvis or carious spine. Varieties.— Tht three most common varieties of calcuH met with in the bladder are the uric acid, the oxalate of hme, and the phosphatic. They may occur almost pure or they may be mixed. According to Sir Henry Thompson the uric acid and urates form one-half of the number met with ; the phosphatic one quarter ; the mixed, one quarter; and the oxalates only three per cent, of the whole. The uric acid and the oxalate of lime are generally formed on a nucleus of one of these substances which has de- scended from the kidney. The phosphatic is formed in the bladder itself, either on a nucleus of phosphates deposited on some inspissated mucus or a foreign body, or on one of the other forms of stone which has descended from the kidney, and which, sooner or later acts as a foreign body. The oxalate of lime is the most slow of formation, and is consequently the hardest and most compact. The phosphatic forms very rapidly, is soft and friable, and often of very large size. Sometimes alternate layers of uric acid oxalate of lime, and phosphates occur in the same stone {^alternating calatlus), a condition probably due to varying states of the patient's health, effects of medicines, bladder irritation, etc. A description of the various forms of calculi is given in the section on Urinary Calculi (page 677). The character of the stone may to some extent be guessed at by the state of the urine. Thus, if the urine is acid, it will prob- ably be either oxalate of lime or uric acid ; if alkaline, phos- phatic. Calculi vary in size from that of a hemp-seed to a large mass weighing many ounces ; but large stones at the pres- ent day, in consequence of improved diagnosis and the dimin- ished dread a patient has of an operation, are the exception. They generally occur singly, but there may be two, or even more ; they are then usually faceted from rubbing against one another. Spontaneotis fracture sometimes happens, and has been attrib- uted : I, to the swelling or chemical alteration of the cementing material with which the particles of the calculus are held to- gether; 2, to two stones coming into collision; 3, to the com- 686 DISEASES OF REGIONS. pression of the calculi by the hypertrophied muscular coat of the bladder. The calculus may be variously situated in the bladder. It is usually free just behind the prostate, but it may be in the upper fundus behind the pubes, or in one of the sacculi so often found in long-standing diseases of the bladder (encysted). Calculous matter may sometimes be deposited upon growths in the bladder or upon the ulcerated mucous membrane. The terminations of stone. — If neglected, cystitis is set up, and inflammation may spread up the ureters to the kidneys, leading to the changes described under Suro^ical Diseases of the Kidneys. In consequence, moreover, of the obstruction to the urinary out- let, the bladder may become hypertrophied, and the ureters and kidneys dilated in the way described under strictu?-e. Symptoms. — The three chief symptoms are — i. Pain, generally referred to the end of the penis, and worse after micturition on account of the stone then falling on the sensitive trigone and the walls of the bladder contracting upon it. 2. Frequent micturi- tion ; and, 3. A little blood in the urine. These symptoms are increased on exercise, especially riding, and after the jolting of a railway journey, etc., and are least marked at night when the pa- tient is at rest. Other symytoms that may be present are the passage of gravel ; sudden stoppage of the stream during mictur- ition ; the presence of muco-pus in the urine owing to cystitis ; piles in adults and prolapse of the rectum in children, due to straining ; and elongation of the prepuce in boys, caused by the constant handling to relieve pain after micturition. Stone in the bladder may be simulated by cystitis, an enlarged prostate, a long or adherent prepuce, a narrow meatus, a growth in the bladder, calculous or other disease of the kidney, a peculiar choreic con- dition of the bladder (the stammering bladder of Sir James Paget), tubercle of the bladder, and ascarides in the rectum. An accurate diagnosis, however, can only be made by sounding the bladder ; though in boys the stone may be felt by the finger in the rectum whilst pressure is made with the other hand above the pubes. Sounding:; the bladder. — I'he ordinary sound (Fig. 330) is a solid steel instrument with a short bulbous beak. Thompson's sound is hollow to allow some of the urine to be drawn off if desired, and has a handle like that of his lithotrite, to facilitate the necessary movements in the bladder. Having warmed and oiled the sound, pass it like a catheter, letting it glide into the bladder by its own weight without using any force. When the sound is in, gently push it onwards to examine the posterior part of the bladder. Then turn the beak alternately to either side ; and depress the STONE IN THE BL.A.DDER. 687 handle between the patient's thighs to search the upper fundus. Then turn the beak downwards to examine the base or lower fundus. If the stone is not detected, let out a httle of the urine, or change the patient's position, or raise his pelvis and try again. Fig. 330. Ordinary sound. The stone may not be felt, because it is of small size, or has be- come encysted, or entangled in a fold of mucous membrane. A guarded opinion, therefore, should be given, and a further ex- amination made another day. A stone may be known to be present by the peculiar ring which is both felt and heard on strik- ing it. This ring is quite unlike the sensation given to the sound by its coming into contact with phosphatic deposits on a rough- ened or fasciculated bladder, or with one of the pelvic bones. Having discovered a stone, the next care should be to determine approximately — i, its probable size and composition; 2, whether it is free or encysted ; 3, whether there is one stone or more ; and, 4, the condition of the bladder and urethra, i. The size of the stone can be roughly estimated by the amount of resistance offered on pushing it before the sound or by passing the sound over it, and by feeling it through the rectum with the other hand pressing on the hypogastrium. Its exact size can only be ascer- tained by seizing it with the lithotrite, the distance the blades are then apart being indicated by the scale on the handle. The composition of the stone may be approximately arrived at by {a) the character of the ring on striking it — the clearer the ring the harder the stone, {b) the condition of the surface, which is rough in the oxalate of lime, smooth in the phosphatic, {c) the re-action of the urine, and {d), the general health of the patient. 2. A stone, when encysted, is always felt at the same spot in the bladder, and when seized with the lithotrite cannot be moved. The sound cannot be passed all round it. There is no blood present, and the symptoms are usually less severe, and are not increased by exercise. 3. The presence of a second stone can only be de- termined with certainty by seizing one stone with the lithotrite, and then striking the other. Treatment. — The stone may be removed by crushing {lithotrity), or cutting {lithotomy). In adults, lithotrity, with but few excep- tions, should be the rule. In children, up to twelve or fourteen years of age, lithotomy has hitherto been the recognized opera- 688 DISEASES OF REGIONS. tion ; but I believe that when the brilHant results obtained by Surgeon-]\Iajor Keegan and others come to be better known, that even in very young children, lithotrity, as in adults, will also be the rule, lithotomy the exception. I have myself crushed six or seven stones in young male children, some as young as three years, and successful cases are now being frequently reported. In adults, lithotomy should be practised in place of lithotrity, when 1, the stone is very large and hard ; 2, when the urethra is the seat of intractable stricture ; 3, when the stone is encysted ; and, 4, when the bladder is sacculated. A large stone, if soft, should be crushed ; and a hard stone, if not too large, is no bar to the operation. Surgeon- Major Keegan has crushed a uric acid stone, the fragments of which weighed two ounces and three quarters, and an oxalate of lime which weighed one ounce and three drachms. And in a boy, aged thirteen, I crushed and suc- cessfully removed a very hard stone weighing only a few grains less than an ounce. Hard stones, however, weighing above an dunce, and especially in boys, had better be removed by cutting, unless the Surgeon is experienced in lithotrity. Cystitis and kidney disease render the prognosis of both operations unfavor- able ; but in these affections it does not appear that crushing with complete removal of the fragments is attended with more risk than is lithotomy. A large prostate renders lithotrity difficult no doubt, but does not, as a rule, contra-indicate it. Stricture of the urethra is only an impediment to lithotrity when the stricture can- not be dilated. The conditions, however, most favorable for suc- cess in lithotrity are, as well expressed by Sir Henry Thompson, "a capacious urethra, a bladder capable of retaining three or four ounces of urine, absence of ordinary signs of renal disease, and fair general health." LnHOiRiTV, LiTHOLAPAXY, or BiGELOw's OPERATION consists in crushing the stone in the bladder, and removing the ivhole of the fragments through a large evacuating catheter. Formerly, it was taught that the presence of the lithotrite in the bladder for more than a few minutes at a time was productive of great irritation, and it was consequently advised that the crushing of the stone should be extended over several sittings of only a few minutes each, and the fragments allowed to be passed by the natural efforts of the patient. To the late Professor Bigeluw is un- doubtedly due the credit of having enunciated the principle that the bladder is not so intolerant of instruments as was formerly supposed, and that it was to the presence of the fragments, rather than to the lithotrite, that the irritation, cystitis, etc., so common after the old method, should be ascribed. The operation. — The patient, having been prepared for the opera- LITHOTRITY, LITHOLAPAXY, OR BIGELOW'S OPERATION. 689 tion by careful attention to the general health, rest, and such local means for allaying chronic cystitis as were pointed out under that head, should be placed under an anaesthetic, with the pelvis raised a few inches, the thighs slightly apart, the knees supported on a pillow, and the body and legs well wrapped up in blankets to avoid a chill. The rectum should be emptied by a purge the day before, and by an enema on the morning of the operation. A few ounces of urine in the bladder is desirable. If necessary, incise the meatus (a stricture, if present, should have previously been di- lated), warm and oil the lithotrite (Fig. 331), and pass it with all Fig. 331. Thompson's lithotrite. gentleness, letting it glide by its own weight through the spongy and membraneous portion of the urethra, and do not depress the handle till the blades have reached the prostate. Then bring the shaft to an angle of 35° with the horizon, and it will ghde through Fig. 332. Lithotrite in situ. (Listen's Surgery.) the prostatic urethra, over the trigone of the bladder, and may possibly be felt to graze the stone. The blades now rest in the lowest part of the bladder and point upwards (Fig. 332). Hold. 29* 690 DISEASES OF REGIONS. the handle tightly with the left hand, and, without moving the in- strument, open the male blade by drawing out the wheel-shaped end with the right hand. Pause a few seconds to allow the cur- rents set up in the urine by this movement to subside. Then gently press in the male blade, and the stone will probably be caught. If so, continue the pressure on the wheel to retain the stone between the blades, whilst the button is moved by the thumb to convert the sliding into the screw movement. Rotate the instrument slightly to make sure that the mucous membrane is not caught by the blades ; slightly depress the handle to raise the blades from the walls of the bladder, and screw home. The stone will probably be felt to crack and break into fragments. If the stone cannot be seized in this way, systematically explore the bladder thus : — Open the blades and rotate 45 degrees ; pause and close. Do this first to the right, then to the left. Then raise the blades slightly by depressing the handle ; rotate alternately to right and left 90 degrees; further raise the blades and rotate 135 degrees. Finally, reverse the blades by rotating half a circle. In this way the stone will probably be found. In these manoeuvres the blades should be opened before rotating them in order that the stone may not be displaced by the male blade, and after rotating a pause should be made before closing them to allow the currents to subside. Having crushed the stone and larger frag- ments, withdraw the lithotrite, first screwing tight home to en- sure complete closure of the blades in order to prevent laceration of the urethra. Next introduce a large evacuating catheter (No. 16, or larger) ; let the urine escape and inject two or three ounces of warm water. Attach the aspirator, previously filled with water at a temperature of 98°, and compress the india-rubber bulb, driving some of the water into the bladder. Let the bulb expand and the outward current will bring away some of the fragments and debris, which will fall into the receiver and be ])revented from returning into the bladder by the trap (see Fig. 333) on again compressing the bull). Continue compressing and relaxing till fragments cease to come away. Then if any are felt by the evacuating catheter le-introduce the lithotrite, or a smaller one, and crush again and aspirate as before, repeating this till all the fragments are j-emoved. The operation frequently lasts for an hour to an hour and a half or longer. Fig. 333. Thompson's improved cvaciuitor and trap. LATERAL LITHOTOMY. 69 1 Afte7'-treatmcnt. — Opium, if no serious kidney disease is present, may be given ; and hot hip-baths if there is much pain. If there is retention the catheter should be used at regular times, or tied in if its passage causes much irritation and pain. Complete rest in bed for a few days or longer should be enjoined. If cystitis follows the operation, Sir Henry Thompson strongly recommends a weak injection of silver nitrate (gr. i to f.si.). As a rule, how- ever, I have found no after-treatment required, even in young boys. Indeed, in several cases the child has been up and play- ing about the ward the day after the operation. Afte}-- complications. — i. Rigors and fever; 2, retention of urine ; 3, acute cystitis; 4, prostatitis and abscess, and 5, orchitis and epididymitis, occasionally occur. More rarely, 6, haemorrhage; 7, suppression of urine, and 8, phlebitis of the prostatic plexus of veins, followed by pyaemia. The impaction of a fragment of the calculus in the urethra (formerly common when the fragments were left in the bladder) cannot occur if the bladder has been thoroughly evacuated. Causes of death. — Death may occur from i. Acute nephritis ; 2. Pyelitis; 3. Cystitis; 4. Perforation or rupture of the bladder; 5. Peritonitis; 6. Saproemia or pysemia; or 7. Exhaustion. But a fatal termination is rare except where there is some chronic kidney disease. LiTHOTOiviY, or cutting for the stone, may be performed through the perineum or above the pubes. Perineal lithotomy may be done in many ways ; the lateral, as usually performed, and the median, will only be described. •• Lateral lithotomy. — The patient should be prepared by rest in bed for a few days, and the rectum cleared by a mild purgative the day before, and by an enema on the morning of the operation. The bladder should contain five or six ounces of urine, or if the patient is unable to retain so much, an equal quantity of warm water should be injected. Anesthetize the patient, introduce a full-sized staff with a groove on the left side into the bladder, and try to strike the stone. If the stone is not felt, withdraw the staff and pass a sound. If still unsuccessful, send the patient back to bed, as the stone may have been passed per urethram or become encysted. If felt by the sound, re-introduce the staff, but do not operate until the staff itself strikes the stone, that you may be sure that the staff has passed into the bladder, and not into a false pass- age. It is usual to ask an assistant to strike the stone also. Next place the patient in the lithotomy position, /. e., with the soles of the feet secured in the p'.ilms of the hands by the lithotomy shackles, and bring his nates well over the end of the table. Entrust the staff to an assistant, who should hold it perpendicu- 692 DISEASES or REGIONS. larly, with its concavity hooked well up under the pubes and ex- actly in the middle line. Seat yourself in front of the patient, and having introduced the left forefinger into the rectum to make sure that it is empty, and to induce it to contract, enter the knife (Fig. 334), which should be held horizontally, a little to the left of the middle line and about an inch and a quarter in front of the verge of the anus, and carry the incision downwards and to the left, to Fig. 334. Lithotomy knife. a point one-third nearer to the tuberosity of the ischium than to the margin of the anus. Pass the left forefinger into the upper angle of the wound and feel for the staff; divide with the knife the superimposed tissues ; insert the finger-nail into the groove in the staff, the back of the finger being to the patient's left ; and guided by the nail, press the point of the knife into the groove just Fig. 335- Parts cut in lithotomy. (Ferguson's .Surgery.) in front of the membraneous portion of the urethra (Fig 335). Now run the knife with the i)oint pressed firmly in the groove onwards into the bladder, keeping its blade well lateralized, i. e., LATERAL LITHOTOMY. 693 Fig. ^36. directed downwards and to the left. Take care not to depress the handle too much for fear of cutting the prostate too widely, nor to hold it too horizontal lest the point slip out of the groove and penetrate the tissues between the bladder and the rectum. Having entered the bladder, shghtly enlarge the wound in the prostate in withdrawing the knife, and pass the left forefinger, which is in the wound, onwards along the staff into the bladder. If the stone is felt by the finger, ask the assistant to withdraw the staff. Take the forceps in the right hand, pass them along the left forefinger towards the bladder, and, on with- drawing the finger, open the blades, and the stone will probably be driven by the gush of urine between them. Having assured yourself that the stone is grasped by the forceps in its smallest diameter, extract it by making traction downwards and backwards in the axis of the pelvic outlet. Re-introduce the finger into the bladder to ascertain whether there may not be another stone, and if in doubt use the searcher. Inject two or three syringefuls of cold water into the bladder : dust the wound with iodoform ; apply no dress- ings ; tie the legs together if the pa- tient is a child, and send him back to bed as quickly as possible. If there is haemorrhage, tie any bleeding point which is seen, or if the blood comes from the deep part of the wound, in- troduce the petticoated tube (Fig. 336), assuring yourself that the end is in the bladder by injecting water and passing a probe through it. Then plug firmly round with strips of lint between the petticoat and the tube. At Guy's Hospital lateral lithotomy is performed on a straight staff, by the operation known as Key's, A good description of the method will be found in Bryant's Surgery. The si7-uctiires divided in the operation are: — i, the skin; 2. the superficial and deep fascia ; 3, a few branches of the external haemorrhoidal vessels and nerves ; 4, the transversus perinei muscle, vessels and nerve ; 5, a few fibres of the accelerator urinae and levator ani muscles ; 6, the compressor urethrge muscle ; 7, the membraneous portion of the urethra ; and 8, the prostate. The dangers of the operation are ; — A. Before the point of the Petticoated tube. 694 DISEASES OF REGIONS. knife has entered the groove in the staff — i, wounding the rectum, either from cutting too perpendicularly, or from not having had it cleared out by an enema ; 2, wounding the artery of the bulb in consequence of beginning the incision too high, or directing the point of the knife subsequently too much upwards ; and 3, miss- ing the groove in the staff. B. On entering the bladder — i, let- ting the point of the knife slip out of the groove in the staff and enter the cellular tissue between the bladder and rectum; 2, cut- ting the pudic artery from holding the knife too much lateralized ; 3, sending the point of the knife through the posterior wall of the bladder ; 4, cutting the prostate too widely, and dividing its cap- sule, whereby the urine may be extravasated into the cellular tissue of the pelvis ; 5, wounding the prostatic plexus of veins ; 6, tearing the urethra across, and so pushing the bladder off the end of the staff, whilst trying to pass the finger into the bladder (this accident is due to not making the opening into the urethra large enough, and is most common in children in whom the tissues are readily lacerable) ; 7, making too small an incision in the prostate so that the parts are bruised or torn in removing the stone, and inflammation is set up ; 8, seizing the walls of the bladder by the forceps. These dangers may he best avoided by obseiTing the fol- lowing rules — I, feel the stone with the staff heioxe you begin the operation; 2, see that the rectum is empty, and make it contract by introducing the finger; 3, make the external incision free ; 4, feel both edges of the groove in the staff with the finger, and place the point of the knife betzveen them ; 5, keep the point of the knife well pressed into the groove of the staff; 6, take care that the finger is pushed into the bladder in contact with the naked staff; 7, do not remove the staff till the finger touches the stone. The difficulties of the operation. — In adults the chief difficulty is to extract the stone ; in children to get into the bladder. A. The difficult)' in entering the bladder depends chiefly on — i, not mak- ing the opening into the urethra free enough, and so pushing the finger between the bladder and the rectum ; 2, a deep perineum, so that the finger cannot reach the bladder ; in such case a blunt gorget must be substituted for the finger. B. The difficulties in extracting the stone are — \, the stone may be too large ; 2, it may get behind the prostate ; 3, it may be lodged in a pouch in the upper fundus ; 4, it may be encysted ; 5, it may break or crumble up; 6, it may be so small that it slips from between the blades of the forceps ; 7, there may be an enlargement of, or tumor in, the prostate, whereby the urethra is greatly lengthened; 8, there may be some rickety or other deformity of the pelvic bones. When the stone is behind the prostate, curved forceps, with the LATERAL LITHOTOMY. 695 blades turned down, must be used ; when the stone is above the pubes, the blades must be turned upwards, the handle depressed, and the stone pressed down by the hand above the pubes. When too small to be seized, the scoop must be substituted for the for- ceps. If the stone breaks, the fragments must be removed by aid of the scoop and syringe. If encysted, it may be scratched out with the finger-nail, or freed with a probe-pointed bistoury. If too large to be extracted, the wound should first be slightly en- larged ; or, this being insufficient, three expedients remain— i, to make an incision in the opposite side of the prostate ; 2, to crush the stone ; 3, to do the suprapubic operation. The first of these is probably the best. To overcome the difficulty of an enlarged prostate, the blunt gorget must be used and the forceps slid along it. A fibrous tumor in the prostate may be previously shelled out. Where the pelvic outlet is too small to allow of ex- traction, suprapubic lithotomy must be done. Causes of death after lithotomy. — i. Diffuse septic inflamma- tion of the cellular tissue of the pelvis, due either to infiltration of the urine from too free cutting, or to bruising of the parts in ex- tracting a large stone through a small incision; 2, peritonitis due to the spread of the inflammation to the peritoneum, or to a wound of the back of the bladder ; 3, shock from too prolonged an operation; 4, exhaustion from primary or secondary haemor- rhage; 5, blood-poisoning, due to the absorption of the products of putrefaction (saprEemia), or to septic phlebitis of the prostatic plexus of veins and pycemia ; 6, cystitis; and 7, suppression of urine. The state of the kidney is of the most serious import. Where these are healthy, as in children, lateral lithotomy is one of the most successful operations in surgery ; but in adults, in whom grave kidney mischief often exists, it is liable to be followed by one or more of the above complications, especially diffuse pelvic inflammation. Thus, in boys, when death occurs it is gen- erally the result of some one of the accidents liable to^ occur during the operation ; in adults the cause is usually dependent primarily on kidney mischief. The after-treatment 'y~, very simple, and consists in little more than keeping the patient clean, and in regulating the secretions and diet. Adults may be placed on a mattress, with a hole opposite the perineum, for the purpose of letting the urine drain through. During the first few hours it is essential to see that the wound is free. Should the urine not escape from it, it is prob- ably plugged with a clot of blood ; the finger must then be passed into the wound, or if a tube has been introduced, this must be cleared by a probe or feather, or by syringing. From the third to the fifth day, in consequence of inflammatory swelling, more or 696 DISEASES OF REGIONS. less of the urine is passed by the urethra, but as this swelling sub- sides, the greater part may again pass by the wound ; more, how- ever, is gradually passed by the natural way and less by the wound, as the latter slowly heals. Should secondary haemorrhage occur, the wound must be plugged ; or if this fails to arrest it, perchloride of iron or the actual cautery must be used. For the treatment of the other complications see Cellulitis, Peritonitis, etc. jNIedian LiTHOTOMV. — Pass a staff, grooved on its convexity, into the bladder, and with the left forefinger in the rectum, feel for the apex of the prostate. Make an incision with a straight bistoury, with its back towards the rectum, in the median line of the perineum, beginning about half an inch in front of the anus. Insert the point of the knife into the groove of the staff just in front of the prostate, notching the apex, and cut a little upwards, opening the membraneous portion of the urethra. Withdraw the knife, slightly enlarging the external incision upwards if necessary, and pass a long bulbous probe along the groove of the staff into the bladder. Withdraw the staff, and gently work the forefinger into the bladder along the probe, thus dilating the prostate. Ex- tract the stone in the usual way. The operation is suitable — i. For small stones or foreign bodies ; 2. When it is important that there should be little loss of blood ; 3. For the removal of new growths ; and 4. For exploring the bladder in doubtful cases of disease. All the cutting is done entirely in the median line where no vessels exist ; the deeper parts of the wound are merely dilated, not cut. Median lithotomy may be combined with lithotrity through the wound (^perineal lithotrity), a straight lithotrite being then used. Suprapubic lithotomy consists in opening the bladder between the pubes and the peritoneal fold. It is the method that should be employed for the removal of very large stones, and for certain forms of tumor in the bladder. First, pass a Petersen's india- rubber bag into the rectum and dilate it with water, and distend the bladder with a weak antiseptic solution, it will then rise well into the abdomen and appear as a prominent tumor, dull to per- cussion above the pubes. Make an incision in the middle line immediately above the symphysis (Fig. 284, b), and having di- vided with scissors the tissues forming the linea alba, expose the wall of the bladder by gently separating the fatty tissue that lies in front of it with the finger or director, avoiding the peritoneal fold, and, if possible, the large veins which ramify in this situation. The bladder having been fixed by inserting a sharp hook into its walls, make an incision into it ; introduce the finger to ascertain the size of the stone; enlarge the wound, if necessary, by cutting towards the pubes, and extract the stone with the finger and INCONTINENCE OF URINE. 697 Scoop, or with the forceps. The wound in the bladder may be left open, and the patient placed on his side to ensure an efficient drain and prevent the tissues being infiltrated with urine ; or it may, if the bladder and urine are healthy, be closed by suture. Some tie in a full-sized catheter, but it is not necessary, and is perhaps harmful. Calculus in the female bladder is much less common than in the male, a fact in great part due to the shorter and more dilatable urethra in women, to the absence of a prostate and con- sequent exemption of the female from chronic retention and phosphatic deposits, and perhaps also to the more regular habits of women. The symptoms are similar to those in the male, but are sometimes apt to be accompanied by incontinence of urine. They may at times be simulated by vascular growths in the urethra, by uterine disease, and by hysteria. Treatment. — i. When the stone is small, rapid dilatation of the urethra with the three-bladed dilator or dressing forceps is the best method of extraction. 2. When of larger size (above three- quarters of an inch in children and one inch in adults), lithotrity with removal of the fragments at one sitting should be done. 3. When too large for removal by dilatation, and the bladder is too contracted to allow of crushing, the suprapubic operation is called for. Slow dilatation, dilatation with incision {uTethral lithotoiu}') , and incision through the vagina {vaginal lithotoiny) are very liable to be followed by incontinence of urine, especially in children. Incontinence of urine or enuresis. — Involuntary escape of urine from the bladder may occur under several conditions. Thus — I. The urine may dribble away as fast as it enters the bladder, in consequence of paralysis of the sphincter vesicse and inability to close the urinary outlet {true incontinence). 2. The urine may be passed involuntarily during sleep without any organic change in the urinary apparatus being discoverable {nocturnal or active incontinence) . 3. The urine may constantly flow away, in conse- quence of the bladder being over-distended and capable of hold- ing no more {retention with incontinence, ox false incontinence). This last condition, which usually depends on obstruction to the outflow, will be described under Retention of Urine (p. 723) . The importance of recognizing that it is one of the nature of retention rather than of incontinence cannot be too strongly insisted upon. Whenever, therefore, a patient complains that he is unable to hold his water, or that it is continually dribbling away, an over-distended bladder should be suspected, the abdomen examined for such, and a catheter passed. I. True incontinence of urine is very rare. /// males, it may be 30 698 DISEASES OF REGIONS. due — (a) to a peculiar form of enlargement of the middle lobe of the prostate whereby the urethra is rendered patent instead of being obstructed as is more commonly the case in enlarged pros- tate ; {/>) to a like patency of the urethra from the impaction of a calculus at the neck of the bladder, or from a prostatic calculus ; (c-) to disease or injury of the spinal cord, implicating the lumbar enlargement, and inducing the bladder to become so contracted and thickened that it cannot hold any urine. In females, it may be due — («') to over-dilatation of the urethra, as in extracting a calculus from the bladder; {b) to the injury of the parts during parturition; and {c) to vesico-vaginal fistula. The treatment coxi- sists in removing the cause, or if this is impracticable, in render- ing the padent's condition as comfortable as possible under the circumstances by a urinary convenience. 2. Nociur7wl or active incontinence generally occurs in children, and must be distinguished from the involuntary passage of urine, which is an occasional symptom of thread-worms, calculus, long prepuce, or growth in the bladder. In nocturnal incontinence proper, beyond that the child wets his bed, no sign of disease of any kind is discoverable. Treatment. — Presupposing that the absence of thread-worms, calculus, long prepuce and growth in the bladder has been ascertained, the treatment should consist in tonics, cold baths, and the administration of belladonna in increas- ing doses till symptoms of belladonna poisoning appear. The child should lie on his side, not on his back, and be awakened at regular intervals to pass water. I have found the continuous gal- vanic current of service ; one pole should be applied over the urinary centre in the lumbar region, the other to the perineum. In obstinate cases. Sir Henry Thompson advises the application of a solution of silver nitrate (grs. x to 5J) to the neck of the bladder. H/EMA'iUKiA, or bloody urine, is generally a symptom of disease or injury of the urinary organs, but may also occur in certain con- stitutional conditions, as scurvy, purpura, malaria, the hsemor- rhagic diathesis, and in some fevers. When blood is present in large quantities, the urine will be bright red or coffee or porter colored ; when in smaller quantities, of various shades of brown, to which the term "smoky" is applied. Blood maybe simulated by urates, indican, bile, or rhubarb or other coloring matter which may have been introduced by impostors. The dark greenish color of the urine, which is produced by the absorption of carbolic acid from a wound, must not be mistaken for blood. Blood may be distinguished by blood-globules being seen under the microscope ; by the spectroscope ; or by the ozonic ether test. Add a few dro])s of tincture of guaiacum to the suspected urine, and then an ACUTE PROSTATITIS. 699 excess of ozonic ether ; shake the mixture and allow it to stand ; it will assume a blue color if blood is present. The same reaction occurs if the patient is taking potassium iodide. Albumen will be detected in the urine if blood is present in quantity. Source of the blood. — The blood may come from — i, the kidney or ureter; 2, the bladder or prostate ; or 3, the urethra. When from the kidney or in-eter \t may be due to {a) injury, {/>) con- gestion or inflammation, {c) Bright's disease, {d) the administra- tion of turpentine, or the application of a cantharides blister, {e) the presence of a parasite, the Bilharzia hgematobia, in the pelvis of the kidney in persons who have been in Africa, (/) the impac- tion or passage of a calculus, {g) the passing of a catheter up the urethra, or (/z) malignant disease. IVhen from the bladder or prostate it may be due to («) injury, (^) calculus, {c) cystitis or prostatitis, or {d) villous or malignant growths. When fro?n the urethra it may be due to {a) injury, {b) gonorrhoea or chan- cre, {c) erectile growths, {d) calculus, (1?) rupture of corpus spongiosum in chordee or sexual intercourse. Diagnosis. — Blood from the urethra comes before the urine, is frequently pure, and may continue flowing between the acts ot micturition. From the bhidder or prostate, it generally comes after the urine, or the urine contains more blood at the end than at the beginning of micturition ; it is often clotted from remaining some time in the bladder, and the urine then is of a porter-like color. From the kidney it comes with the urine, with which it is intimately mixed {smoky urine). The urine may then contain blood-casts of the renal tubes, or when it comes from the ureter, fibrinous casts of the ureter. The treatment resolves itself into remedying where possible the cause (see Diseases of Kidney, Bladder, etc.). When clots have collected in the bladder, they may be washed out with a stream of warm water ; but when they are decomposing, it may be neces- sary to open the bladder through the perineum and remove them. DISEASES OF THE PROSTATE. Acute prostatitis. — Causes. — Generally gonorrhcea, or stric- ture of the urethra ; less frequently cystitis, impacted calculus, and passage of instruments. Occasionally in gouty subjects it appears to occur idiopathically. Symptoms. — Micturition is fre- quent, and attended with pain, especially at the end of the act ; there is throbbing and continuous pain in the perineum and neck of the bladder, and pain during defgecation. When examined by the finger in the rectum, the prostate is found hot, swollen, and painful, and the passage of a catheter causes great pain. The 700 DISEASES OF REGIONS. febrile disturbance which accompanies it, is perhaps ushered in by rigors. Terminations. — Resolution, abscess, or chronic inflam- mation. Treatment. — Six or more leeches to the perineum; hot hip-baths ; hot poultices to the perineum ; and a purgative at the onset, followed by alkaline medicines. A catheter is only to be passed if there is retention of urine. Abscess of the prostate is generally preceded by acute in- flammation ; but chronic abscess may be produced by catheterism in chronic enlargement of the organ. Acute abscess may be suspected, when in the course of acute prostatitis rigors and re- tention of urine supervene. Fluctuation can at times be felt through the rectum, but the abscess is generally first discovered on passing a catheter for the relief of the retention of urine, when a quantity of pus escapes from the urethra. At times the abscess may burst into the rectum or perineum. Treatment. — Free incis- ion in the middle line of the perineum to let out the pus. When the pus forms around the prostate instead of in its substance, a periprostatic abscess is said to have occurred. The cause, symp- toms, and treatment are similar. Chronic prostatitis generally occurs as a sequel to the acute. The symptoms are similar, but of much less intensity ; and there is a glairy discharge with, sometimes, a drop or two of blood in it. The urine is cloudy and contains pus and prostatic casts. Noctur- nal emissions are frequent. If the in- flammation is not relieved, cystitis may follow, and the bodily and mental health become seriously impaired. Treatment. — Blisters to the perineum, gentle laxa- tives, tonics, especially iron, change of air or a sea voyage, sea-bathing, a gene- rous diet, and the avoidance of stimu- lants, horse-exercise and sexual indulg- ence. The application of silver nitrate to the prostatic urethra is recommended by some Surgeons when there are noctur- nal emissions. Hypertkophy, or chronic enlargement of the prostate, must be carefully distin- guished from the enlargement due to in- flammation. It seldom occurs under the age of fifty or sixty, and is a common, though not an invariable, disease of old men. It may be due to hyjjertrophy ot all the tissues forming the prostate ; or the glandular, muscular, or fibrous tissue only may be affected, then often forming distinct masses in the substance of Fig. 337. Enlargement of the middle lobe of the prostate. (St. Bartho- lomew's Hospital Museum. J CHRONIC PROSTATITIS. 70I the organ. The enlargement may involve the whole prostate, or may be confined to one or other of the lateral lobes or to the so- called middle lobe (Fig. 337). The cause is not known. The effects of chronic enlargement of the prostate are very seri- ous when the outflow of urine is impeded, similar changes occur- ring in the bladder, ureters, and kidneys as described under stricture. The bladder behind the enlargement forms a pouch in which some urine may remain after each act of micturition unex- pelled, and there, mixed with pus and mucus from the walls of the inflamed bladder, undergo decomposition, probably owing to the action of micro-organisms, the urea being converted into ammon- ium carbonate, and the phosphate in consequence precipitated. Symptovis. — Increased frequency of micturition, especially at night ; inability to propel the stream to the same distance as for- merly, owing to the muscular fibres of the bladder being involved in the disease ; and difficulty in commencing the act. Later, the bladder is imperfectly emptied ; the retained urine becomes am- nioniacal and alkaline in reaction ; cystitis is set up, and retention of urine may finally occur. Diagnosis. — These symptoms may depend upon causes other than enlarged prostate. It is only by a physical examination that the nature of the disease can be accurately made out. On intro- ducing the finger into the rectum the prostate is felt enlarged, un- less the middle only is involved. On passing a catheter no ob- struction is met with in the urethra ; /. e., the catheter passes six or seven inches without meeting with any, and then has to be well depressed before it can be made to enter the bladder. Or an ordinary catheter may not be long enough to enter the bladder, and a prostatic catheter may have to be used. Treatment. — In the early stages, so long as the bladder can be completely emptied by the patient's own efforts, the treatment should be directed to improving the general health. But as soon as it is found that obstruction is beginning to come on, Harrison's olive-shaped bougie may be passed daily so as to exert pressure Fig. 338. Coiide catheter. on the prostate, and dilate the canal. If it is found, after urine has been passed, that the bladder still retains some ounces, then catheterism must be commenced. A soft catheter, or when the middle lobe is enlarged, a coude or bi-coude (Figs. 338, 339), 702 DISEASES OF REGIONS. should be used at regular intervals, and any cystitis which may exist should be treated as already described. As the disease ad- vances the passage of the catheter may cause a very irritable con- dition of the bladder. Under such circumstances it becomes a question whether the bladder should be tapped above the pubes, Fig. 339. •lESKEEEHaiEEasi Bi-coude ciithctcr. and a cannula kept permanently in ; or whether an incision in the middle line of the pernineum should be made to drain the blad- der. I prefer the latter method. When retention occurs, and it cannot be reheved by a catheter, the bladder must be tapped above the pubes. Recently the obstruction has been overcome by punching out a piece of the prostate with an instrument in- vented for the purpose, by boring a new channel with the galvano- cautery. and by opening the bladder above the pubes and remov- ing with the knife or cautery the obstructing portion of the middle lobe {^prostatectomy^. The removal of the obstructing middle lobe holds out the best prospect of success. Castration is recommended as likely to cause shrinking of the prostate, in the same way as the removal of the ovaries leads to atrophy of fibroids of the uterus. TuBtRCLE OF THE PROSTATE may occur in the course of general tuberculosis, or in connection with tubercular disease of the genito-urinary tract. It gives rise to inflammation, and sometimes suppuration, in or about the organ ; but its diagnosis will depend 'on the presence of tubercle in other ])arts, as the testicle, bladder, vesiculai seminales, etc. The local scraping away of caseous material may give some temporary relief. Malignant disease. — Carcinoma in the old, and sarcoma in the young, may occur in the prostate, but both are rare. Pain, in- creased frequency in micturition, with passage of blood, often pure, at the end of the act ; the presence in the urine of shreds of the growth ; the detection in the rectum of a swelling of the prostate of unequal consistency and of rapid growth ; enlarge- Tnent of the lumbar and often also of the inguinal glands; and wasting and cachexia, are the symptoms by which it may be known. I'he treatment can only be palliative ; /. e., morphia to subdue pain, nstrin;:;ents to check hemorrhage, and catheterism or supra-pubic puncture to relieve retention. Prosta'JIc cai,culi are often found in abundance in the prostate GONORRHCEA. 703 of old men, in the form of small, brown, seed-like bodies. They are composed of phosphates, with a little carbonate of lime and a large proportion of animal m.atter, and are believed to be formed by the inspissation of the prostatic secretion, and the subsequent deposit upon it of the earthy salts. Usually they give rise to no syvipioms but occasionally one or more encroach upon the urethra, and may attain such a size as to project into the bladder, then causing painful and frequent micturition, invol- untary erections and escape of semen, or perhaps retention or incontinence of urine. A grating sensation, but no true ring, may be elicited on the passage of a sound. At other times the calculi may escape into the bladder and there, collecting in con- siderable numbers, give rise to symptoms of stone. Moreover, one or more may be periodically passed by the urethra. T^reat- nient. — Unless the symptoms are severe, the calculi are better left alone ; but should they attain a large size, or give rise to reten- tion, etc., they should be removed through a median incision in the perineum. Extraction by the urethral forceps is not likely to succeed ; but there is no harm in trying, if all gentleness is used. Where they have collected in the bladder they may be washed out by Bigelow's evacuator. DISEASES OF THE URETHRA. Simple urethritis, or inflammation of the urethra of a non- specific character, may be due to injury, catheterism, gout, the irritation of worms, the abuse of alcohol, or contact with leucor- rhceal discharges. Signs. — Simple inflammation of the urethra is attended by a catarrhal, and at times by a muco-purulent dis- charge, and except in the mildest forms, it cannot always, without taking into account the history of the case, be distinguished from gonorrhoea. Like the latter affection it may, though much more rarely, be complicated by cystitis, prostatitis, epididymitis, neph- ritis, synovitis, and ophthalmia. The treatment is similar to that for gonorrhoea. GoNORRHCEA is an acute, infective, and specific inflammation, attended with a muco-purulent discharge. In the male it is most common in the urethra, in the female in the vagina and about the vulva ; but it may attack any mucous membrane exposed to contagion. Cause. — In the male it is nearly always due to direct contagion, and in the female it is also commonly contracted in this way ; but in the female it may possibly be developed dc novo, i. ibles are developed ; the patient loses weight, his countenance becomes anxious, he suffers from chilliness and occasional rigors, from pain in the loins, and later, from feverish attacks and un- mistakable signs of kidney mischief. Thus a stricture which in itself, if kept properly dilated, is not a serious disease, becomes so when neglected, and chronic bladder and kidney trouble are al- lowed to be set up. It may then end fatally from an intercurrent attack of acute cystitis or nephritis, or from extravasation ot urine and its consequences occurring during an attack of reten- tion. The effects of obstruction to the out- flow of urine from the bladder on the urinary apparatus. STRICTURE OF THE URETHRA. 709 A diagnosis can only be made with certainty by examining the urethra with instruments. First take a No. 8 or 9 black bougie or catheter, and if this passes easily try successively larger sizes till the obstruction is met with. If, on the other hand, it will not pass, try a smaller bougie till one is found that will go into the bladder. If the obstruction to the passage of the bougie is met with within six inches of the meatus, a stricture exists ; but if it is further than this the case is one of enlarged prostate. Do not mistake the catching of the end of the bougie in the lacuna or at the triangular Hgament, or the spasm that may be present on the first trial, for a stricture. Having discovered the stricture, meas- ure the distance from the meatus on the catheter or bougie. Next pass a bulbous stem (Fig. 342) through the stricture, and then Fig. 342. Bulbous stem. withdraw it, noting on the stem where the bulb is caught in the act of withdrawal. This, when compared with the distance noted on the catheter, will indicate the length of the stricture. In the same way the existence of other strictures can be discovered. The calibre of the stricture may be measured by Otis' urethro- meter (Fig. 343). The method of passing a bougie or catheter can be much better Fig. 343. ~"*^^^ Otis' urethrometer. learnt by five minutes' practice than by any written instructions. Here only the general rules for passing such will be given, i. Carefully examine the instrument to see that it is quite clean, perfectly smooth, not defective in any part, and, in the case of a catheter, that it is pervious, in order to avoid respectively the dangers of septic infection, laceration of the urethral mucous mem- brane, the breaking off of the end of the catheter in the stricture, and the annoyance of finding that when the catheter has been passed it is choked and urine will not flow through it. 2. Warm and oil the instrument; a cold catheter is unpleasant to the yiO DISEASES OF REGIONS. patient, and tends to produce spasm ; an unoiled catheter does not glide easily along the urethra. 3. Place the patient in the recum- bent position if instrumentation is to be practised for the first time, lest faintness be produced. In old-standing cases, where the urethra is callous, the patient may stand with his back against a wall. 4. Pass the instrument with the greatest gentleness and use no force. The difficulties that may be met with in passing an instrument are: i. The point may catch in a lacuna or fold of mucous mem- brane. This is best avoided by keeping the point at first on the floor of the urethra. 2. It may hitch where the urethra passes through the triangular ligament. Should it do so, withdraw it a little, and direct the point against the roof of the urethra. 3. It may enter a false passage. This may be known to have occurred («•) by the handle being deflected from the middle line, (/^) by the catheter being felt to be out of the right passage by the finger in the rectum, {c) by free bleeding if the false passage is recent, (c/) by no urine escaping, (,?) by the point not moving freely as it does when in the bladder. The formation of a false passage may be prevented by using no force ; and entering an old one may be avoided by using a silver catheter and directing its point along the wall of the urethra opposite to that in which the open- ing into the false passage is situated. The local and constitutional effects that occasionally follow the introduction of instruments. — Among the local effects may be mentioned — i, haemorrhage; 2, false passage; 3, abscess; 4, ex- travasation of urine, and 5, inflammation of the prostate, testicle, or bladder. Among the constitutional effects — i, syncope; 2, rigors ; 3, urethral fever; 4, suppression of urine ; and 5, pyaemia. Local effects — i. Haemorrhage may be due to laceration of the mucous membrane of the urethra by the careless passage of the instrument, or to congestion of the urethra in the neighborhood of the stricture ; in either of these cases the blood may flow on the removal of the catheter, the point of which, moreover, will be blood-stained. Haemorrhage, however, may come from the kidney, consecjiient u])on reflex congestion due to the irritation of the neck of the bladder by the catheter. The blood will then only appear in the urine after some time has elapsed (see Hema- turia, p. 698). 2. A false passage may be produced by using too much force, or by applying force in the wrong direction. It is known to have been made by the catheter being felt to slip suddenly onwards, by the handle deviating from the middle line, by the point being felt out of the urethra by the finger in the rectum, and by the ])atient complaining of severe ])ain. The catheter should be at once withdrawn and not passed again for a STRICTURE OF THE URETHRA. 7I1 week or more, to allow the wound to heal. 3. Abscess ; 4, extra- vasation of urine ; and 5, inflammation of the prostate, testicle, and bladder, require no comment here. General effects — i. Syncope occasionally occurs on the first passage of a catheter. It is best avoided by passing the instrument with the patient in the recumbent posture. 2. The rigors which sometimes follow the first introduction of an instrument appear to depend upon some nervous shock, and may occur where all gentleness has been employed and no local injury whatever has been inflicted. 3. Urethral fever is most frequent in old people, and may supervene within a day or two of the first catheterization. It begins with rigors followed by high fever, and usually terminates in a few days with profuse sweating. Occasionally, however, it may end fatally, in which case there is nearly always some chronic kidney disease discovered at the autopsy. Sir Andrew Clark has called attention to the possible occurrence of death after the passage of an instrument in old men without any kidney or bladder trouble to account for it. 4. Where suppression of urine has been ob- served there has always been some pre-existing kidney mischief. 5. Pyaemia is rare, but has occasionally been noted. The treatment of organic stricture resolves itself into restoring the patency of the urethra by causing the absorption and destruc- tion of the inflammatory or cicatricial material producing the obstruction, and subsequently preventing recontraction. The methods employed for restoring the patency of the urethra are : I. Slow dilatation. 2. Rapid dilatation. 3. Forcible dilatatio7i or splitting. 4. Division of the stricture from witliifi (internal urethrotomy). 5. Division of the stricture from ivithout (external urethrotomy). 6. Destruction of the stricture by caustics. 7. Electrolysis. Treatment by caustics may be said to have now be- come obsolete, and will not be further referred to. Of the other methods slow dilation is no doubt the simplest and safest, and is the one that in the large majority of cases should be used. Where, however, time is an object or the stricture cannot be di- lated by the slow method beyond the size of a No. 4 or 5 catheter, or severe constitutional or local symptoms are set up on each oc- casion that a catheter is passed, rapid dilatation may be tried. Where again the continual presence of a catheter in the urethra cannot be borne on account of the local irritation which it causes, or the stricture is resilient and rapidly recontracts after it has been fully dilated, internal urethrotomy or electrolysis may be practiced, especially if the stricture is in the penile portion of the urethra. Further, when the stricture is of cartilaginous con- sistency, and wfll not yield to dilatation, or the perineum, in addi- tion, is riddled with sinuses, external urethrotomy by Syme's or 712 DISEASES OF REGIONS. Wheelhouse's method may be performed. Lastly, when, after persistent attempts, it is found that an instrument cannot be passed through the stricture, electrolysis may be attempted, or external urethrotomy by Wheelhouse's method may be under- taken. \\'hen the symptoms are urgent, as from retention or extravasation of urine, other measures may be required. See Retention and Extravasation of Urine (pp. 721 and 723). For- cible dilatation or splitting does not commend itself to my judg- ment, and should not in my opinion be employed. If a catheter will not pass on the first attempt it must not at once be assumed that the stricture is impervious, as it may yield on a future occasion ; but gentle and persevering attempts with fine catgut bougies, filiform bougies, French silk bougies, or whalebone bougies, should be made. The patient, presupposing there is no retention, may be asked to pass water, and whilst the urine is flowing, and the stricture is in consequence dilated by the stream, a bougie one or two sizes smaller than the stream may sometimes be slipped in. If the point of a catheter is firmly grasped, indicating that it is in the mouth of the stricture, gentle pressure may then be used to push it onwards. If in any of these ways a fine bougie can be got in, it should not be removed till the patient is compelled to pass water, when a small catheter may be subsequently substituted for it, or a railway catheter slid over the bougie before the latter is removed. If after persevering at- tempts, even with the patient under the influence of chloroform, success is not attained, the patient should be prepared for a further trial by rest in bed for a week or so, daily hot baths, purgatives, and the administration of opium. When other means have failed, before resorting to a cutting operation, electrolysis under some circumstances may be tried. Slow or iniermittent dilatation is the simplest and safest method of treatment, and does not usually necessitate the patient leaving his ordinary employment. The various catheters and bougies employed are so well known as hardly to reciuire descrip- tion here. All that need be said is that the soft, flexible, black French bougie, with a bulbous end, is now as a rule generally preferred to a metal or gum-elastic instrument. A bougie or catheter should be passed once or twice a week, beginning with the largest instrument that can be introduced without using force. On the next occasion the same instrument should be again passed and at once withdrawn, and the next size substituted for it, and allowed to remain for a few minutes. In this way the urethra is gradually dilated to its full size. Formerly it was not thought necessary to pass a larger instrument than No. 12, Fnglish scale ; now, however, ii:t\\ surgeons are satisfied till the dilatation has INTERNAL URETHROTOMY. 713 been carried to the size of No. 14. To prevent recontraction the patient should be taught to pass a catheter for himself, and in- structed to do so at first once a week, then every month or six weeks, and subsequently two or three times a year, according to the tendency the stricture may show to recontract. Rapid or continuous dilaiation is very useful : i, when time is an object; 2, when much difficulty has attended the introduc- tion of an instrument, owing to the tightness of the stricture or presence of a false passage ; 3, when the passage of an instrument causes great pain, irritation, haematuria, or rigors ; 4, when gradual dilatation has failed. It consists in tying in a silver cathether for twenty to forty-eight hours, and, on removing it, tying in a size or two larger, and so on till the urethra is fully dilated. The in- strument should not fit the stricture too tightly, and its end should not project far into the bladder. It is better, as soon as the stricture begins to yield, to substitute a gum-elastic for a metal instrument. This method necessitates confinement to the couch or bed for ten days or a fortnight, and is not unattended with risk. It frequently causes great pain ; and rigors, fever, urethritis, cystitis, epididymitis, and ulceration of the bladder from the irri- tation of the point of the catheter, may be induced by it. If the catheter merely causes pain, opium may be given, or the urethra be injected with a solution of cocaine ; whilst if it produces rigors, fever, cystitis, etc., it must be removed. It is generally believed that the mere presence of the catheter in the stricture causes the absorption of the inflammatory material in the submucous tissue, and that this result is not effected by mechanical stretching, since a catheter that does not fit the stricture tightly answers better than one that does, and causes less irritation. The method of tying in a catheter will be learnt by every student whilst dressing. Forcible dilata'jion, splitiing, (jr rupture, has been much advocated by Mr. Holt. He passes through the stricture an in- strument consisting of two parallel blades with a central stem fixed between them, and then over this stem forces a tube the size of the urethra, thus separating the blades and splitting or rupturing the stricture. A full-sized catheter is then passed. The operation is not unattended with danger, and is more liable to be followed by an early relapse than either rapid dilatation or in- ternal urethrotomy. Indeed, internal urethrotomy has now to a great extent taken its place in the treatment of linear, contractile, and penile strictures (the strictures to which splitting is said to be especially adapted), since the cicatrix following laceration of the tissues is much more prone to contract than that following a clean cut. Internal urethrotorh', or division of the stricture from within 30* 714 DISEASES OF REGIONS. the urethra, is an excellent operation, but should only be under- taken when the simpler and safer method of treatment by dilata- tion has failed. It consists of making a clean longitudinal cut with a guarded knife completely through the stricture, and sub- sequently in keeping the edges of the wound apart by the passage of a full-sized bougie till the ovoid gap thus left has been filled with new tissue — the cicatricial splice of the x^merican Surgeons. The cicatrix following a clean cut shows much less tendency to contract than a cicatrix following a laceration or rupture ; hence the superiority of internal urethrotomy over the method of split- ting or ruptare. It is a less severe operation than external urethrotomy, and when a urethrotome can be passed through the stricture should generally be performed in preference to the latter. The cases suitable for it are : i. Intractable strictures that cannot be dilated beyond the size of a No. 5 or 6 catheter. 2. Strictures which rapidly recontract after dilating instruments are discon- tinued. 3. Cases in which the passage of instruments is con- stantly followed by retention of urine, hsematuria, rigors, urethral fever, or other constitutional symptoms. It is especially ajipli- cable to strictures within three or four inches of the meatus. Anaesthesia of the urethra should be induced by injection with a 20 per cent, solution of cocaine. The operation may be done by cutting — I. From before backwards; and 2. From behind for- wards. The latter method requires that the stricture should be dilated up to the size of a No. 4 or 5 catheter to enable the Fig. 344. Tecvan's urethrotome. A, staff; n, n, stylct.s; c, olivary bougie; D, kuife; u, knife sheath. sheathed blade of the instrument to be passed through it ; the former can be done if the stricture will admit a No. 2 catheter. There are many ways of performing both methods. The follow- ing appear to be the best : — 1 . Internal division of the stricture from before backwards. — If the stricture is sufficiently near the meatus it may be simply divided by a straight blunt-pointed bistoury ; otherwise Teevan's INTERNAL URETHROTOMY. 715 urethrotome (Fig. 344), which is a modification of Maisonneuve's, or Berkley Hill's instrument, should be used. Teevan's consists of a slender staff a with an open slot running along it to within two inches of its head. Within this staff is fitted a stylet b. The slender olivary bougie c is first wriggled through the stricture into the bladder ; the staff a is then screwed on to the bougie and made to follow it, the bougie coiling up in the bladder. When the stylet is withdrawn the urine will escape, if the instrument has passed into the bladder and not into a false passage. The knife D, covered by the sheath e, is then placed inside the slot, and the stem of the sheathed knife is pushed down to the stricture. The knife is next protruded to half an inch, and then withdrawn in its sheath, which is pushed forward to see if the stricture is com- pletely divided. If it be not, the process is repeated. Teevan divides the roof of the urethra to avoid the bulb, and the conse- quent danger of haemorrhage from that structure. As soon as the canal is free from one end to the other, he pass a full-sized silver catheter to prove that the calibre of the urethra has been restored, and completely empties the bladder. He advises that a catheter should not be left in, and no instrument passed for four days. Fig. 345. Thompson's modification of Civiale's urethrotome. 2. Internal divisio)i of the stricture from behind fojivards. — ((?) Sir Henry Thompson uses a modification of Civiale's urethrotome (Fig. 345). He first dilates the stricture to the size of No. 4 or 5 bougie ; then passes the bulb of the urethrotome, which contains the guarded knife, about a third of an inch beyond the stricture ; protrudes the knife by a suitable arrangement in the handle, and draws it firmly towards the meatus for about an inch and a half, dividing the stricture along the floor of the urethra, and a little of the healthy mucous membrane at each end of it. He then passes a No. 14 or 16 bougie, and if this is felt to be held at any point re-introduces the urethrotome, and divides what remains of the stricture. A No. 12 gum-elastic catheter is then tied in for twenty-four to forty-eight hours, {b) Dr. Otis uses what he calls a dilating urethrotome (Fig. 346). It is introduced beyond the stricture, the screw at the handle is turned, dilating the in- strument up to a millimetre or two beyond the normal calibre of the stricture, in order to make the latter completely salient. Then the blade is drawn through the stricture, dividing it from 710 DISEASES OK REGIONS. behind forwards. Otis claims that when the stricture has been completely divided, re-contraction does not occur. This, how- ever, would appear to be contrary to the experience of Surgeons generally, the stricture returning (though less rapidly), as it does after all methods of treatment, if a bougie is not occasionally passed. For strictures in front of the scrotum, internal urethrotomy is a very successful operation; but in deeper situations it has been followed by abscess, severe hcemorrhage, extravasation of urine, Fig. 346. Otis' urethrotome. cystitis, nephritis, and pyaemia. It would appear to be attended with a mortality ranging from i to 3 per cent. External urethrotomy, or opening the urethra from the perineum, may be required for two distinct conditions, i. For certain strictures which, though pervious to instruments, are of an intractable nature. Here the operation known as Syme's should be done. 2. For strictures through which, even after the utmost perseverance, an instrument cannot be passed. In these cases the stricture may be divided by VVheelhouse's modification of the old method of perineal section ; or the urethra may be Fig. 347. Syme's staff. opened by Cock's method, /. c, behind the stricture at the apex of the prostate, and the siricture left undivided in the hope that, relieved from the pressure and irritation of the urine, it may be- come pervious to instruments. Syme's nie/hod of external urethrotomy or perineal section. — Syme advises this operation for — i, irritable, and 2, contractile strictures "that are indomitable by the ordinary means of treat- ment." For such, however, internal urethrotomy is now gene- INTERNAL URETHROTOMY, 717 rally preferred, and Syme's operation reserved for 3, indurated and cartilaginous strictures, complicated by intractable perineal fistulse where dilatation has failed. Introduce Syme's shouldered staff (Fig. 347) so that the slender part passes through the strict- ure into the bladder, and the shoulder of the thicker part rests against the face of the stricture. Place the patient in the litho- tomy position, and make an incision one inch and a quarter long through the middle line of the perineum over the stricture. Having felt the staff distinctly in the wound, take it in the left hand, " and guarding the knife with the right forefinger, insert its point into the groove on the bladder side of the stricture, and divide the stricture from behind forward. When completely di- vided, the thicker part of the staff can be pushed on into the bladder." A full-sized catheter should be tied in for twenty-four hours. The difficulties attending Syme's operation are — i, to be sure that the staff is in the bladder, and not in a false passage ; and 2, to pass a catheter afterwards. These are obviated by the modification suggested by Teevan. He advises a catheter-staff with a groove on its convexity, along which the knife can be run to divide the stricture. When introduced, it is known to be in the bladder by the escape of urine on removing the stylet. A bougie is then screwed on to its end, and a gum-elastic railway catheter is passed over the bougie and staff till arrested by the stricture, and is there fixed by a screw. When the stricture is thought to be divided, the catheter is advanced over the staff; and if all is divided, will pass on into the bladder. The catheter- staff can now be withdrawn, and the catheter, if desired, left in the bladder. Syme's operation is very useful, but like other methods, is liable to be followed by recontraction if a bougie is not occasionally passed. Perineal section must not be confounded with Syme's opera- tion, to which this term is sometimes apphed. The older opera- tions of perineal section were performed by cutting into the urethra either in front of or behind the stricture, and then trying to divide the stricture without a guide. They were the most difficult operations in Surgery. The stricture was often missed altogether and an incision made by its side, and the greatest dif- ficulty was experienced in finding the proximal end of the ure- thra. Indeed, after a long search the Surgeon had ofteai the mortification of having to send the patient back to bed without having succeeded in reaching the bladder. These difficulties have to a great extent been overcome by Mr. Wheelhouse, who, instead of cutting down upon the end of the staff on the face of the stricture, opens the urethra half an inch in front of it, and passes a director through the opening thus made in the urethra into the stricture and divides the latter, 7i8 DISEASES OF REGIONS. Wheelhouse's modification of perineal section. — Pass Wheelhouse's staff (Fig. 348), with the groove downwards, to the stricture. Place the patient in the Hthotomy position with the pelvis raised so that light may fall into the wound. Make an incision in the middle line of the perineum, and open the urethra on the groove, Fig. 348. Wheelhouse's staff. (not on the point of the staff) so as to be half an inch \x\ front of the stricture. Seize the edges of the healthy urethra on each side by artery forceps, and hold them apart. Withdraw the staff a little, turn it so that the groove looks toward the pubes, and catch up the upper angle of the opened urethra by the hooked end. The urethra is thus held open at three points (Fig. 349). Search Wheelhouse's method of opening urethra. (Hryant's Surgery.) for the stricture, and pass a slender probe-pointed director through it into the bladder. Divide the stricture with a probe- pointed bistoury run along the groove in the director. Pass the point of the j)robe-gorget (F"ig. 350) along the groove of the di- rector towards the bladder, dilating the divided stricture. Intro- duce a gum-elastic catheter from the meatus into the wound, and guide it by the gorget into the bladder. Withdraw the gorget, and retain the catheter in the urethra for three or four days. The catheter should allow a catgut bougie to pass through it to act as a guide when it has to be changed. URETHRAL OR URINARY ABSCESSES. 719 Cock's operalion of perineal section, or tapping the dilated urethra at the apex of the prostate "unassisted by a guide staff." Secure the patient in the hthotomy position. Pass the left fore- finger into the rectum, and place its points on the apex of the prostate. Plunge a double-edged scalpel (Cock's knife) boldly into the median line of the perineum, and carry it towards the tip of the finger in the rectum. Enlarge the incision by an upward and downward movement of the knife, but do not withdraw it. When the point is felt near the tip of the finger, pass it onwards into the urethra. Withdraw the knife, keep the finger in the rectum, and guide a probe-pointed director into the bladder. Withdraw the finger from the rectum, and pass a cannula along the director into the bladder, and tie it in for a few days. This appears to be Fig. 350. Wheelhouse's probe-gorget. a good operation for impervious stricture with fistulse and much induration of the perineum, and is held in considerable favor by some of Guy's Surgeons. For such strictures, however,' Wheel- house's operation is more generally performed. Electrolysis has recently been advocated for stricture, and several successful cases in this country have been reported by the late Dr. Stevenson and Mr. Bruce Clarke. It consists in passing a catheter-electrode down to the face of the stricture, connecting it with the battery, and applying the other electrode to some other part of the body. It is believed to act by causing some chemical change in the cicatricial tissue, thus leading to its ab- sorption. It has been employed for stricture where an instrument after persistent attempts. cannot be passed, and as a substitute in some cases for dilation. Sufficient time has not elapsed to judge of the results that may be expected from this method of treat- ment. It is certainly not unattended with danger — extravasation of urine and even death having followed its employment. Urethral or urinary abscesses may occur at any part of the urethra, but the most common situation is in the perineum. Cause. — They are most often formed in connection with stricture, 720 DISEASES OF REGIONS. and are then due to ulceration and local extravasation of urine behind the seat of obstruction. The)' may also result from injury inflicted either from without or from within, as passing an instru- ment along the urethra, or the impaction of a calculus ; or they may occur during an attack of gonorrhosa from inflammation ex- tending to one of the urethral follicles, or to Cowper's glands. The sis^/is of a urethral abscess in the perineum, its most common sit- uation, are the presence of a hard, brawny, deeply- seated swelling, generally beginning in the middle line just in front of the anus, and as it increases in size, making its way to one or other side of the perineum in the direction of the groin. At first, while the pus is bound down by deep fascia, there is no fluctuation, and it is only as it approaches the surface that this sign of abscess can be detected. The abscess is attended with throbbing pain, often with sharp constitutional disturbance, and occasionally with a rigor ; it may also cause retention of urine. Tj-eatincnt. — Fluctua- tion must not be waited for, but a catheter passed down the urethra, and a free incision made in the median line of the peri- neum into the swelling. If the abscess is not opened, it may break externally on the perineum, or it may burrow amongst the tissues and break into the rectum ; and if not already in connec- tion with the urethra, as when the abscess forms external to it, it may break into that canal. Urinary fistula are generally the result of urinary abscess in connection with stricture of the urethra. They may also be due to wounds of the urethra, made accidentally, or by surgical opera- tion, or to ulceration following impaction of a calculus. They are commonly divided into three kinds: — i. The perineal; 2, the scrotal ; and 3, the penile. — The perineal may be single or mul- tiple ; the scrotal are nearly always multiple ; and the penile single. In long-standing cases the fistulje may burrow among the tissues of the groin, nates, and thighs, and may even open into the rectum. Treatment. — When due to stricture, the fistulee will generally readily heal when the stricture is cured and a free natural pass- age is established for the escape of urine. Should they not do so — I. h perineal fistu/a when small may be induced to close by passing a soft catheter to prevent the contact of urine whenever the patient micturates, or l)y inserting into the fistula a hot wire or a ])robe coated with silver nitrate. If these means fail, the edges of the fistula may be pared and brought together by sutures. When the parts are indurated and the stricture is of the cartilaginous kind, external urethrotomy and laying open of the fistulas should be practised. 2. ^SVri^/^/yf.f/'///*^' nearly always re- quire freely laying open, and when secondary fistulse extend to EXTRAVASATION OF URINE. 72 1 the groin or buttock they should also be treated in this way. 3. Penile fisiulce when latge, and especially when the result of slough- ing consequent upon the impaction of a calculus, usually require a plastic operation. Extra VASAiiON of urine is commonly, though not always, the result of stricture, and is then due either to the dilated urethra behind a stricture ulcerating and giving way, or to a lacunar ab- scess bursting into the urethra. In either case, the urine is forced by the contraction of the bladder into the surrounding cellular tissue. The urethra may give way ( i ) in front of the anterior layer, (2) between the two layers, and (3) behind the posterior layer of the triangular ligament. In the first and by far the most common situation, it is the bulbous portion of the ure- thra that gives way. Here the urine is prevented from passing — I, backwards into the pelvis by the anterior layer of the tri- angular ligament being attached to the rami of the pubes and ischium and sub-pubic ligament; 2, downwards into the ischio- rectal fossa by the anterior layer of the triangular ligament being continuous around the transverse perineal muscle with the deep layer of the superficial fascia of the perineum ; 3, laterally, on to the thighs by the deep layer of the superficial fascia of the peri- neum being attached to the rami of the pubes and ischium. Hence it passes in the middle line into the cellular tissue of the scrotum and penis, and laterally on to the abdomen, where it is prevented from passing down the thigh by the deep layer of the superficial fascia of the groin (which is continuous with the deep layer of the superficial fascia of the perineum) being attached along the line of Poupart's ligament. When the membi-aneous portion of the urethra is ruptured, the urine is confined at first between the two layers of the triangular ligament, and if not let out will make its way (i) forwards, through the anterior layer, and take the course as given above; or rarely (2) backwards, through the posterior layer, and then, as when the urethra gives way behind the poster- ior layer, will make its way around the neck of the bladder, and will be almost inevitably fatal. Wherever the urine spreads, it causes inflammation and sloughing. Symptoms. — The history of a case of extravasation is not un- commonly as follows : A patient with a tight stricture is strain- ing to pass water; he feels something give way, experiences a sen- sation of relief, and perhaps owing to the tension being removed by some urine being forced into the cellular tissue, the super- added spasm for a time ceases, and a few ounces of urine are passed through the urethra. In half an hour or so a pricking or burning sensation is felt in the perineum, soon followed by pain, and by rapidly increasing swelling of the perineum, scrotum and 31 722 DISEASES OF REGIONS. penis. If the urine is not let out by timely incisions the swelling extends to the groin, and in some cases has been known to reach as high as the axilla. The skin now appears dusky or purplish- red and oedematous, and gangrene and sloughing of the infiltrated tissues rapidly ensue. The absorption of the septic products gives rise to constitutional disturbance and fever, which though it may at first run high, soon assumes a low typhoid character, and the patient, especially if the subject of chronic kidney disease, frequently sinks into a comatose state and dies. When the ex- travasation occurs between the two layers of the triangular liga- ment, it may remain localized, giving rise to a hard circumscribed swelling in the perineum, which may slowly make its way towards the scrotum ; and lastly, when the extravasation occurs behind the posterior layer of the triangular ligament and the urine is ex- travasated into the pelvic cellular tissue, the symptoms resemble those of extra-peritoneal rupture of the bladder. Treatment. — A catheter should be passed into the bladder, or where this is impossible, down to the stricture, and in either case a free incision in the middle line of the perineum extending into the urethra made on the catheter. P"^- 351- Free incisions through the skin ' -^ • (" .. -'^ of the scrotum, penis and groins, . ' in fact, wherever the urine has j penetrated, should hkewise be • ./ made to allow of its draining '>^- ' away, and the wounds rendered as / far as possible aseptic by the free application of iodoform or other antiseptics. The patient's strength ' at the same time must be sup- ported by fluid nourishment and stimulants ; whilst opium should be given, unless contra-indicated ^'' on account of kichiey disease. Calculus impacto'J in urethra. (St. Bar- Q.rr^^TT- txr 1 in- TiurTuia a A ci-r,in tholomew's Hospital -Museum.) bfONE IN IHE UREIHRA. A Small calculus or fragment of one may become impacted in any part of the urethra, but most frequently in the membraneous portion (F'ig. 351), or just within the meatus. When sharp and angular it causes much pain, and when large enough to obstruct the urethra gives rise to retention, and, if not soon removed, to ulceration, followed by extravasation of urine. Treatment. — If far forward, it may often be expelled, whilst straining to ])ass water, by holding the meatus and suddenly let- ting go ; or gentle manipulation, aided, if necessary, by incision of the meatus, may suffice. I-'.xtraction by the urethral forceps RETENTION OF URINE. 723 should next be tried (Figs. 352 and 353), and this failing, a free incision over the stone must be made. Thus, if impacted in the membraneous portion, it should be removed through an incision in the middle line of the perineum ; if in the penile portion just in front of the scrotum, it should be pushed back if possible into the membraneous portion and removed through the perineum, as an incision in the penile portion cf the urethra is apt to be fol- FiG. 352. Urethral forceps (Arnold's). lowed by a fistula, and should, if possible, be avoided. If com- pelled to incise the penile urethra the incision should be free, so as to prevent laceration of the tissues in extracting the stone. The edges of the wound should then be united by suture, and a soft catheter tied in the urethra for a few days till the incision has healed. Vascular tumors are much more frequent in the female than in the male urethra. In the female, they occur as small florid excrescences usually situated about the entrance of the urethra, Fig. 353. Hogan's urethral forceps. often surrounding it like a ring and perhaps extending some dis- tance up it. They give rise to increased frequency of micturition, pain during the act, and intermittent attacks of haemorrhage, thus somewhat simulating the symptoms of a calculus ; but inspection will at once reveal the nature of the affection. Ti-eatmeni. — Ligature, or the applicadon of nitric acid or the therrao-cautery, generally suffices for their cure. Retention of urine, or inabihty to pass water, must be dis- tinguished from suppression of urine, in which none is secreted by the kidneys, Crt;//jrd'.^Retention may depend upon either ^a) obstruction to the outflow of urine from the bladder, or (/') in- ability of the bladder to expel its contents consequent upon atony of its muscular coat or paralysis. Retention, therefore, is 724 DISEASES OF REGIONS. a symptom of several diseases, i. In the old, it is commonly due to enlarged prostate with superadded congestion, combined with atony of the bladder from over-distension. 2. In adii/t men it may be due to organic stricture with temporary spasm of the un- striped muscular fibres of the urethra, or to congestion of the mucous membrane owing to gonorrhoea, a drinking bout, or cold and wet. 3. In -ivomen it may be the result of hysteria, or the pressure of an enlarged uterus or other pelvic tumor, or of the foetal head in parturition. 4. In children it is commonly caused by an impacted calculus or ligature of the penis, and more rarely by phimosis. 5. At all ages and in both sexes it may be due to reflex spasm after an operation on the rectum, shock following any severe injury or operation, a tumor in the neck of the bladder or urethra, and an abscess in an}' part of the urethra. It may also be due to paralysis consequent upon disease or injury of the brain or spinal cord, and to atony of the muscular coat of the bladder. In the two latter conditions, however, after the bladder has be- come distended and will hold no rnore, the excess of urine pas- sively overflows, dribbling constantly away ; and this condition of false incontinence must be distinguished from true incontinence, in which the urine runs away from the bladder as fast as it is secreted by the kidneys. Symptoms and signs. — When retention has come on slowly, as from the gradual contraction of an organic stricture, there may be but little local pain and no constitutional disturbance, even al- though the bladder may be distended by many ounces of urine. Where, however, it is produced suddenly, there is usually great pain followed by severe constitutional symptoms — a small and frequent pulse, a dry and brown tongue, and perhaps delirium, sym])toms probably due to the sudden check to secretion by the kidneys, and to the stretching of the bladder. The bladder it- self, unless greatly hypertrophied and contracted, rises out of the pelvis, and may be felt as a distinct tumor, dull to percussion, and at times extending as high as the umbilicus, or in extreme cases even to the ensiform cartilage. The patient, unless drunk, usually com])lains of inability to pass water. When, however, the blad- der has become gradually distended and urine is passively flowing away, he may complain of inability to hold his water, and be quite unaware that the bladder is full and may object to have a catheter passed till the condition has been explained. The pres- ence of a swelling in the abdomen, and the flowing of urine through the catheter immediately after the patient has passed water and believes that he has emptied his bladder, should serve for the diagnosis. ' \\\ supi)ression, the bladder is found empty on passing a catheter. RETENTION OF URINE. 725 Resua's of retention. — If the bladder is soon relieved no appar- ent harm maj ensue. If neglected, hov/ever, the over-distension may lead to — i, atony of the muscular coat- 2, cystitis; 3, neph- ritis ; 4, rupture of the urethra behind the obstruction : 5 (rarely), rupture of the bladder itself; and 6, passive overflow of urine, the bladder remaining full. Treatment. — The distended bladder must be relieved, and if the distension is extreme and the symptoms urgent, at once. The way of doing this will vary according to the cause, and will be considered under the following heads : 1. Retention from spasm of the jinstriped fibres surrounding the urethra, sometimes called spasmodic stricture. Spasm is rarely, if ever, sufficient, alone, to cause retention. Generally some slight organic narrowing of the urethra is also present. The usual history of retention from spasm is a drinking bout, or exposure to cold or wet in a gouty or rheumatic subject ; while on careful questioning, the patient admits that the stream has been noticed to be small or forked, or that a similar attack of retention has previously occurred. If the retention has existed for some time, and there is much pain and considerable distension of the blad- der, a full-sized flexible catheter (No. 8 or 9) should be passed, if necessary under chloroform. When, however, the symptoms are not urgent, and an instrument has never been passed, a hot bath and a full dose of tincture of opium will generally suffice. In retention due to spasm following operations, a well-oiled soft- rubber catheter should be passed. When the spasm is associated with a severe organic stricture other means may have to be taken. See Treatment of Retention from Organic Stricture. 2. Retention from congestion of t]u mucous }nembrane of the urethra, sometimes known as congestive stricture. Congestion, hke spasm, is seldom sufficient of itself to produce retention; and is nearly always associated with at least a shght organic stricture or with some enlargement of the prostate. It is usually the re- sult of gonorrhoea, or other conditions causing inflammation of the urethra. The treatment is similar to that of retention from spasm. 3. Retention from hypertrophy of the prostate only occurs after middle life. It is then generally due to congestion induced by cold, the abuse of alcohol, etc., causing the already existing obstnic- tion to become complete. First, try to pass a No. 9 French single coude catheter (Fig. i'^'^^, then a double coude (Fig. 339), and these failing, a gum-elastic catheter with a large curve. Should the point hitch at the middle lobe of the prostate, withdrawing the stylet for half an inch will cause the end to slightly tilt up. 726 DISEASES OF REGIONS. and it will then often readily glide into the bladder. If not suc- cessful in this way the silver prostatic or the beaked catheter must next be tried, but serious mischief may be done by these instru- ments unless the'greatest gentleness is used. They should never be employed until other forms have failed. If a catheter passes easily it may be withdrawn after the bladder is relieved ; but if passed with difficulty it had better be left in, as more harm may be done by having to pass it again than by leaving it in situ. When the bladder is greatly distended all the urine should not be drawn off at once, lest syncope be induced. A catheter failing, the reten- tion may be relieved by : i, puncture above the pubes ; 2, punct- ure through the rectum ; and 3, forcing a catheter through the prostate {tiinnellini:^). The first method is decidedly the best. The second is seldom applicable, as the enlargement, as a rule, leaves no room between the prostate and the pouch of peritoneum for puncture, which, if attempted, will probably wound the peri- toneum. The third method is attended with extreme danger, and is seldom practised at the present day. 4. Retention from organic stricture. — The symptoms and diag- nosis of stricture have already been described. Here only need be mentioned the treatment to be adopted in cases of retention from this cause. An endeavor should first be made to pass a catheter, if necessary under an anaesthetic. If this fails, and the symptoms are not urgent, a hot bath and a full dose of tincture of opium may be given, and another trial made in a few hours. Where, however, there are signs of grave kidney mischief, opium must be withheld or given with great caution. Should these means not succeed, or if from the first the symptoms are urgent, one of the following methods may be resorted to, viz.; i, Aspiration or puncture of the bladder above the pubes; 2, Wheelhouse's oper- ation ; 3, Puncture of the bladder through the rectum ; 4, Cock's operation of opening the urethra behind the stricture through an incision in the perineum; and 5, Forcing a catheter into the bladder. The last method is highly objectionable, and should on no account be [)ractised. Of the other methods aspiration above the pubes, repeated, if necessary, should the stricture not quickly yield after the s])Tsm has been removed by emptying the bladder and thus reducing the tension, is in my oi)inion the best. Punct- ure through the rectum is strongly recommended by some Sur- geons ; but it is open to the objection that suppuration between the bladder and rectum, extravasation of urine, and a permanent recto-vesical fistula, are liable to follow, to say nothing of the an- noyance to the patient from the presence of the cannula in the rectum, and the excoriation of the parts by the urine, which, not- withstanding care, is apt to occur. The vas deferens, moreover. PUNCTURE OF THE BLADDER THROUGH THE RECTUM. 727 may be injured, and atrophy of the testicle ensue. Cock's operation is difficult to perform, and does not appear to possess any advantage over aspiration or puncture above the pubes. Should the passage of a catheter not be effected after the bladder has been aspirated on several occasions, Wheelhouse's operation should be under- taken. Aspiration, though as a rule attended with excellent re- sults, is not absolutely free from danger. Thus it should not be practised when the urine is unhealthy, or the walls of the bladder are thin and atonied, lest a drop or two escape through the punc- ture and set up septic inflammation and suppuration, which may be followed by extravasation of urine. 5. Retention from hysteria should be combated by such moral and physical treatment as is applicable to that disease. A cathe- ter should not be passed if it can be possibly avoided. A hot sponge applied to the pubes is often successful. 6. Retention f7-om paralysis or atony of the bladder, from abscess or tumor of the urethra or bladder, from impacted calculus, and from ligature of the pelvis, is discussed under the heads of Paraly- sis of the Bladder, Impacted Calculus, etc. Puncture of the bladder above the pubes (Fig. 284, b). — Make a small incision through the skin immediately above the pubes, having first ascertained by percussion that the bladder has risen well out of the pelvis, and thrust Cock's curved trocar and cannula downwards and backwards into the bladder. Withdraw the trocar, secure the cannula in situ, and pass through it a soft catheter connected with a long rubber tube to carry away the urine. In a few days, when the parts are consolidated, the can- nula should be changed. When the bladder is distended, a gtgved inch rises above the pubes uncovered by peritoneum, but when contracted and hypertrophied it may rise but little, if at all. Under these latter circumstances the trocar and cannula must be passed close to the pubes, for fear of wounding the peritoneum. Aspiration is performed in a similar way, except that the aspi- rating needle or trocar is thrust in without any preliminary inci- sion of the skin. If a small aspirating needle or cannula is used there is no danger of extravasation, as on its vvithdrawal the puncture in the bladder is closed by the contraction of the mus- cular fibres ; and even should a drop or two of urine escape no harm will ensue, provided the urine is healthy. It is a most useful emergency operation, and, if necessary, may be repeated on several successive occasions. PuNcruRE of the bladder THROUGH THE RECTUM. — Place the patient in the lithotomy position. Pass the left forefinger into the rectum, and place its tip just beyond the back of the prostate. Take Cock's long curved trocar and cannula, with the point of 72$ DISEASES OF REGIONS. the trocar slightly withdrawn within the cannula. Introduce it through the anus, and guide it by the finger in the rectum to a spot immediately behind the prostate exactly in the middle line. Press the cannula firmly on the fluctuating trigone of the bladder, and plunge the trocar boldly into the bladder, in a direction up- wards and forwards towards the umbilicus. Withdraw the trocar and secure the cannula /;/ situ with suitable tapes. Do not plug the cannula, but fix an india-rubber tube on its end and convey this to a vessel beneath the bed. DISEASES OF THE GENITAL ORGANS. DISEASES OF THE PENIS. Paraphlmosis is the strangulation of the glans penis by a tight prepuce- which has been drawn back over it, and cannot be re- placed. Thus, it is not infrequently met with in boys, from the accidental uncovering of the glans and neglect to draw the pre- puce forward again. In adults it is generally due to swelling, caused by gonorrhoea or venereal sores, but it may occasionally occur during coitus. It is attended with great oedema of the glans and prepuce, and if not soon reduced may lead to ulcera- FlG. 354. Mclliod of dividing the stricture in parnphimosis. (Tiryant's SurRcry.) tion at the line of constriction, or even to sloughing of the penis. 7'reat7ncni. — Seize the penis between the first and second fingers of each hand, press the blood and oedema out of the glans with the thumbs, and at the same time push the glails backwards and try to' draw the prepuce forwards over it. If this fails, divide with a knife (Fig. 354) the constricting band, which lies just be- DISEASES OF THE GENITAL ORGANS. 729 hind the fold of oedematous prepuce at the bottom of the furrow on the dorsum of the penis. Phimosis is a condition in which the prepuce is elongated, and its orifice contracted, so that it cannot be drawn back over the glans. It may occur as a congenital affection ; or it may be acquired, and is then usually due to the cicatricial contraction of the orifice following syphilitic ulceration or repeated attacks of gonorrhoea. The orifice when very small may cause difficulty of micturition or even retention of urine ; whilst the straining to pass water may induce prolapse of the rectum, hernia, irritation of the bladder, and symptoms of stone, and if not reheved may produce the harmful effects on the urinary organs described under stricture ; or the deposit of the urinary salts beneath the prepuce may lead to the formation of preputial calculi. The inability to uncover the glans may cause pain and difficulty in coitus, and by preserving a mucous membrane-like character to the glans predispose to vene- real disease ; whilst the secretion which collects beneath the prepuce may, in conse- quence of the irritation it Fig. 353. is apt to set up, induce priapism, habits of mas- turbation, inflammation sometimes simulating gonorrhoea, adhesion of the glans to the prepuce, or even as age advances the formation of an epi- thelioma. The treatment may be considered under the head of i, circujn- cision ; 2, slitting the pre- puce; and 3, dilatation of the preputial orifice. 1. Circumcision. — Lay hold of the prepuce transversely with a pair of polypus forceps, on a level with the corona (Fig. 355) ; let the glans slip back, close the forceps, and shave off the prepuce in front of them with a clean sweep of the knife, llemove the forceps, slit up the mucous lining of the prepuce in the middle Hne quite back to the corona, break down any adhesions between the prepuce and glans, wash away the secretion, twist or tie any spurting vessels, and stitch the flaps of mucous membrane to the skin with interrupted horse-hair or catgut sutures. Dress with boracic lint or iodoform gauze. 2. Slitting the prepuce may be done with scissors, or with a curved bistoury guided by a director, introduced between the Seizing the prepuce preparatory to the operation of circumcision. (Bryant's Surgerj-.) 73© DISE.\SES OF REGIONS. glans and prepuce. In either case the mucous membrane should be united to the skin-flaps by fine sutures after twisting and tying any bleeding vessels. Care should be taken not to pass the di- rector into the meatus, and to ensure that the mucous membrane is slit quite back to the corona. 3. Dilatation of the prepuce may be accomplished in slight cases by a daily endeavor to draw back the contracted prepuce over the glans. It may also be done by the preputial dilator, or by forcible separation of the blades of the dressing forceps, though such means are not often successful. Primary venereal sores or chancres. — Two chief varieties of venereal sore or chancre occur, the syphilitic or infecting, and the local contagious or non-infecting. Either of these may be accom- panied by sloughing or phagedaena, and is then spoken of as sloughing and phagedaenic sore or chancre. 1. The primary syphilitic chancre has already been described in the section on syphilis (p. 66). 2. The local contagious or non-infecting sore, the soft chancre or chancroid, as it is sometimes called to distinguish it from the hard or svphilitic chancre, is a specific form of ulceration probably de- pending upon a distinct variety of micro-organism. Though this ulcer, like the syphilitic, may occur on any part of the body that is inoculated with the specific virus, it is so much more frequently met with on the genitals that it is described with diseases of these organs. It is not followed by constitutional symptoms. Signs. — Non- infecting or soft chancres are most frequent at the junction of the glans and prepuce, where they often take the form of a ring of small ulcers around the corona glandis. More rarely they are met with on the muco-cutaneous or cutaneous surface of the organ. They usually begin as a small pustule or slight excori- ation within a few days of inoculation, and when fully established, appear as small oval ulcers, with sharply-cut edges and a slightly depressed base covered with a greyish slough, and surrounded by a red areola of inflammation. When irritated, as by the rubbing of the clothes, or the retention of the secretion beneath a long prepuce, they may become indurated ; but the induration has not the sharply-defined character of the syphilitic sore. The inguinal glands become enlarged {bubo), and matted together into a single mass, often of considerable size, and have a marked tendency to suppurate. The pus taken from them apparently contains the same micro-organism as that of the sore, since when inoculated on the same or another person a similar sore is produced. Diagnosis. — The main differences between a non-infecting or soft sore, and an infecting or hard, are the following : — The soft sore is generally unattended with induration ; in the hard the EPITHELIOMA. 73 1 induration is generally well marked ; the soft occurs within a few days of inoculation, the hard not till after three to five weeks ; in the soft the secretion is abundant and purulent, in the hard scanty, and often consists of little more than epithelial debris ; the soft can be reinoculated on the same patient, and hence is frequently multiple ; the hard cannot be reinoculated on the same patient, and hence is single unless, as very rarely happens, the patient is inoculated in two places at the same time. The bubo following the soft sore is single, soft, and very liable to suppurate ; that following the hard sore is multiple, hard, and shotty, and very rarely suppurates. A patient, however, may be inoculated with syphilis at the same time that he receives a soft sore. Hence, when the incubative period of syphihs has passed, the soft sore may take on the characters of the hard sore. Till this period is over, therefore, a cautious prognosis as to ihe probable occurrence of secondary symptoms should be given. It is con- sequently not uncommon to find a patient with a chancre which presents characters both of the hard and soft sore. Treatment. — Local treatment only is necessary, and consists in scrupulous cleanliness, protection of the sore from irritation, and the appHcation of black-wash, zinc lotion, or iodoform. Should the glands become inflamed, rest in the recumbent posture is essential. If the suppuration threatens, hot poultices must be applied and a free incision in a vertical direction made as soon as pus has formed. Should any intractable sinuses, as frequently happens, be left after the bubo has suppurated, they should be laid freely open, and allowed to granulate from the bottom. 3. The sloi/ghi?}g sore is due to want of cleanliness or the re- tention of irritating discharges by a long foreskin, and generally occurs in weakly or debilitated subjects. The sore, which is cov- ered with a yellow slough, and is surrounded by an angry areola of inflammation, spreads rapidly, and is attended with consider- able swelling and oedema of the penis. The general appearances of the ulcer and its appropriate treatment have already been given in the section on Ulcers (p. 48). 4. The phagedcEiiic sore — Phagedrena may attack both the hard and soft sore, bist is said by Mr. Hutchinson to be a more fre- quent complication of the former than of the latter. Like the sloughing sore, it may be due to want of cleanliness and neglect, or to the irritation of the discharges retained by a long foreskin. It seldom, however, occurs to any serious extent, except in those whose constitutions are broken down by want of food, abuse of alcohol, debauchery, or exhausting disease. For a description of the characters and treatment of this ulcer see p. 48. Epithelioma of the penis generally begins as a warty growth or 732 DISEASES OF REGIONS. as an ulcer on the glans or inner surface of the prepuce. Old age is looked upon as the chief predisposing, and the irritation of retained secretion under a long prepuce as the common ex- citing cause. The indurated, sinuous and everted edges of the ulcer, the warty base, sanious and foul discharge, rapid growth, advanced age of the patient, and later, the involvement of the inguinal glands, will generally serve to distinguish it from warts or venereal ulcers, for which it may be mistaken. If allowed to nm its course the whole penis becomes infiltrated with the growth ; the lumbar, as well as the inguinal glands, become involved ; sloughing and ulceration ensue, and the patient generally dies of exhaustion or hsemorrhage. The internal organs are not usually affected. Treatment. — If seen early, the growth alone may be removed. As a rule, however, the penis should be amputated in front of the scrotum unless the glands are much involved or the disease extends backwards beyond this point. In such a case the scrotum may, under certain conditions, be %\)\\X., the whole penis, with the crura, removed, and the urethra stitched to the perin- eum. The inguinal glands, if not too extensively diseased, should be also removed. Amputation of the penis is often performed by one sweep of the knife ; when thus done the urethra is liable to retract and cause subsequent trouble in micturition. It is best therefore to divide the corpus spongiosum about half an inch further forward than the corpora cavernosa, and then split the urethra and secure it by four sutures to the skin. The skin should be drawn well forward before it is divided, as otherwise it is apt to obscure the more retractable stump, and render the securing of the arteries difficult. Too much skin, moreover, is liable to obstruct the orifice of the urethra. Haemorrhage during the operation should be restrained by Clover's clamp or by the fingers of an assistant. The two dorsal arteries and the arteries of the corpora cavernosa and of the septum usually require ligature. Amputation by the galvanic ecraseur is strongly advised by some, but is open to the objection that it may be followed by secondary haemorrhage on the separation of the sloughs. DISEASES OF THE SCROIUM, SPERMA'IIC CORD, AND TESTICF.E. Epithelioma of the scrotum, often called sweep's cancer, from the frequency with which it occurs in chimney-sweepers, owing to the irritation of the soot, generally begins as a dark wart or tuber- cle which ultimately ulcerates, producing a sore with hard sinuous everted edges, and an irregular warty tuberous base. At times it begins as a chronic eczema. The irritant would appear to be not HYDROCELE. 733 merely the carbon of the soot, but one or more of the products of the destructive distillation of coal, as the cancer does not occur from soot produced by the burning of wood, and is found amongst workers in coal-tar and its products. The inguinal glands become involved, and occasionally the testicle, but the disease does not, as a rule, affect internal organs. Death is commonly due to the exhaustion produced by the ulceration in the inguinal glands, or haemorrhage from the opening of a large blood-vessel in the groin. T}-eatmeut. — Free and early excision with the knife, and removal of the inguinal glands if enlarged and hard. If the testicle is in- volved it should be excised at the same time. The skin of the part is very lax, and although the testicle may be denuded it rap- idly becomes covered in. QEdema of the scrotum, owing to the laxity of the tissues, is common. It may occur in kidney and heart disease as part of the general dropsy, or it may be caused by inflammation of the neigh- boring parts, as the testicle. It is also met with in extravasation of urine, and may occur after an operation for hernia, varicocele, etc. ERYS1PEL.AS OF THE scROTUiM may be the result of slight injuries, abrasions, etc., or may occur idiopathically. It is attended with great swelling, redness and oedema, and is very liable to terminate in extensive sloughing and gangrene. The same general and local treatment should be adopted as described under Erysipelas, with free and early incisions should suppuration threaten. Eczema and prurigo of the scrotum require no special mention. Elephantiasis scroti is an enormously hypertrophied condition of the skin and connective tissue of the scrotum, and probably depends (like a somewhat similar condition known as lymph- scrotinn, in v/hich a milky fluid exudes from the skin) on the presence in the blood of the filaria sanguinis hominis. The dis- ease is common in the East, but is seldom met with in this coun- try, and then hardly ever except in those who have lived in the East. The penis is sometimes affected in a similar manner. Treatment. — The hypertrophied mass may be dissected off the testicle and penis, after elevating it for some hours before the operation, in order to drain it as much as possible of blood. The base of the mass during the operation should be constricted by an elastic band. Hydrocele is a collection of serous fluid in connection with the testicle or spermatic cord. There are several varieties of hydrocele. Thus, the fluid may be contained in the tunica vagi- nalis {commoJi or vaginal hydrocele^; and this is further spoken of as congenital when the tunica vaginalis communicates, through the non- obliteration of its funicular process, with the general peri- 734 DISEASES OF REGIONS. toneal cavity, or as acute when associated with acute inflammation of the testicle or epididymis. Again, the fluid may be contained in a cyst in connection with the testicle or epididymis {encysted hydrocele of the testicle or epididymis^, or contained in a cyst formed in connection with the spermatic cord {encysted hydrocele of the spermatic cord). The condition described by Pott and Scarpa as diffuse hydrocele of the spermatic cord appears to be a general dropsy of the loose connective tissue of the cord, and is so rare that it may be dismissed without further comment. Common or vaginal hydrocele is a collection of serous fluid in the cavity of the tunica vaginalis. Causes. — Infancy, middle age, heredity, gout, and malaria are said to predispose to it ; whilst slight injuries, repeated strains, the presence of loose bodies in the tunica vaginalis, and certain chronic diseases of the testicle, are sometimes exciting causes. Often, however, no apparently efficient cause whatever can be discovered. Pathology. — By some it is looked upon as a passive dropsy, due to a loss of balance between the secreting and absorbing power of the tunica vaginalis ; by others it is believed to be due to chronic inflammation. The fluid is of a pale straw color, with a specific gravity of 1020 to 1030, and contains a large quantity of albumen. The dilated tunica vaginalis is usually thin, but in long standing cases it is occasionally greatly thickened, and may be of cartila- ginous consistency. The coverings are the same as those of the testicle, viz., skin, superficial fascia, dartos, and intercolumnar, cremasteric and infundibuliform fasciae. Symptoms. — Ordinary hydrocele forms a smooth, tense, elastic or fluctuating swelling in the scrotum, of a pyriform, globular or oval shape, and is frequently slightly constricted at its middle or at its lower or upper ])art. The chief diagnostic sign is its trans- lucency. If the walls are very thick it may appear opaque when examined for translucency in the usual way by the light of a can- dle, but I have never met with a hydrocele, however thick its walls, which was not found translucent when a powerful light, as that of an opthalmoscopic lamp, was used. The cord is free, and there is no impulse on coughing, signs which serve to distinguish it from a hernia. When the hydrocele extends up the funicular portion of the tunica vaginalis into the inguinal canal there may, however, be a transmitted impulse from the abdominal wall ; it might then be mistaken fcjr an irreducible hernia. The dullness on ]jercussion, the history that it began at the bottom of the scro- tum, and the translucency, if the light be powerful enough, will distinguish it. 'l"he testicle is situated behind and near its lower part, save in exceptional cases, where adhesions have been con- COMMON OR VAGINAL HYDROCELE. 735 tracted to the anterior wall, or the testicle has descended retro- verted. The t7'eatment may be palliative or radical. Palliaiive treat- ment consists in tapping the hydrocele with a trocar and cannula, and repeating the operation from time to time as required. Be- fore tapping a hydrocele the situation of the testicle should be made out, lest it be injured by the trocar. This can usually be done by marking the opaque spot whilst examining for translu- cency, and by the patient's sensation on handling it. If the sac is not very tense the testicle can be felt. Choose a spot for puncture near the bottom of the swelling, free from scrotal veins, which can readily be seen through the skin, and having made out the situation of the testicle, grasp the tumor from behind with the palm of the hand so as to make it tense, and plunge the trocar and cannula, held as in Fig. 356, sharply into the sac to ensure Fig. 356. Tapping a hydrocele. (Bryant's Surgery.) perforating the wall. The trocar should be directed at first back- wards, and then immediately turned upwards to avoid wounding the testicle. Having withdrawn the fluid, remove the cannula, and apply a small pad of lint or strapping. The radical cure is commonly effected by injecting tincture of iodine into the sac through the cannula after having withdrawn the fluid. The quantity injected is usually about two drachms. If ten drops of a 5% solution of cocaine are injected befoie the iodine no pain generally is felt. The iodine sets up some slight amount of inflammation, and generally cures by restoring the balance between the secreting and absorbing power of the tunica vaginalis, or occasionally by causing adhesions between the two layers of the tunica vaginalis. Should the injection fail, it may be repeated ; or the tunica vaginalis may be laid open, a portion cut away, and the remainder united by suture and drained. But 736 DISEASES OF REGIONS. even this treatment cannot always be depended on for curing the hydrocele. The only absolutely certain method is to lay open the sac and allow it to granulate up from the bottom. The hydroceles so frequently seen in young children generally undergo a spontaneous cure, and nothing beyond a discutient lotion is usually necessary. Should the hydrocele prove intract- able, however, it may be punctured with a fine trocar and can- nula, and, if necessary, afterwards injected with a weak solution of iodine. Congenital hydrocele is a collection of fluid in the sac of the tunica vaginalis, the funicular process of which through an arrest of development has remained unobliterated. The fluid, there- fore, unless the aperture of communication is very small, can be readily pressed back into the abdominal cavity, and an expansile impulse is given to it on coughing or crying. In this respect it resembles a hernia; but its translucency and the fact that the fluid goes back slowly and without the sudden slip or gurgle, as is the case in a hernia, should serve to distinguish it. It should not be forgotten that a piece of omentum or intestine may descend into the sac of the hydrocele. At times, the aperture of com- munication between the funicular process and the general peri- toneal cavity is closed, and though the hydrocele still extends more or less up the inguinal canal, the fluid cannot be pressed back into the abdominal cavity. To this condition the name ot infantile hydrocele has been given. Treatment. — k truss should be api)lied over the inguinal canal to cause obliteration of the funicular portion of the tunica vaginalis, and to prevent the descent of a hernia, and subsequently the hydrocele may be treated in the ordinary way. As a rule, how- ever, when the obliteration of the funicular portion has been accomplished, the hydrocele undergoes a spontaneous cure. Encysted hydrocele of the tesmcle. — This term is applied to a cyst or cysts formed in connection with the testicle or epi- didymis, but having no communication with the cavity of the tunica vaginalis. Cysts in connection with the testicle itself are very rare and require no further description here. Encysted hydroceles of the epididymis, however, though still rare, are more often met with, and may be divided into (i) the subserous cysts, which are of no clinical importance, and (2) the spermatic cysts. The latter are thin-walled, membraneous cysts lined with tesselated epithelium, and containing a watery, slightly opalescent or milky fluid, in which there is often an abundance of spermatozoa. The presence of the spermatozoa may be due to the ru])ture into the cyst of one of the seminal ducts ; or to the cyst being developed in connection with a seminal duct. The origin of these cysts is VARICOCELE. 737 doubtful. They are generally believed, however, to be developed from some of the foetal remains (Wolffian body, Miillerian duct, etc.) so abundant in the situation of the epididymis. Signs. — They appear as tense, fluctuating, translucent, movable, globular, smooth or lobulated swellings, without impulse on cough, and situated immediately above or behind the testicle. The cord is generally free. They are often combined with an ordinary hydrocele. The treatment is like that of ordinary hydrocele. Encysted hydrocele of the spermatic cord is a collection of serous fluid in an unobliterated portion of the funicular process of the tunica vaginahs. The fluid is similar to that of an ordinary hydrocele. The coverings of the cyst are those of the funicular process, viz., the skin, and the superficial, intercolumnar, cremas- teric, and infundibuliform fasciae ; the vas with the arteries and veins are behind it. Signs. — An encysted hydrocele of the cord appears as a well- defined, tense, oval or globular, fluctuating, freely movable swell- ing in the course of the spermatic cord. It is unconnected with the testicle below, and cannot be reduced into the abdomen above, although it may be pushed back some distance up the in- guinal canal. It is translucent, and gives no impulse on coughing. But when high up in the inguinal canal, it may be difficult to distinguish from a small irreducible hernia, as an impulse is communicated to it from the abdominal walls, and it may be im- practicable to detect its translucency. A cautious puncture with a grooved needle may then be necessary to diagnose it. Treatment. — Painting with tincture of iodine may first be tried. This faihng, the cyst should be punctured with a small trocar and cannula. Should it refill, it may be injected with iodine, like an ordinary hydrocele, or it may be laid open by an antiseptic inci- sion. But before undertaking its radical cure, it must be ascer- tained that there is no communication with the peritoneum. This may usually be done by noting that no decrease in size takes place on applying steady pressure for some little time. Varicocele is a dilated and varicose condition of the spermatic plexus of veins (Fig. 357). The causes of varicocele are not really known. It has been attributed to an extra lax state of the parts, induced by debility and general \vant of tone ; congestion from too early or continual excitement of the sexual organs ; occupations involving long stand- ing ; and to certain anatomical peculiarities (all of which, how- ever, are present in every healthy male), such as the great length of the spermatic veins, the dependent position of the -testicle, the plexiform arrangement of the veins in the scrotum, etc. But it 31* 738 DISEASES OF REGIONS. Varicocele. (St. Bartholomew's Hospital Mu- seum.) often occurs in men in good health, and in whom the parts are not lax. The reasons given for its much greater frequency on the left than on the right side are — i, that the left vein is longer than the right ; 2, that an obstacle is offered to the outlet of the left vein by its opening at right angles into the renal vein ; 3, that the blood pressure is less in the vena cava than in the renal vein ; 4, that the left vein is crossed by the sigmoid flexure, and is hence liable to be pressed upon by fjecal accumu- lations. Mr. W. G. Spencer, who has recently worked at this subject, believes that the presence of the large veins is due to a congenital variation from the normal process of development, whereby many of the veins of the Wolffian body (from which the spermatic veins are formed) remain unobliterated, and capable of being dilated by anything obstruct- ing the return of venous blood from the testicle. More of these veins, he says, are normally obliterated on the right than on the left side. Symptoms and diagnosis. — There may be merely a sense of weight and fulness in the scrotum, or dragging or even severe pain, worse after the day's work but relieved by recum- bency. The symptoms, however, are often more mental than physical, the patient fearing impotence or sterility, and sometimes becoming hypochondriacal in consequence. The varicose veins, which may sometimes be seen through the skin of the scrotum, form a soft, irregular, opaque, knotted, pyriform mass, in which there is a distinct expansile thrill or impulse on cough. The swelling is confined to the scrotum, and although it may be re- duced on the patient's lying down, it does not go back with a gurgle or slip like a hernia, and gradually returns when the patient rises, notwithstanding that the finger is placed over the external abdominal ring. The testicle, though perhaps, as a rule, a little smaller than natural, is seldom much atrophied. The treat mcnt may be either palliative or radical. The palliative treatment consists in cold sponging, the use of shower-baths, healthy exercise, regulation of the bowels, and the administration when indicated of ferruginous tonics ; whilst the mental anxiety of the patient should be relieved by the assurance that atrophy or impotence need not be feared. Locally, a sus- pensory bandage should be worn, or the veins braced up by drawing the lower part of the scrotum through a IVormald's ring. The radical treatment should only be undertaken (i) when the varicocele is large or causes much pain ; (2) when it acts as a bar to entering the public services; or (3) when it appears to be in- HEMATOCELE OR COiAfMON HEMATOCELE. 739 ducing atrophy of the testicle. Whether it should or should not be undertaken for the cure of mental distress, must be left to the judgment of the Surgeon in each individual case. The operations for the radical cure, which have for their object the obliteration of the enlarged veins, are many. Here only is described the method by subcutaneous ligature and division. Separate the vas, which can always be felt as a rounded cord from the veins ; pass with a nsevus-needle a thread of catgut or kangaroo-tail tendon between the veins and the vas, and then back again between the veins and the skin, and tie the veins, allowing the knot to slip through the puncture in the skin. Repeat the procedure three quarters of an inch above, and place the scrotum in an antiseptic dressing. The spermatic arteries escape injury as they slip away with the vas, to which they are attached. Other methods consist in the subcutaneous division of the veins with the galvano-cautery wire ; excision of the veins ; compression of the veins by hare-lip pins and figure-of-eight sutures ; division of the veins with the elastic ligature, etc. The method described above can be recommended as safe, painless, efficient, easy of performance, and as necessitating the minimum amount of rest subsequent to its performance. Tumors of the spermatic cord, though occasionally met with, are too rare to require any description in a work of this character. Torsion of the spermatic cord, /. e., a twisting of the cord so that the epididymis is felt in front instead of behind the body of the testis, is occasionally met with either in a testis to all exter- nal appearance previously normal, or in a testis retained in the inguinal canal. The twisting has been attributed to spasm of the cremaster. If unrelieved the testicle will atrophy or necrose. Symptoms. — The torsion is attended by a tender and painful swelling in the groin or scrotum, dull on percussion, irreducible, and without impulse on cough, the symptoms generally coming on suddenly after great strain or exertion. Vomiting is nearly always present, and there may be constipation. Thus when the testis is retained a strangulated hernia is very closely simulated. Treatment. — When seen early the cord may be readily un- twisted if the testis is in the scrotum, the symptoms at once dis- appearing as in Nash's case. If the testis is in the groin or inguinal canal, it should be removed and the canal and ring closed by sutures. H.-EMATOCELE or COMMON HEMATOCELE is an cffusion of blood into the cavity of the tunica vaginalis. Blood may also be effused into an encysted hydrocele of the testis, epididymis or cord, into the substance of the testicle itself, or into the tissue of the scro- tum ; and to such the terms hsematocele of the testis, hagmatocele 740 DISEASES OF REGIONS. of the cord, etc., have been applied. All of these conditions, however, are too rare to admit of any description here. Cause. — An ordinary h^ematocele may be due to a blow on the testicle, or a strain in lifting heavy weights, or a like injury to a hydrocele ; to puncture of the testicle or a blood-vessel in tapping a hydrocele ; or to the giving Fig. 358. way of a weakened or varicose vessel in consequence of the alteration in tension on removal of the hydrocele-fluid by tap- ping. At times, however, it may occur spontaneously, and is then probably due to some atheromatous or other change in the vessels, or chronic in- flammation of the tunica vagi- nalis. Pathology. — The effused blood may be absorbed, or it may clot Haematocele. (St. Bartholomew's HosDital , , , ., , ^1 n Museum.) * ^ud be deposited on the walls of the sac, giving the haemato- cele on section the appearance of an aneurysm (Fig. 3s8) ; or the central portions of the clot may break down into a chocolate- colored fluid, which under the microscope is seen to consist of disintegrating blood-corpuscles and hDem.atin and cholesterin crystals. At times suppuration may take place, the fluid in the sac then consisting of a mixture of broken-down blood and pus. Calcification of the walls in old-standing cases may occur. Signs and diagnosis. — Hematocele comes on suddenly, appear- ing as a smooth, tense or semi-fluctuating, oval or globular, non- translucent swelling in the scrotum. At first there may be con- siderable pain in the testicle and ecchymosis of the scrotum ; but later, neither as a rule will be present. Testicular sensation is generally discovered behind the swelling. The freedom of the cord and absence of impulse on coughing should at once serve to diagnose it from a hernia, and its non-translucency from a hydro- cele. But from malignant and other growths it is often difficult to distinguish it ; and indeed in some cases it is only after punc- ture with a grooved needle, or even after an exploratory incision, that this can be done. The history of its sudden onset, its shape, the absence of the varying consistency noted in malignant dis- ease, the non-involvement of the glands or of the cord, and the presence of testicular sensation posteriorly, should help in the diagnosis. On puncture a chocolate-colored fluid escapes in the one case ; arterial blood, or nothing at all, in the other. ACUTE INFLAJNI.MATION OF THE TESTICLE. 74 1 Treatment. — When the hasmatocele is recent, rest in bed, the application of cold or of evaporating lotions, and the elevation of the part on a pillow, may lead to the absorption of the blood. If this fails, the blood may be withdrawn with a trocar and cannula. When such is done, however, the sac in my experience generally refills, and I believe time is gained in the end by at once making a free incision into the sac, turning out the clots, securing any bleeding vessel that may be seen, and allowing the wound to heal by granulations. In long-standing cases, and especially when the walls are much thickened, this treatment is clearly in- dicated ; but if, on laying the sac open, the walls are found of cartilaginous consistency, perhaps calcified, and the patient is old or broken down in constitution, excision of the testicle is then called for, as otherwise long-continued suppuration, which may terminate in exhaustion and death, may ensue. Where suppura- tion has occurred, a free incision should, under any circum- stances, at once be made. Acute inflaminiation of the testicle is generally spoken of as orchitis or as epididymitis, according as the body or the epididy- mis is primarily or chiefly affected. Causes. — Gonorrhoea is the most frequent cause ; but injury of the testicle, or irritation of the prostatic urethra, as from the tying in of a catheter, or from the impaction of a calculus or fragment of a calculus, are not uncommon causes. Orchitis sometimes occurs during an attack of mumps, and is then said to be due to metastasis. It has also been attributed to the use of strong injections for the cure of gonorrhoea. How inflammation of the testicle is induced by the irritation of the urethra is a dis- puted question. It is variously taught, however, that it is due to — I, inflammation spreading along the vas ; 2, reflex irritation ; and 3, metastasis. Pathology. — The walls of the tubules and the intertubular con nective tissue become infiltrated with inflammatory products, and the tubules filled with desquamated epithelium. Resolution usually occurs, leaving the testicle little or not at all impaired either in structure or function. Suppuration, however, is occa- sionally induced ; and when the epididymis is chiefly involved, the inflammatory material, in place of being absorbed, may be converted into fibrous tissue, which, subsequently contracting, may cause obstruction of the tubules of the epididymis. Such may be known to have occurred by the presence of a small hard lump in the region of the globus minor or major. An effusion of fluid into the tunica vaginalis {acute hydrocele^ is very common, but more so in epididymitis than in orchitis, because the visceral layer of the tunica vaginalis is in contact with the inflamed tissue 742 DISEASES OF REGIONS. in the former case, but is separated from it by the thick tunica albuginea in the latter. Si!^/2s. — In a well-marked case there is intense pain in the testicle, with a dragging or aching pain in the groin and along the course of the cord. The testicle is swollen, and exquisitely tender on handling; the cord feels slightly thickened ; and the skin of the scrotum is oedematous and of a dusky-red color. When the inflammation falls on the epididymis, the pain and swelling will be chiefly confined to the lower and back part of the testicle — the region of the epididymis — and fluid will often be detected in the tunica vaginalis. The discharge, if the inflamma- tion of the testicle occurs during an attack of gonorrhoea, gener- ally ceases or becomes less when the inflammation is at its height. The local signs are often accompanied by sharp febrile disturb- ance, raised temperature, furred tongue, nausea or even vomiting, and constipation. Treatment. — When the attack is acute, rest in bed with the testicle supported on a pillow is desirable. Hot fomentations, and in the intervals hot linseed-meal poultices, applied to the testicle and groin, give the most reUef. Internally a brisk purge should be given at the onset, followed by saline laxatives and small doses of antimony. If the pain is very severe, opium may be given ; or a vein of the scrotum opened ; or the tunica vagi- nalis or testicle punctured to reUeve tension, either with a needle in several places' or with a tenotomy knife. If suppuration occurs, a free incision should be made to let out the pus. In subacute attacks, where the patient is unable to leave his work, a suspensory bandage should be worn. Chronic inflammation of the testicle may be a sequel to the acute disease ; or it may begin as a chronic or subacute affection, and like the acute form may involve either the body of the testi- cle or the epididymis, or both. The two chief causes of chronic inflammation are undoubtedly syphilis and tubercle ; but it may occur quite independently of either of these affections, and should then, for the sake of distinction, be called simple chronic orchitis or epididymitis. The syphilitic and tubercular {oxxs\% are described separately under those heads. Si^ns. — The testicle appears enlarged, smooth, laterally com- pressed, egg-shaped, hard, heavy, and painful on pressure ; the testicular sensation is not lost ; the vas is but slightly thickened ; the skin is non-adherent, and the epididymis (except when the disease is limited to that part) is not distinguishable from the body of the organ. In chronic epididymitis an indurated, painful, and tender lump is felt in the situation of the globus minor or major. TUBERCULAR DISEASE OF THE TESTIS. 743 Treatment. — Mercury or iodide of potassium should be given internally, and strapping applied to the enlarged organ when the body is chiefly affected. In chronic epididymitis, in addition to internal remedies, inunction with mercurial ointment may be of service. Tubercular disease of the testis, also known as strumous orchitis, or strumous sarcocele, is variously believed to depend upon the presence of the tubercle bacillus, or upon a chronic inflammation in Fig. 359. a strumous subject, and to begin either as a tubercular affection in the intertubular connective tissue, or as a catarrhal inflammation in the interior of the tubules. Pathology. — Opportunities for examining the testicle in the early stages of the disease are not com- mon. Hence, the uncertainty as to the origin and exact nature of the inflammation. Typical nodules of tubercle, however, have been found, and tubercle bacilli have been demonstrated either in sec- tions of the organ or, when few in ^.^^^^^^,^ ^^ ^^^ ^^^^i^,^ ^s^ b^^^^^,. number, after cultivation. The omew's Hospital Museum.) disease generally begins in the epididymis, and thence may spread to the body of the organ. It may also extend up the vas to the vesiculae seminales and pros- tate, and thence to the bladder, and even to the ureters and kid- neys. In some cases the testicle appears to be the starting point of a general tuberculosis ; in others, merely to be involved in com- mon with other organs in the general disease. In many in- stances, however, the disease may remain localized to the testicle, and no other manifestation of tubercle occur in the body. The inflammatory products infiltrating the epididymis and testicle, have a great tendency to undergo caseation, forming the yellow masses of cheesy-hke material so characteristic of the disease (Fig. 359)- Sip;ns. — The disease usually begins very insidiously and with little pain. The epididymis, especially the head, and later the body of the testicle, are found enlarged. The testicle is usually but sightly tender on handHng, and the testicular sensation is not lost ; a hydrocele may be present, or part of the tunica vaginalis may be obliterated. Subsequently the cord, especially the vas, becomes thickened and the skin adherent; whilst still later, the 744 DISEASES OF REGIONS. skin may give way and a fungus composed of the infiltrated tubules protrude, or a discharging sinus be produced. The vesiculse seminales or prostate may now be felt enlarged on examining by the rectum, and bladder or urinary troubles may set in; whilst symptoms of tubercle in the lung, larynx or other organs may supervene and the patient succumb to tubercular disease. At other times no constitutional signs manifest themselves, and the patient may comj^letely recover. Diagjwsis. — From syphilitic orchitis it may generally be dis- tinguished by the enlargement of the epididymis, thickening of the cord, adhesion of the skin, enlargement of the vesicul?e semi- nales, and concomitant signs of tubercle elsewhere. Treatment. — In the early stages, before the vas or vesiculse seminales have become involved, some Surgeons advise the removal of the organ, for the purpose of preventing, if possible, general dissemination of the disease, and where both testicles are affected, even the removal of both. Others, however, rely on constitutional treatment, and only advise the removal of the testicle should it become destroyed by the disease. If the vesiculse seminales are found affected in the early stages, or signs of tubercle are dis- covered in other parts, the testicle should of course on no account be excised. The constituiiojial treatment is that already described under Tubercle (p. 63). The local treatment con?>\si?, in suspen- sion of the organ, avoidance of horse or other violent exercise, and recumbency during an exacerbation of the inflammation. Should the tubercle soften and suppuration occur, the abscess must be opened and the wound dressed with iodoform or other antiseptic. If intractable sinuses remain, they should be scraped with a Volkmann's spoon. If a fungus forms it will frequently recede under rest in bed, cleanliness, and the application of a stimulating ointment or of iodoform. Should the testicle become completely disorganized it had better be excised. Syphilitic disease of the testicle occurs during the late secondary and the tertiary stages of syphilis. Pathology. — 'I'he lesion in the earlier stages of syphilis usually takes the form of a small- cell-infiltration of the intertubular connective tissue ; in the later stages, of distinct gummatous masses, resembling gummata in other situations. The body of the testicle alone is usually affected, and though, in some instances, syphilitic epididymitis is met with, the cord and epididymis generally escape. In the secondary stage both testicles may be imiilicated, either simul- taneously, or, as more often happens, one after the other, the disease here, as in other secondary affections, manifesting its tendency to be symmetrical. Under appropriate treatment the small-cell-infiltration may be completely absorbed, leaving the SYPHILITIC DISEASE OF THE TESTICLE. 745 Syphilitic testicle. Gummatous variety. (St. Barthlomew's Hospital Museum.) testicle apparently little, if at all affected ; or it may undergo fibroid changes, and the subsequent shrinking of the fibrous tissue produce more or less atrophy of the organ. But it seldom breaks down and suppurates, as the gummatous form in patients with undermined constitutions is apt to do. In the tertiary affection one testicle only is, as a rule, involved, the asymmetrical character of tertiary syphilis being thus borne out. The gummatous ^''^- 3^°- masses may clear up under treatment, but where the con- stitution is impaired they are liable to break down and sup- purate. The typical appear- ance of a gummatous testicle on section is seen in Fig. 360. The organ is occupied by large yellowish-white nodules of a tough, fibrous, non-vascular material ; some of the gummata are distinct; the remainder have coalesced into a mass which occupies the anterior part of the organ, A loose fibroid tissue, which is very vascular and of a pink color in the original specimen, surrounds and separates the nodules. S/'g/is. — Syphilitic disease is very insidious and painless in its onset, the testicle often attaining some size before the patient's attention is directed to it. The testicle is enlarged, very hard, not tender on handling, and, as a rule, absolutely painless ; the testicular sensation is completely lost ; the skin is not involved, appears but natural, and is freely movable over the swelling. The signs, however, vary somewhat according to the stage of syphilis at which the testicle is affected. Thus, in the secondary stages, the testicle is smooth, oval, and often laterally compressed ; in the tertiary, nodular and irregular, and the tunica vaginalis fre- quently contains fluid (vai^/zui/ hydrocek). In the secondary, usually both testicles are affected ; in the tertiary often only one. In the tertiary, moreover, the gummata, in neglected cases, or where the constitution is undermined, may break down, the skin become involved in the inflammation and give way, and a sore having the characters of a tertiary syphilitic ulcer result. More rarely a fungus may protrude. The characters of the secondary and tertiary disease, however, often merge into each other. A syphilitic testicle may have to be diagnosed from simple orchitis and from tubercular disease. The freedom of the cord and 746 DISEASES OF REGIONS. epididymis, the absence of all pain and tenderness on handling, the loss of testicular sensation, the hardness of the organ, the non- imphcation of the skin, the presence of a vaginal hydrocele, the history of syphilis, the fact that the patient has not had gonor- rhoea or a previous attack of acute orchitis, nor received an in- jury to the testicle, and the absence of signs of tubercle in other organs, point to the disease being of a syphilitic origin. It must not be forgotten, however, that syphilis may occur in a strumous subject ; and that the characters of the two affections may then be more or less combined. Tieafment. — The earlier the testicle is affected in the course of constitutional syphilis, the more marked will be the effect of mer- cury ; the later, of iodide of potassium. Often the best results are obtained from the two drugs combined. Locally, the testicle may be merely suspended ; or it may be strapped in the earlier stages with advantage. Any fluid in the tunica vaginalis will com- monly be absorbed during the treatment, though sometimes tap- ping may be required. Should the skin give way, and an ulcer be produced, it should be treated like other syphilitic ulcers. In rare instances, where the testicle is totally disorganized, extirpa- tion may become necessary. Enchondromata or cartilaginous tumors of the testicle are Fig. 361. Fig. 362. ^^^'''^''^t^^?ss^:0''^'K;,^„^ ::,,,, .y^^^' Knchondroma ol the testicle. (St. Bartholomew's Hos- pital Museum.) Soft carcinoma of the testicle. I St. liartholomew's Hospital Museum.) very rare. A beautiful example, however, is shown in the ac- companying illustration (Fig. 361). They may be known by their extreme hardness. Removal of the testicle is the proper treatment. Malignant disease of the ticsticle generally occurs in the MALIGNANT DISEASE OF THE TESTICLE. 747 form of a round- celled sarcoma, more rarely in the form of soft carcinoma ; but v,'ithout a microscopical examination, the two diseases, even on section, are often quite indistinguishable. Sarcoma begins in the intertubular connective tissue, and most frequently occurs in early life ; carcinoma in the tubules, as a pro- Hferation of the epithelial lining, and is most common after the period of middle age. In both, the body of the organ is pri- marily affected, and all distinction between it and the epididymis is soon lost. Some effusion into the tunica vaginalis may at first occur ; the two surfaces, however, rapidly become adherent, the skin is implicated, and a fungating mass protrudes externally. The lumbar glands are generally affected, the inguinal only be- coming involved after the skin has been reached. In a typical case (Fig. 362) the growth appears, on section, like a mass of brain-matter blotched in places with blood : whilst fibrous bands, the remains of the trabeculae testis, are generally seen traversing the growth. Masses of cartilage are often found in the sarco- mata, and cysts, sometimes containing intracystic growths, are not uncommon {cystic sarcoma). The disease formerly described as cystic sarcocele would generally appear to be of such a nature. Signs. — The swelling is at first generally uniform, smooth, elas- tic or tense, and hard, and no distinction between the body and the epididymis can be made out ; but later the cord becomes thickened and the lumbar glands enlarged, and the tumor may feel hard in one place and soft in another. Ultimately the skin becomes adherent, gives way, and a fungating mass, covered with a sanious discharge, protrudes. Diagnosis. — The rapid growth, large size, and more or less globular shape of the tumor ; the lancinating pain ; the implica- tion of the skin and lumbar glands ; the enlargement of the scrotal veins ; the protrusion of a bleeding fungus : and, later, the con- stitutional cachexia, will indicate malignancy. In the early stages, however, a puncti^re or even an exploratory incision may be nec- essary to distinguish it from chronic orchitis, haematocele, and syphilitic^-orchitis. Thus, in malignant disease, arterial blood will generally flow ; in hsematocele a chocolate-colored fluid contain- ing hsematin crystals and broken-down blood corpuscles will escape ; and in chronic orchitis, whether simple, syphilitic, or tubercular, ncjthing beyond perhaps a drop or two of blood will be withdrawn by the cannula. At times a piece of the growth may come away in the end of the cannula, and a microscopical examination of this will further aid in the diagnosis. Treatment — Unless ihe glands are much affected, the cord is thickened, and great emaciation or cachexia is present, with signs of the disease in the internal organs, excision of the testicle should 748 DISEASES OF REGIONS. be performed. When this appears undesirable from the above- mentioned reasons, all that can be done is to give opium to relieve pain and tonics to keep up the general health, and to apply some disinfecting lotion to remove the fcetor attending the fungating mass. After removal of the testicle an early recurrence of the disease in the lymphatic glands or in the internal organs is only too probable. Excision of the testicle. — The parts having been shaved, make an incision over the growth from the external abdominal ring to the bottom of the scrotum. Free the cord from its con- nections, and having clamped and divided it, enucleate the testicle with a few touches of the knife, taking care not to cut through the scrotal septum, and so remove the other testicle at the same time, a danger best avoided by giving the sound testicle into the charge of an assistant. Next tie the spermatic artery in the stump of the cord, and the cremasteric and deferent'.al arteries, if seen ; and having secured the cord by a Spencer Wells' forceps, in order to prevent it slipping into the inguinal canal, loosen the clamp, and tie any other vessel that may then bleed before finally releasing it. Atrophy of the testicle may be simply the result of old age, or it may be due to — 1, inflammation, especially that occurring dur- ing an attack of mumps ; 2, interference with its blood supply, as from the compression of the spermatic artery by a new growth or aneurysm ; 3, obstruction to the venous return, as in varicocele ; 4, direct pressure on the organ, as by an old htcmatoceie, or by the abdominal muscles, or by a truss when the testicle is retained in the inguinal canal. Neuralgia of the testicle is occasionally met with, but pain in the testicle should not be pronounced neuralgic till the various diseases of the kidney, rectum, bladder and prostate, which may give rise to reflected pain in the testicle, have been excluded. When no cause for the pain can be discovered, the ordinary neu- ralgic remedies should be given, although the prospect of success from their use is not great. Retained tf.siicle. — Non-descent of the testicle is said to be due to — I, the formation of adhesions in any part of its course into the scrotum ; 2, disjiroportion between the size of the testicle and the abdominal rings ; 3, paralysis of the gubernaculum testis; 4, too short a condition of the spermatic cord ; and 5, malforma- tion of testicle. Thus the union between the vas deferens and the testicle, /. c, the union of the Wolffian duct and the portion of blastema from which the body of the testicle is dcveloi)ed, may not occur, and the vas descends alone. The testicle may be retained in one of three situations, viz., i, in the abdominal cavity ; 2, in the inguinal canal ; and 3, just outside the external abdominal DISEASES OF THE VULVA. 749 ring. In the two latter situations it is often associated with a congenital hernia. Treatme7it. — In \\\& first situation nothing can be done. In the third the testicle should be coaxed into the scrotum by gende and oft-repeated manipulations, and a truss with a <-shaped pad, the arms of the < embracing the testis, applied over the inguinal canal should there be signs of a hernia. If this truss does not keep up the hernia, the testis had better be removed and the canal and ring closed by suture. In some instances the cord may be elongated sufficiently to allow the testis to be placed in the scro- tum by detaching the globus minor from the body of the organ, and thus turning the testis upside down. The sac of the hernia may then be removed and the canal and ring closed. When the testicle is retained in the inguinal canal, time should be given it to descend, and a truss applied if possible over the internal ring. Should it not descend as the child grows older, the question of its removal must be raised, as in this situation atrophy of the organ is nearly sure to ensue, and it is liable to be frequently attacked by inflammation, and to be affected by malignant disease. More- over, it exposes the patient to the risks of hernia. In some cases, however, it may be returned into the abdomen, and kept there by a truss, or by closing the canal. SURGICAL DISEASES OF THE FEMALE GENITAL ORGANS. DISEASES OF THE VULVA. Adhesion of the labia majora sometimes occurs as a congeni- tal affection. The labia should be separated by forcibly drawing them asunder, with the assistance, if necessary, of a probe, and a piece of iodoform gauze placed between them to prevent re- adhesion. If neglected, it may be a source of inconvenience at puberty. The parts are then more firmly adherent, and may require division by the knife. Vulvitis, or inflammation of the vulva, is in adults most usually the result of gonorrhoea, but occurs in young children from other causes, such as cold, injury, the irritation of thread-worms, etc. Sometimes the sebaceous glands and hair-follicles of the labia are chiefly affected, the parts then appearing dotted over with small red pimples, and later, if suppuration occurs, with small pustules. There is usually much redness and oedema, and an offensive dis- charge. It is of some importance to recognize the fact that the disease may occur in children from simple causes, as amongst the poor, mothers are apt to think their child has been tampered with. Treatment. — In addition to the removal of the cause, cleanliness, 75° DISEASES OF REGIONS. rest, attention to the general health, and the use of a mild astrin- gent lotion, is all that is usually required. Abscess occasional))' follows inflammation of the vulva. It is often due to the extension of inflammation (generally gonorrhoeal) to Bartholin's gland, or to suppuration in a labial cyst. A free and early incision should be made to prevent burrowing of pus, which is otherwise apt to occur, leading to the formation of obstinate fistulcC. Should these form, they should be laid freely open. Cysts in the labium are generally due to the obstruction of a raucous follicle or the duct of Bartholin's gland, as the result of irritation. Dermoid and sebaceous cysts are more rarely met with. The mucous cysts generally contain a glairy fluid, and as their walls are thin, appear as semi-translucent, oval, elastic swell- ings. They occasionally suppurate. Excision of a portion of the wall, and cauterization, plugging, or scraping away the lining membrane to ensure healing from ihe bottom, is all that is usually necessary. Tumors. — Fibrous tumors are occasionally met with in the labium. They are usually of the soft variety, and often contain myxomatous elements. They are frequendy allowed to attain a large size. Removal is the only treatment. Fatty tumors and ncevi are also met with ; sarcomata but rarely. Fpithelioma is not uncommon, and may generally be distin- guished from venereal warts and syphilitic, tubercular or lupoid ulceration by the surrounding induration, the sinuous and everted edges of the ulcer, the history of the case, the age of the patient, and the early enlargement of the inguinal gl mds. Early and wide removal of the growth, together with any inguinal glands that may be felt enlarged, holds out the only prospect of success ; but when the growth has attained any size, a rapid recurrence is but too frequent. Condylomata and venereal waris are very common in this situation. They require no special description, and should be treated as described under Venereal Diseases in the Male. Pruritus may depend on various causes. These should be sought, and, if possible, removed, the irritation being allayed in the meantime by such remedies as are mentioned under Pruritus ^/;/(p. 653). Elephantiasis of the lap.ium is rare. Like the similar condi- tion of the scrotum, it may attain a large size. It may be re- moved by the knife, or better, as the haemorrhage is free, by the galvano -cautery. Noma is an infective inflammation of the vulva, attended by phagedaenic ulceration, and is not infrequently met with in the ill-fed, weakly children of the poor, esi)ecially after the exanthe- VESICO-VAGINAL FISTULA. 75 1 mata. Like cancrum oris, it probably depends upon the presence of a specific micro-organism. It begins as a dusky-red, indurated patch on one labium, with much swelling and oedema, and spreads rapidly, the central parts often becoming gangrenous. It is at- tended with severe constitutional disturbance, which soon assumes the typhoid type, and death from exhaustion or septiccsmia fre- quently ensues. The treatment should be energetic. The affected part should be scraped with a Volkraann's spoon, or destroyed by fuming nitric acid or the cautery, and an antiseptic dressing ap- plied ; whilst fluid nourishment, stimulants, and iron should be freely given, and opium cautiously administered in doses suitable to the age of the child. In milder cases the apphcation of boro- glyceride may suffice. In very severe cases, the continuous warm bath has been found of great service. DISEASES OF THE VAGINA. Acute vaginitis is generally due to gonorrhoea, but may occur as the result of the use of strong injections, the introduction of foreign bodies, cold, and the exanthemata. It is attended with the signs of inflammation, and with a profuse, generally puru- lent, and sometimes blood-stained discharge. There is pain on urination and defaecation, and tenesmus. The inflammation may spread to the uterus, and thence to the Fallopian tubes, or to the urethra and Bartholin's glands. Saline purgatives, rest, warm hip-baths, and cleansing the part with Condy's lotion, followed by astringent injections, is the proper treatment. Tumors of the vagina are rare, and require no special notice. Cysts of the vagina are occasionally, though rarely, met with as the result of the distension of the mucous follicles ; and others are described as originating from remnants of the Wolffian duct, or from the dilatation of lymphatics. They should be treated by the excision of a portion of the cyst-wall, combined with cauter- ization. Vesico-vaginal fistula, when not due to malignant disease, are generally the result of sloughing, consequent upon the press- ure of the child's head in a prolonged or instrumental labor, though they may be occasionally produced in other ways, as from the impaction of a foreign body in the vagina or urethra, injury, etc. They give rise to incontinence of urine, and are productive of great inconvenience. They may be so small as merely to ad- mit a probe, or nearly the whole of the anterior wall of the vagina may be destroyed. The common situation is just below the neck of the uterus. Treatment. — Where the fistula is very small, touching it with the actual cautery may succeed in closing it ; but 752 DISEASES OF REGIONS. a plastic operation is usually necessary. The rectum having been cleared by an enema, the patient should be placed in the lith- otomy position, and a duck-bill speculum introduced. The edges of the fistula should then be pared, and brought together with silver-wire or silk-worm-gut suture. The sutures should be placed sufficiently close to prevent the passage of urine between them. A good way of testing if they are close enough, is to inject milk into the bladder, so that should any escape through the fistula, its color will make it visible. Smith's needle will be found very con- venient if wire sutures are used. The bladder should be emptied by a catheter at regular intervals ; the vagina syringed out with an antiseptic solution, and dusted with powdered iodoform ; and the bowels kept confined for a week or more. Recto-vaginal fistul^c may occur from causes similar to those leading to the vesico-vaginal variety ; they are also sometimes congenital. They are commonly situated just within the entrance to the vagina, and may be closed in the same way as the vesico- vaginal fistula. Utero-vesical and UTERO-RECiAL FiSTUL/E may also occur, but are too rare to require any description here. Imperforate hymen, if overlooked till after puberty, is a seri- ous affection, as the vagina, and later the uterus and Fallopian tubes, may become distended with the retained blood, conditions known respectively as hainaio-kolpos, hocinaio-melra and hcemalo- salpivx. If relief is not obtained, enormous distension may occur, and the tubes or uterus give way, setting up peritonitis. Or the hymen itself may yield, and all end well ; or saprsemia may occur from putrefaction of the blood and absorption of the septic products on the admission of air; or septic peritonitis may be produced by the sudden alteration of pressure or the contrac- tion of the uterus causing rupture of the tubes and escape of fluid into the peritoneum. Treatment. — Before puberty, division or excision of a portion of the hymen is a simple and safe oper- ation ; but when distension has occurred, it is attended with great risk, as if a free opening is made there is danger of peritonitis from the same causes as when spontaneous rupture takes place, and if a small opening is made, of saprpemina from decomi)osi- tion. The safest plan, perhaps, is to make a small opening, and to keep the parts aseptic by iodoform or the like. Mai J'ORMAi IONS of the, vagina. — Atresia or imperforate vai:;ina. The vagina may be completely absent, or divided by a transverse or horizontal septum. ""J'he uterus and ovaries may also be ab- sent, and no trouble will then result; but when these are present, similar results to those described under imperforate hymen may follow. Atresia of the vagina may also be due to adhesions or OVARIAN TUMORS. 753 the contraction of cicatrices following ulceration, etc. The ab- sence of the uterus may be determined by introducing a catheter into the bladder and the finger into the rectum, when the two will be felt to be in close apposition. In such a case no operation should be undertaken, as all that would be achieved would be to open the peritoneal cavity. When the uterus and ovaries are present, and distension has occurred, if the vagina is only par- tially absent an attempt maybe made to form a vagina by dissect- ing carefully through the tissues between the bladder and the rectum in the direction of the os. When this is found, the parts must then he prevented from re-adhering by introducing lami- naria tents, frequent digital examinations, etc. Where the vagina is completely absent the uterus may become distended, and may then either be punctured through the rectum, or in some instances, together with the ovaries, be removed. CvsTOCELE AND RECTOCELE are the names given to a prolapse of the anterior and posterior wall of the vagina respectively. In the former the bladder of course protrudes; in the latter, the rectum or pouch of Douglas, which may contain some small intestine. Partial prolapse of either wall is a frequent accompaniment of ex- tensive ruptures of the perineum. These affections generally fall under the care of the Obstetrician, but at times the Surgeon may be called upon to perform a plastic operation for their cure. This consists in removing a portion of mucous membrane from the upper or lower wall of the vagina as the case may be, bringing the raw surfaces together with sutures, and keeping the bladder empty with a catheter till firm union has taken place. DISEASES OF THE OVARIES AND FALLOPIAN 'JUBES. Ovarian tumors. — Ovarian tumors may grow either from the ovary itself, or from the broad ligament, and may be either solid or cystic. Amongst the solid tumors, which are rare, carcinoma and sarcoma are the most common. Amongst the cystic the so- called multilocular cysts are most frequently met with ; but other forms, as the unilocular, the dermind, and the parovarian cysts, may also occur. For a description of these tumors and of their pathologv, which, at the best, is but imperfectly understood, the reader is referred to a special work on the subject. Symptotns. — There m.ay be no symptoms at first ; but as the tumor increases in size, it gradually encroaches on the space normally allotted to the pelvic and abdominal viscera, giving rise to one or more of the following symptoms : Thus, from pressure on the bladder and rectum there may be increased micturition and constipation ; from pressure on the iliac vessels, oedema of 754 DISEASES OF REGIONS. the lower limbs and genitals ; from pressure on the sacral and lumbar plexus, pains in the back, pudenda, and legs ; from pres- sure on the stomach, nausea and vomiting ; on the intestines, diarrhoea or colicky pains ; on the portal vein, ascites and haemorrhoids ; on the kidneys and ureters, albuminous and highly-concentrated urine, rich in urates. Later, as the tumor extends upwards, there will be embarrassed breathing and dys- pnoea from pressure, on the heart and lungs ; while finally emaci- ation sets in, and the patient dies of exhaustion, if not carried off by an intercurrent attack of peritonitis and rupture of the cyst. The physical signs vary according to the size of the cyst, and the diagnosis at first may be attended with some difiiculty. But as the cyst rises out of the pelvis, and the abdomen becomes gradually distended, the condition known as ovarian dropsy is produced, the physical signs of which somewhat resemble dropsy of the peritoneum {ascites) depending on visceral disease. In ovarian dropsy the abdomen is dull in front, resonant in the flanks ; the dulness is not altered by position ; and the distension is greatest in the hypogastric and umbilical regions. Whereas in ascites the abdomen is resonant in front, dull in the flanks ; the dulness is altered by position, the dull flank becoming resonant when the patient is placed on the opposite side ; the distension is most marked laterally ; and the circumference is greatest at the level of the umbilicus. In both a percussion wave or thrill generally exists, but in ovarian disease it is usually limited to the dull area, whilst in ascites it is as a rule felt all over. In ascites, moreover, there is probably other evidence of the visceral disease which is producing the dropsy ; and if the abdomen is punctured the fluid will be found to be of a thin and serous character. In ovarian disease the utems is usually displaced. An ovarian tumor may also have to be distinguished from pregnancy, tympanites, encysted dropsy of the peritoneum, tumors of the omentum, sub- peritoneal cysts and tumors, fibroids of the uterus, pelvic hajmatocele and abscess, extra-uterine pregnancy, and a distended bladder; but the differential diagnosis cannot be attempted in a work of this character. Having, however, determined that the disease is an ovarian cyst, the next point to make out is whether it is unilocular or multilocular, free or adherent. The mulliloc- itlar cyst is usually irregular ; fluctuation is absent, or more marked in some parts than in others ; and there is no thrill or fluctuation wave on percussion, unless one of the cysts has at- tained a ])reponderating size. The unilocular cyst is smooth, rounded, regular, and elastic ; fluctuation is felt equally distrib- uted over the whole of the dull area. If adhesions are present the cyst is fixed, unless they take the form of elongated bands, in OVARIOTOMY. 755 which case a friction rub or sound may be felt or heard. The nmbihcus moves with the cyst ; but no movement is detected on examination by the rectum or vagina. If thei'e are no adhesions the cyst moves on respiration, but the umbiUcus does not move with the cyst, and the cyst is not found fixed on examination by the rectum or vagina. Such are the chief points to be attended to ; but often the signs are delusive, and where a tumor is ex- pected to be of a unilocular character and free, it may be found to be multilocular or solid and extensively adherent to the neigh- boring parts. Treatment. — The only effectual treatment is to remove the tumor by the operation of ovariotomy, an operation which, though formerly attended with a high rate of mortality, may now be said to be one of the most successful of the major operations in sur- gery. Repeated tappings, and tapping and injecting with tincture of iodine, have now very rightly almost ceased to be employed, although tapping may still at times be called for under excep- tional circumstances, which cannot here be discussed. Before ovariotomy is undertaken, however, the patient should be very carefully prepared by attention to the bowels and kidneys, any congested condition of the latter being relieved by aperients, diaphoretics, warm baths, and the administration of citrate of potash, lithia, etc. OvARiOTOiNiY. — The patient having been well wrapped up, with woolen stockings on the legs, etc., the bladder emptied by a catheter, the skin of the abdomen previously cleansed with soap and water and antiseptics, and the anaesthetic administered, a mackintosh cloth with an oval opening is placed over the abdo- men and secured round the opening to the skin by adhesive ma- terial. The parts should then be again sponged with antiseptics, and an incision made in the middle line about three inches long midway between the pubes and the umbilicus (Fig. 284, a). This incision may be afterwards prolonged if necessary. The peritoneum having been reached, and all haemorrhage stopped with pressure forceps^ the peritoneal cavity is carefully opened on a director, the hand introduced, and adhesions felt for. If the cyst is free, Spencer Wells' trocar and cannula are thrust through the cyst-wall, the fluid evacuated, and the cyst gradually drawn out through the wound as it is reduced in size by the escape of the fluid. The pedicle is now transfixed by a long needle armed with a suture of China silk, the suture severed, and the needle withdrawn. The two portions of suture are next twisted, and the pedicle firmly tied on both sides. The ])edicle is then divided on the cyst aspect, and the cyst removed, care being taken to pre- vent any of its contents escaping into the abdomen. If the cut 756 DISEASES OF REGIONS. surface of the pedicle appears dry, the sutures by which it is tied are cut off short, and it is allowed to slip back into the pelvis ; but if any bleeding point is seen, this must first be secured. Should adhesions- be felt on opening the abdomen, they should be care- fully broken down by the hand, or divided if necessary, care being taken not to injure the intestines and to secure all bleeding vessels. After the cyst has been removed, the other ovary should be examined, and if diseased, also removed. The sponging-out or irrigation of the abdomen is now begun, and must be continued as long as any blood-stained fluid can be squeezed from the sponges. The sponges should be thrust down deeply into Doug- las's pouch, and when all the blood-stained fluid has been re- moved from this part of the peritoneum, a sponge attached by a string should be left there until just before closing the wound, to ensure that no collection remains in this dependent situation. If irrigation is employed, an india-rubber tube attached to a can containing the irrigating fluid should be passed in various direc- tions into the abdominal cavity, and the fluid allowed to flow until it runs away perfectly clear. The irrigating fluid may consist of boiled water at a temperature of 98°, or water containing some mild antiseptic, as boracic acid. Mr. Tait uses ordinary tap water. A large soft sponge is finally placed over the surface of the intestines whilst the deep parietal sutures are being intro- duced. These should be passed about half an inch apart, and made to include the skin, peritoneum, and edge of the muscles, so that when tied two free surfaces of peritoneum are in contact. The sutures being all in situ, the flat sponge and the sponge in Douglas's pouch are withdrawn, and the wcund is closed by tying the sutures. Superficial sutures are next introduced between the deep, to ensure the accurate appositition of the skin. The mackintosh is now removed, a gauze-dressing firmly secured by strips of strapping, and a flannel bandage applied over all. Under some circumstances, as where many adhesions have been broken down, and there is likely to be oozing into the pelvis, or where the peritoneum has been accidentally soiled by septic material of any kind, a drain-tube should be placed in the wound. The tube is passed through a tightly-fitting hole in the centre of a sheet of thin rubber (Fig. 363). The end of the tube should then be placed in the bottom of Douglas's pouch, and the parietal wound closed except at the situation of the tube, and dressed with anti- septic gauze placed between the skin and the rubber sheet. Over the mouth of the tube an aseptic sponge is laid, and the rubber sheet wrapped around it so as to prevent any discharge from the tube reaching the permanent dressing. The rubber is unfolded at intervals, the sponge removed, and a capillary pipette SALPINGITIS. 757 passed down the tube to draw off any discharge that has collected. The tube is retained till the discharge ceases to collect in it and becomes of a serious character. The after treatment consists in keeping the patient at rest, soothing pain and procuring sleep by morphia, emptying the bladder at regular intervals by the cathe- ter, and allaying vomiting if present by ice or teaspoonfuls of hot water, or if intractable by washing out the stomach. Tympanites is greatly relieved by the occasional passage of a long rectal tube. No food should be given for the first twenty-four hours; then nutrient enemata should be administered, and after three days a Fig. 363. Method of draining after ovariotomy. A A. Rubber sheet. D D. Dressings, s s. Integu- ments. T. Drain-tube. I i. Intestines. P, Pipette. return to slop diet should be cautiously made. The stitches may be removed from the third to the seventh day, and the wound then supported by strapping. If signs of peritonitis ap- pear, Mr. Tait gives a turpentine enema and saline purge. See Peritonitis (p. 393). Salpingitis — Hvdro-salpinx — Pvo-salpinx — H^mato-salpinx. — As the result of gonorrhoea, inflammation of the uterus or pel- vic peritoneum, and occasionally of parturition, the Fallopian tubes may become inflamed {salpingitis), and their orifices adherent, and as a consequence they may become distended with serum {hydro-sa/pinx) (Fig. 364) or with pus {pyo-salpinx) ; whilst much more rarely, as the result of an injury or from obstruction in the uterus or vagina, they may become distended with blood 758 DISEASES OF REGIONS. {Jiceuiato-salpiux^ . The symptoms are pain, worse on exertion, straining, or coitus ; and intensely painful, irregular or profuse menstruation, together with a history of uterine or ovarian trouble. On examination an ovoid, generally tender perhaps fluctuating swelling will be felt externally and through the roof of the vagina, and on both sides if both tubes are affected. The swelling will be movable or F"^- 3^4- immovable according as it is free or adherent, and may be distinguished from an ovarian cyst by its shape, and by being felt anteriorly rather than on either side of the neck of the uterus. Pyo- salpinx may generally be distinguished from hydro- salpinx by the occurrence of rigors and fever ; but a diagnosis is often impossible. 7 '/ra tin en t. — The re m o - val of the tube and ovary in the case of hydro- or pyo- salpinx is the treatment that has been adopted ; but it should only be done when the symptoms are severe. Tapping through the vagina has not been attended with success. The operation of removal may be done in a manner similar to oophorectomy. Hsemato-salpinx, as a rule, requires no active treatment. Oophorectomy, or Battky's operation, consists in the removal of the ovaries, and has been done for inflammation, neuralgia, amenorrhcen, mollities ossium, fibroids, etc. The operation is performed like ovariotomy. A small incision being made in the linea alba, midway between the umbilicus and the pubes, two fingers are introduced into the peritoneal cavity, and first one, and then the other ovary brought out of the wound. The pedi- cle, which consists of broad ligament and its contained structures, is transfixed and ligatured as in ovariotomy, the ovary cut off, and the pedicle dropped back into the abdomen. Hvs'iEREOioMY, OR RKMOVAL OF THE UTERUS, may be donc through the vagina (Schrocifrr's operation) or through an incision in the abrlominal walls {Frei/mPs operation). In the former, an incision is made through the vaginal mucous membrane around Double hydro-salpiiix. u. IJladder. K. Rectum. R. T. Right tube opened. L. T. Left tube. O. Ovary, u. I'terus. (Si. Barlholomcw's Hospital Mu.scum). ACUTE INFLAMMATION. . 759 the cervix, the peritoneal cavity opened, the broad ligament transfixed and ligatured, and the uterus severed from its connec- tions and drawn out through the vagina. In the operation through the abdominal wall, the peritoneal cavity is opened, as in ovariotomy ; the broad ligament transfixed and ligatured ; and the uterus drawn up from the pelvis and carefully severed from its connections. For a detailed account of these operations, however, the student is referred to a larger work. DISEASES OF THE BREAST. Facet's disease of the nipple, sometimes spoken of as eczema, is an intractable form of ulceration around the nipple. It lasts for many years, and yields to no treatment. A considerable propor- tion of cases develop carcinoma of the breast. Recently small vegetable parasites known as psorosperms have been found in the tissues surrounding the ulcer, and are believed by some Patholo- gists to be the exciting cause of the disease. Treatment. — When all mild measures are unavailing, many Surgeons recommend amputation of the breast for fear of cancer subsequently forming. Neuralgfa of the breast is not uncommon in young unmarried women, and appears to be frequently due to some ovarian disturb- ance. The pain is often severe, perhaps shooting down the arm, and may be constant or periodic ; whilst the skin over the breast, as well as the gland itself, is exceedingly sensitive on handling. Nothing, except at times a slight fulness, can be detected on ex- amination. The treatment consists in improving the general health by tonics, cold baths, and outdoor exercise, and in regu- lating the ovarian functions. No local treatment is necessary ; indeed, the patient's attention should be taken off the breast as much as possible. Inflammation of the breast may occur at any age, and in the male as well as the female. In in/ants it is sometimes attended with a serous or milky discharge from the nipple, and is often made worse by ignorant nurses applying friction to "rub away the milk." At or adont puberty it is met with in boys as well as in girls, but more frequently in the latter. Often beyond the patient appearing somewhat out of health no cause can be dis- covered, although in hospital patients a history of a blow is not uncommon. The inflammation may clear up, or terminate in an abscess. Acute inflammation, however, most frequently occurs during lactation, especially in primiparse, and generally during the first month after parturition. It then appears to be most often due to the irritation of the nipple by the child sucking, particularly when 760 DISEASES OF REGIONS. the nipple is shrunken or retracted, or is in a cracked condition. Occasionally it is the result of excessive secretion of milk, and con- sequent hyperccsthesia of the ducts ; or it may not appear till later during the period of lactation, when the patient's powers have been pulled down by long suckling. Syifipfo/ns. — A feeling of uneasiness in the breast, then a chill or sHght rigor, followed by fever and the local signs of inflamma- tion, and often subsequently of abscess. Treatment. — The breast should be placed at perfect rest by slinging it in a silk handkerchief passed over the shoulder, and by taking away the infant from the sound as well as from the affected side ; the milk, if the tension is great, should be drawn oft regularly by the breast pump ; and belladonna and glycerine appHed to diminish the secretion, and opium or poppy fomenta- tions to relieve pain. Signs of abscess must be watched for and an early incision made. A smart saline purge, followed by saline laxatives and light nutritious slop diet, is usually necessary. Abscess of the breast may occur in three situations: — i. Superficial to the gland {supra-mammary abscess') ; 2. In the sub- stance of the gland {^intra-mammary abscess) ; and 3. Behind the gland { post mammary abscess), t. The supra-mammary variety resembles an abscess in any other situation, and requires no further comment. 2. The intra-mammary, which is generally the result of inflammation occuring during lactation, may be confined to one part of the gland ; or pus may be formed in several situations at the same time, and if not let out by timely incisions may riddle the breast in all directions. 3. In the post-mammary, the inflamma- tion begins either in the cellular tissue behind the breast, or in the posterior lobes of the gland, the resulting abscess then bursting into the cellular tissue behind the breast. The whole breast is pushed forward and presents a characteristic conical appearance. There is deep-seated and throbbing pain, increased on moving the arm, with some oedema and mottled redness of the skin. The pus usually gravitates towards the lower and outer part of the breast, where the abscesss commonly points; or it may burrow through the gland, producing fistulous tracks which are often very difficult to heal. Treatment. — In all varieties an early and free incision should be made, preferably under an anaesthetic. In the intra-mammary the incision should radiate from the nipple, so as not to cut across the galactophorous ducts ; and should be free, not a mere puncture, lest the abscess cavity degenerate into a sinus. In the post- mammary the incision should by j^reference be made at the most dependent part to ensure an efficient drain, though of course pus wherever jjointing must be let out. Should sinuses or fistulas form, CHRONIC LOBULAR INFLA1\OL4T10N OF THE BREAST. 76 1 they should be laid freely open and thoroughly drained, after be- ing scraped by a Volkmann's spoon. The strength should be supported by a generous diet, and ammonia and bark or quinine and iron given internally, together with stimulants, if indicated. Chronic lobular inflammation of the breast, which has been described by various names, as lobular induration, chronic hyper- trophy, chronic interstitial mastitis, etc., affects generally one lobe, or limited portions of the gland, and is of much interest, in that it is liable to be mistaken for a tumor. It is said to be most fre- quent in married women beyond the child-bearing period of life ; but my own experience is that it is often met with in young and unmarried women. Cause and Fathology. — It is generally attributed to ovarian dis- turbance. A small-cell-infiltration occurs in the connective tissue of the affected lobe, with increased proliferation of the epithelium. Later the cells or fibroblasts form fibrous tissue, which contracts, pressing upon and obliterating the ducts and acini, and causing fatty degeneration of the epithelium lining them. Should some of the acini escape the pressure which has obliterated the ducts leading from them, small cysts may be formed ; but such cysts never attain a large size, in consequence of the unyielding nature of the fibrous tissue by which they are surrounded. Symptoms. — The patient usually complains of a swelling, and sometimes of pain in the breast. On grasping the breast between the fingers the hypertrophied portion feels hke a tumor, but on drawing it from the nipple so as to make the lactiferous ducts tense, it is found to be p;irt of the mamma, and on pressing the breast back on the ribs with the flat of the hand, no distinct tumor is felt, nor anything like the resistance of a new growth. Further, the swelling is usually of a wedge-shape, with its apex towards the nipple, and has not the stony hardness of scirrhus ; and there may be a second nodule in the same breast, or in the breast of the op- posite side. The axillary glands are sometimes enlarged, but are not indurated, and the pain often follows, as pointed out by Mr. Birkett, the distribution of one or more intercostal nerves, the slightest pressure upon which as they issue from the thorax causes acute pain. The above signs will usually serve to distinguish the affection from scirrhous carcinoma. Should, however, as occa- sionally happens, the nipple be retracted, the skin dimpled from the contraction of the fibrous septa, the surface of the gland ren- dered nodular by the presence of several tense cysts, and the patient moreover be about the age at which carcinoma is com- mon, it may be difficult to diagnose between them, especially if the breast is voluminous, so that the characters of the swelling are obscured. Under such circumstances it is quite justifiable to 32* 762 DISEASES OF REGIONS. make an exploratory incision, after having explained the import- ance of a correct diagnosis to the patient. Treatment. — Iron and quinine or the mineral acids are often indicated, and with these some combine the iodide of potassium. Locally a belladonna plaster may be applied, or the stays dis- pensed with to prevent friction, or a thick layer of cotton-wool placed between them and the breast. Inunction with iodide of potassium ointment, or with oleate of mercury, and strapping the breast, are also recommended. Whatever treatment is adopted, it should be persevered in for several months. There is a condition oi Hypertrophy often met with in lads about the age of puberty, and in girls a little below that age. The breast enlarges slowly, often painlessly, generally on one, some- times on both sides. There are no signs of inflammation. Under the influence of belladonna plaster applied for some months, which probably owes its efficacy to the fact that it prevents the patient irritating the breast by constantly feeling it, the hypertrophy usu- ally subsides. Of its exact pathological condition I am not aware, but it is generallly thought to be of a chronic inflammatory nature. Tumors of the breast. — The tumor by far the most frequently met with in this situation is the acinous carcinoma {scirrhiis), which is due to the proliferation of the epithelium lining the acini or the small ducts. C'ertain of the connective-tissue tumors (fibroviata, sarcomata), springing from the periacinous connec- tive tissue, are also of frequent occurrence. They seldom, how- ever, occur pure, but are nearly always mixed with elements re- sembling the tissue of the breast itself (adcnoi/iatous tissue), and hence are spoken of as adeno-fibroma, adeno-sarcoma, adeno- myxoma. Whether these adenomatous elements are the normal breast-tissue, which has become surrounded and enclosed in the fibrous or sarcomatous growth as the ca!je may be, or whether it is an abortive formation of the gland-tissue, is not agreed upon by pathologists. Most, however, believe that it is a new formation. More rarely the gland-tissue may constitute the chief bulk of the \mxs\ox (pure adenoma). 'I'he tumors composing this class were formerly spoken of collectively as chronic mammary glandular tumors. At times cysts are developed in connection with them, and they are then designated cystic adeno-Jihronia, cystic adcno- saj'coma, cystic adeno-myxoma, etc. Various other firms of tumor, viz., tumors composed of fat, cartilage, vessel-tis-ue, nerve-tissue, etc., have also been met with in the breast, but are exceedingly rare. Purr adenomata are very rare. They occur as circumscribed ovoid tumors surrounded by a capsule of connective tissue. On section they appear smooth, lobed, white or tinged with pink. ADENO-SARCOMATA. 763 with here and there small cavities and occasionally distinct cysts. Their general characters have already been given under Ti/inors. All that need here be repeated is that they consist of acini and ducts surrounded by a small amount of vascular connective tissue ; in short, that they resemble the breast preparing for lactation, save that the acini and ducts do not form distinct lobules with an excretory duct, as in the lactating breast. Further, the epithelium does not penetrate the membrana propria and grow into the in- ter-tubular and inter-acinous connective tissue, a point of import- ance as distinguishing them from carcinoma. Signs. — They are most often met with in women between the ages of thirty and thirty-five who have borne children, as small, ovoid, firm but elastic, distinctly circumscribed and movable growths in the breast, with a nodular or slightly bossed surface. They are of very slow growth, do not cause retraction of the nipple or enlargement of the axillary glands, and do not return if completely removed. Enucleation is the treafmenf. Adeno- FIBROMATA are of frequent occurrence. They consist of fibrous and adenomatous tissue, and are siyXedi fibromata by those pathologists who regard the gland-tissue as merely the remains of the normal breast-tissue surrounded by the new growth. They occur as firm, circumscribed, slow- growing and distinctly encap- suled tumors in the substance of the breast, and on section appear lobulated and of a pinkish- white color, and do not yield a juice on scraping. Sigtis. — They usually occur in the breast of young and healthy women as freely movable, firm, ovoid, slightly nodular, generally painless growths, and are often indistinguishable without puncture from a tense cyst. From carcinoma and sarcoma they may be diagnosed by the age of the patient, their slow growth, well de- fined outline, non-retraction of the nipple, non-adherence of the skin, and the absence of glandular enlargement. From pure ade- noma, adeno-sarcoma, and adeno-myxoma, it may be impossible to distinguish them before removal. Enucleation is the only effective treainient. Adeno-sarcomata differ from the adeno-fibromata in that in place of an increase of fibrous tissue around the acini and ducts various kinds of sarcomatous elements are found mixed with more or less mature fibrous or myxomatous tissue ; they often contain cysts. Hence the terms adeno-fibro-sarcoma, adeno-myxo-sar- coma, adeno-cysto-sarcoma, fibro-cysto-sarcoma, etc., which have been applied to them. They occur as circumscribed growths in the breast, resembling the adeno-fibromata, from which it is often impossible to distinguish them without a microscopic examina- tion. 764 DISEASES OF REGIONS. Tlie signs vary according to the amount of sarcoma-elements the growth contains. Thus, when this is small they approach in their clinical character and behavior the adeno-fibromata. On the other hand, when sarcoma-elements abound, they may grow rapidly, and behave like the pure sarcomata. Frequently they grow slowly for many years and then suddenly rapidly increase in size as the patient approaches the middle period of life. When occurring between the ages of thirty and forty they often grow rapidly from the first. Treatment. — The slow-growing and more fibrous forms may be enucleated, but if in proceeding to do this the growth is found to be soft and succulent, the whole breast should be excised, an operation that should invariably be undertaken when the tumor has grown rapidly. Pure sarcomata. — All forms of sarcoma mixed with fibrous and adenomatous elements may occur in the breast, the large spindle- celled variety being the most common. Sarcomata are most fre- quent between the ages of twenty and thirty-five. They begin in the periacinous and peritubular connective tissue, and at first are always encapsuled, but later they infiltrate the surrounding parts and may perforate the skin and fungate. Their malignancy de- pends upon their structure, the round-celled and large-spindle- celled being highly malignant, the small-spindle-celled much less so ; indeed the latter may recur again and again iii situ before finally becoming disseminated, or its tendency to recurrence may completely wear itself out. The small-spindle-celled is usually firm like the adeno-sarcomata, and on section greyish-white, smooth and succulent. The round-celled and large-spindle-celled are soft and elastic owing to their richness in cells and blood- vessels and their scanty amount of intercellular substance. On section they appear of a pinkish-white color, often blotched with blood, while cysts from h?emorrhages and mucoid softening some- times occur in them. Signs. — The small-spindle-celled sarcoma can hardly be diag- nosed before removal from the adeno-fibroma and adeno-sarcoma. The large-spindle-celled and round-celled varieties form smooth elastic tumors, oval or rounded in shape, and are lobed or bossed when cystic ; whilst the veins of the breast are often enlarged and tortuous. They grow rapidly, and may perforate the skin and protrude as a fungus; but unUke carcinoma, they do not infiltrate the skin or cause retraction of the nipple, and the glands are not usually enlarged. The tumor, moreover, is commonly larger than scirrhus, and the patient's age below that at which carcinoma is usually met with. The only effectual treatment is the removal of the whole breast. ADENO-CYSTOMATA. 765 Cystic adenoma of the breast. (St. Bartholo- mew's Hospital Museum.) If there is any doubt whether the tumor is an adeno-fibroma or a sarcoma, it is better to have the consent of the patient before the operation for the removal of the whole breast, should the tumor when cut into appear to have malignant characters. Adeno-cvstomata, cysto -sarcomata, sero-cystic sarcomata, and glandular proliferating cysts, are terms apphed to tumors in the breast in which the growth in the periacinous connective tissue projects into the interior of dilated acini and ducts in the form of papillary or cauliflower-like masses. The periacinous growth, which may consist of fibrous tissue, spindle or round cells, J^'^- 363. or of a mixture of all these, protrudes the wall of the di- lated acinus or duct in front of it, but does not penetrate the epithehal lining, and may ultimately fill the whole acinus, which is thus con- verted into a mere sHt- like space lined with epi- thelium. On section the tumor may present one or more larger cysts, containing variously-shaped cauliflower-like growths sprouting from their walls. Or it may appear completely solid from the cysts having been entirely filled with intra-cystic growths ; on dissection, how- ever, the spaces between the growths and the cyst-walls can al- ways be demonstrated (Fig. 365). When the growth, which is at first encapsuled, attains some size, the skin may give way and the growth protrude in the form of a fungus. The skin, however, does not become infiltrated as in carcinoma. S/g//s. — They generally occur in women between the ages of thirty and thirty-five, as distinctly defined, lobulated. usually pain- less growths, hard in some places and soft and fluctuating in others, and often of large size. The veins over them are enlarged, but the skin is not adherent, the nipple is not retracted, and the glands as a rule are not aff'ected. They commonly grow slowly, but at times rapidly, and seldom or never become disseminated. Their chief distinguishing characteristic is the presence of one or more prominent fluctuating cysts in the tumor. Should a fungus protrude, it may be distinguished from carcinoma by the non-im- plication of the skin around, non-adherence of the growth to the side of the chest, and the absence of the other signs of carcinoma above pointed out. Removal of the breast is the proper ^rca/- ment. 766 DISEASES OF REGIONS. Cysts. — The cysts met with most frequently in the breast are the serous cysts, and certain of the retention cysts. Serous cysts are formed in the breast, as in other situations, by the distension with fluid of the lymphatic spaces of the connective tissue (see Serous Cvsfs). The retention cysts that occur in the breast may be divided into the galactoceks, which are produced by the dila- tation of the galactophorous ducts, and the glandular cysts, due to the distension of the smaller ducts and acini. The former contain a milk-like fluid, or when, as occasionally happens, the watery parts have been absorbed, an inspissated caseous material. The glandular contain a yellowish or brownish-yellow mucoid fluid, sometimes blood-stained, and at times intracystic papillary growths, formed by the ingrowing of the cyst walls. When they occur in elderly people they are spoken of as involution cysts. Their frequency in chronic lobular inflammation of the breast has already been alluded to. Signs. — Cysts in the breast form painless, tense, or semifluctua- ting, smooth, rounded tumors, evidently connected with the breast tissue. Serous cysts may occur in any part of the breast. They are often very tense and hard, and breasts with such in them have been removed for cancer. Hence the valuable rule of mak- ing a preliminary incision if in doubt as to the nature of the tumor. The galactoceles occur during lactation ; they are situated near the nipple, from which a milk-like fluid may sometimes be squeezed out on pressing the cyst. They are soft and fluctuating, and usually single, form quickly, and may attain a large size. Glandular cysts occur chiefly in women of from thirty-five to fifty. They are tense and painless, form slowly, may occur singly, but are often multiple. A sanious fluid sometimes escapes from the nipple if the cyst contains a papillary growth. Treatment. — Simple serous cysts may be laid freely open and allowed to granulate from the bottom, or better be dissected out. Galactoceles, with semi-solid contents, may also be laid freely open and their contents squeezed out. Glandular cysts, when nmnerous, call for the excision of the affected lobule, or if the whole breast is affected and they contain proliferating growths, excision of the entire gland. Involution cysts require no treat- ment. Carcinoma of the breast is nearly always of the acinous form, of which both varieties, the hard (^scirrhous) and the soft {medul- lary), are met with. The hard variety, however, is by far the most common. The general and microscopical characters of car- cinoma have already been given under tumors. Here only the special characters which it presents when occurring in the breast will be referred to. SCIRRHOUS CARCINOMA. 767 Scirrhous carcinoma. — Pathology. — Scirrhus of the breast gen- erally appears as an indurated; nodular, non-encapsuled, tuberous mass, of moderate dimensions, with long processes extending in various directions in the gland-substance and the fatty tissue around, and later, invoh'ing the skin and subjacent pectoral muscle. On section (Fig. 366) the tumor gives a characteristic creaking sensation to the knife, and the cut surface appears slightly concave from the contraction and shrinking of its fibrous stroma thus set free from the traction of surrounding tissues. It is of a hard resisting consistency, of a uniform close texture, semi-translucent, of a greyish-white color often tinged with pink, and has been hkened to the section of a potato or unripe pear. Sometimes it is intersected in every direction by short wavy glis- FlG. 366. Scirrhous carcinoma of the breast. (St. Bartholomew's Hospital Museum.) tening white fibres, with here and there yellow dots and streaks due to section of the epithelial cokunns which have undergone fatty degeneration ; whilst in other places, little masses of the surrounding fatty tissue and of muscle are seen enclosed by the processes of the growth ; and patches of caseous-looking material or white creamy fluid, due to the growth having surrounded some of the ducts which have become only partially obliterated, may be scattered through its substance. The section on scraping yields a juice containing cells, free nuclei, and granular material. Signs. — Scirrhous carcinoma generally begins as a small hard lump in the substance of the breast ; it grows slowly at fir.^t, after- wards more rapidly, and then involves the skin and pectoral muscle ; finally, the skin gives way, and a foul ulcer is produced. 768 DISEASES OF REGIONS. In the meantime, the lymphatic glands in the axilla become in- volved, and as they increase in size press upon the axillary vein and brachial plexus of nerves, producing oedema of the arm and intense neuralgic pain. Later the cancer becomes disseminated through the internal organs and tissues of the body. The health, which on the first appearance of the growth is generally good, now gives way, the skin becomes sallow and earthy in appear- ance, the patient wasted, and cancerous cachexia is said to be present. The foul and profuse discharge from the ulcer, the in- tense pain, the mental suffering, and the implication of internal organs, lead to exhaustion, and death soon steps in to put an end to the patient's misery. Such is the brief outline of the course of the disease when not subjected to surgical interference. Let us now study the characters of the tumor as presented in a typical case. It is usually situated in the upper and outer quadrant of the breast, or just below the nipple. Its surface is hard and ir- regular, its margins ill- defined. The skin at first, when gendy pinched up between the finger and thumb, shows a slight dimp- ling, and later appears distinctly puckered and unmistakably ad- herent to the growth. In the earlier stages the tumor glides freely over the pectoral muscle ; later a slight resistance is felt on moving it from side to side ; whilst finally it becomes firmly fixed to the walls of the chest. The nipple, when the growth is behind it, is retracted, in consequence of the traction which is made by the carcinoma upon the lacteal ducts (Fig. 366) ; but when the growth is situated in the circumference of the breast, there may be no retraction, or the retraction may occur only on one side ; whilst when the cancer begins as an infiltration of the nipple itself, the latter will be harder and more prominent than natural. On raising the arm and drawing the finger-tips transversely across the inner side of the axilla, a hard cord or cords — infil- trated lymphatic vessels — may often be felt extending from the tumor into the axilla, while in the space itself large glands will be discovered if the case is su Anciently advanced. The glands are at first soft, single and distinct, later, hard and matted together, forming an indurated irregular mass which is often adherent to the chest-walls and in advanced cases extends as high as can be felt beneath the clavicle. In the supraclavicular space the en- larged glands may sometimes be detected, first as a mere fulness, subsecjuently as distinct swellings. After the skin over the tumor has given way, an ulcer with sinuous, irregular, everted, and in- durated edges, and a foul, cavernous, irregular, and indurated base is formed, from which is exuded a foul-smelling and sanious discharge. The skin around is indurated from infiltration with the growth ; or -distinct, circumscribed, hard nodules of carci- noma are scattered here and there through it. SCIRRHOUS CARCINOMA. 769 Diagnosis. — When the above signs are present there is no diffi- culty in pronouncing as to the nature of the disease. In the earUer stages, however, whilst the tumor is still small and has not yet become adherent to the skin or to the pectoral muscle, where the breast is large and there is no retraction of the nipple, and as yet there is no enlargement of the axillary glands, the di- agnosis from an innocent tumor, a tense cyst, or lobular inflam- mation will be, to say the least, difficult. The age of the patient, the rate of growth, and the history of the case, must then to a great extent be relied on for distinguishing it. But where the patient, as is occasionally the case, is young, the diagnosis may then be impossible without making an incision into the growth, a proceeding which, under such circumstances, after the difficulty has been explained to the patient, is not only justifiable, but im- peratively called for. Rarer fo7-ms of scirrhus in the breast are occasionally met with. Thus — I. The cancer may begin as a general infiltration of the entire gland, when its course is usually very rapid. 2. It may chiefly affect the lymphatics of the skin, the whole side of the chest in such a case becoming infiltrated, hard, brawny and leath- ery in consistency, a condition known as "hide-bound." 3. It may begin as an infiltration of the nipple, or may be engrafted upon chronic eczema around the nipple. 4. In elderly w^omen it may run a very chronic course, often remaining stationary, if not interfered with, for many years (fibrous or chronic cancer). 5. In very exceptional instances, the carcinomatous mass has appa- rently undergone complete atrophy, even, it is said, after ulcera- tion has occurred, and a spontaneous cure has thus been brought about. Treatment. — In the breast, as elsewhere, the only hope of cure lies in the early and complete extirpation of the carcinoma. Un- less, therefore, the Surgeon is consulted before the skin, pectoral muscle and lymphatic glands are more than slightly involved, he can hold out but little prospect that the disease will not return, and return shortly, or that life will be materially, if at all, prolonged by an operation. Under such circumstances, therefore, there are some Surgeons who hold that an operation with the disease thus advanced ought not to be undertaken, as it can only bring dis- credit on surgery, and may possibly prevent other patients seek- ing advice whilst there is yet a probability that a free and com- plete removal of the breast and axillary glands may eradicate the disease. While admitting that this may be true, we must not lose sight of the fact that even although the growth may soon recur either in the cicatrix or glands, or in internal organs, and although life may not be prolonged, still removal of the growth may rid the 770 DISEASES OF REGIONS. patient of a foul and loathsome disease and often of great pain, at any rate for a time, and death may occur in a less distressing way from dissemination of the carcinoma in internal organs. In the meanwhile the patient's mind will be relieved, even if she is not buoyed up with the hope that there may still be a chance of a non-return. Regarding the question of operation, therefore, it may be briefly said that — i. Where the skin is not involved, or to a very slight extent, the tumor not adherent to the pectoral mus- cle, and the glands are not felt enlarged, or if enlarged are not adherent to the chest wall, free removal of the breast, and, in the last case, clearing out the axilla, is imperatively called for. 2. Where, on the other hand, the skin is extensively infiltrated, the tumor is firmly adherent to the pectoral muscle, the glands are enlarged, hard, and adherent to the side of the chest, enlarged glands can also be felt above the clavicle, and perhai^s have al- ready caused oadema of the arm, marked cachexia is present, and there is evidence of dissemination of the carcinoma in other or- gans and tissues — then no oi)eration should be performed. In cases such as the above, theie can belittle question as to the pro- priety of operating or not operating. But there is a large class of intermediate cases in which some Surgeons would, and some would not, operate. Much will then depend upon the presence or absence of pain, the age of the patient, etc., and each case must be judged on its own merits. When too far advanced to permit of removal, all that can be done is to relieve pain and pro- cure sleep by opium or morphia, and support the strength by a liberal diet and stimulants. Should an ulcer have formed it may in some cases be treated with caustics, as Eougard's paste or pyok- tanin, or dusted with iodoform or charcoal to control the foetor. MEDur.LARY CARCINOMA is much less common in the breast than the scirrhous form, and generally appears at an earlier age. It occurs as a soft, non-encapsuled, compact, white or blood- stained, brain-like mass infiltrating the gland and surrounding tissues. Its growth is much more rapid than the scirrhous variety, and it sooner involves the skin, pectoral muscles, and axillary glands, and rapidly becomes disseminated through internal organs. Early and free removal of the whole breast, and of any glands in the axilla that may be felt enlarged, is the proper treatment. Other varieties of carcinoma in the breast, as the so-called villous or duct cancers, and the colloid, require only a brief notice. Duct carcinoma occurs as one or more rounded masses lying in the breast tissue not far from the nipple. On section these masses appear as red, encysted and definite tumors (Fig. 367). Microscopically they consist of cysts, often containing blood, and into which papillary growths, covered by columnar epithelium, EXCISION OF THE BREAST. 771 sprout. The growths have an alveolar structure, and closely resemble, especially when the disease has recurred, ordinary encephaloid carcinoma. Sigf2s. — The nipple is not, as a rule, retracted, but there is usu- ally a history of a discharge of blood from it, often before a tumor is noticed. In the specimen of which Fig. 367 is a drawing, there was very slight retraction of the nipple. The skin is not infiltrated, the axillary glands are not enlarged, and secondary deposits are very rare. The tumor is firm and elastic, and may contain one or more cysts. It usually occurs in middle age, is of slow growth, and not accompanied as a rule by pain. The /rea^- ment consists in amputation of the whole breast. If this is done, no further trouble usually occurs. Colloid carcinoma of the breast is very rare. Its structure is like that of scirrhus or encephaloid cancer, but here and there large epithelial cell-masses have undergone colloid degeneration. It is of slower growth, and less frequently affects the glands, than Fig. 367. Section of a duct carcinoma of the heart. The tumor has well-defined edges, and is composed of a numbi-T of cysts containing growths and broken-down blood. (St. Bartholomew's Hospital Museum, No. 3, 186, i). either scirrhus or encephaloid, and has a less tendency to recur after removal. The prospective length of life is said to be three or four times that of ordinary scirrhus. Excision of the breast. — The arm being held out from the side by an assistant so as to put the pectoral muscle on the stretch and well expose the axilla, an elliptical incision should be made below and another above the nipple, cutting widely of any adherent or infiltrated skm. The skin above and below should now be re- flected from the breast, and the latter dissected off the pectoral muscle, taking care to lemove the pectoral fascia and any portion of the muscle that appears affected with the disease. Should any gland be felt in the axilla, the incision should be prolonged in an upward and outward direction, the axillary fascia opened by the scalpel, and all the glands that can be felt carefully dissected out or enucleated, in part by the fingers, and in part by the handle of the 772 DISEASES OF REGIONS. scalpel, care being taken not to injure the axillary vessels or large nerve-cords, both of which are situated at the upper and outer part of the space. The skin should now be drawn together by sutures, a drainage tube having been placed in the deeper part of the wound. Where the skin cannot be made to cover in the wound, the flaps should be drawn as much together as possible by stout silver sutures, and the remainder of the wound left to granu- late. The arm should be secured to the side with the forearm and hand across the chest. Some Surgeons, with a view to the more complete removal of glands, divide the pectoral muscles or even cut the pectoral muscles away. This procedure is fol- lowed by so much contraction and subsequent interference with the movement of the arm, that I do not advise it save under ex- ceptional conditions, as when the pectoral is infiltrated or glands cannot be otherwise reached. It does not ensure the complete removal of the disease, since the mediastinal glands may be affected. DEFORMITIES OF THE NECK, KNEES AND FEET. Wry-neck or torticollis is a distortion chiefly dependent upon contraction of the sterno-mastoid muscle. It may be congenital or acquired. Causes. — -The congenital form is attributed to — i, spastic con- traction of the sterno-mastoid muscles due to disease of the nervous system ; 2, malposition in utcro ; or, 3, injury at birth, as, for example, rupture of the sterno-mastoid in a breech presenta- tion. The acquired f 01-711 is due to — i, the head having been held for a long time in the distorted position as a consequence of stiff" neck following cold, rheumatism, injury,or in- FiG. 368. flamed cervical glands ; 2, hysteria : or 3, spasm set up by irritation of the spinal accessory nerve consequent upon central nerve trouble. Signs. — The head, supposing the right sterno-mastoid to be affected, is drawn for- wards and towards the right shoulder and also rotated, so that the chin points to the left. The right mastoid is ])rominent, the right side of the neck concave, and the left convex. In long-standing cases some lateral curvature of the dorsal sj^ine is generally ac- (]nired. The congenital form may be distin- guished from the spasmodic not only by its history, but by the sterno-mastoid becoming tense in the former, and yielding in the latter, Wry-neck .ipparatus. on attempting to Straighten the head. The hysterical variety will be known by the pres- ence of other signs of hysteria. KNOCK- KNEE OR GENU VALGUM. 773 Treatment. — In congenital wry-neck, unless the patient is treated by position while still an infant, division of the sterno-mastoid is generally required, followed by a course of systematic exercises in the slighter cases, and the use of some such instrument as that shown in Fig. 368, in the most severe. The sterno-mastoid is best divided immediately above the clavicle, as here it is furthest removed from the important structures that lie beneath it. A puncture should be made at the inner side of the tendon, a director passed behind it, and the division made towards the skin with a blunt-pointed tenotome. The tense bands of contracted cervical fascia which now start forward will yield to stretching ; it is not safe to divide them. The head should be straightened and thus held by a bandage and sand-bags. The puncture should be given three or four days to heal before the exercises are begun or the instrument is applied. Some advise the division of the muscle about the middle, on the plea that such is a more safe procedure ; whilst others again recommend the division of the tendon by open incision, as in this way the danger of puncturing and admitting air into a vein is avoided. If the subcutaneous division, however, is carefully done in the manner here advised, I do not believe there need be any fear of air entering the veins. I have now per- formed this little operation many times, and have never exper- ienced any difficulty or trouble. At the same time it is only right to state that sudden death has occurred in the hands of some ex- cellent Surgeons, and others have met with alarming symptoms. In spasmodic cases conium, Indian hemp, bromide of potassium, etc., may be tried. These failing, the spinal accessory nerve may be stretched just above the spot where it enters the sterno-mastoid. In very intractable cases a piece of the nerve may be excised, and if the posterior cervical muscles are also involved in the spasm, excision of portions of the posterior division of the first four cervical nerves may be simultaneously or subsequently under- taken. Tenotomy of the sterno-mastoid should in these and in hysterical cases on no account be done. In the latter, hysterical remedies should of course be used. Knock-knee or genu valgum is a deformity in which, when the knees are placed together in the extended position with the patellae looking directly forwards, the legs diverge. One or both knees may be affected, or there may be genu valgum on one side and genu varum on the other. Cause. — Knock-knee is generally the result either of rickets, when it occurs between the second and the seventh year ; or of carrying heavy weights, long standing and the like, when it is iTfost common is growing, underfed and overworked lads and girls from fourteen to eighteen. The deformity is variously believed 774 DISEASES OF REGIONS. to depend on : i, an overgrowth of the internal condyle of the femur, and a corresponding uprising of the inner tuberosity of the tibia; 2, the relaxation of the internal lateral ligament ; or 3, the contraction of the biceps tendon. In the majority of cases the osseous lesion is certainly present, and I have no doubt in my own mind that it is upon this that the deformity in rickety cases usually depends, though I admit that in some of those rapid cases induced by excessive weight-bearing in weakly lads, a relaxation of the ligaments may be the principal factor. The contraction of the biceps tendon when present I regard as the result, and not as the cause of the affection. Treatment. — In slight rickety cases, keeping the child entirely off its legs, the application of splints, and the internal use of appropriate remedies, will gener- ally effect a cure. In confirmed cases, and in older patients, however, little must be expected from splints or instruments. By their use the limb can no doubt be straightened, but only at the expense of stretching the external lateral ligament, the legs being rendered flail-like, and the patient being unable to walk or even stand without his irons. For such, some form of osteoclasia or Osteotomy is usually required. Osteoclasia consists in breaking the bone Fig. 369. either with the hands or with the osteoclast. Manual osteoclasia is seldom employed except for the correction of rickety bow-legs or knock- knee in young subjects when the bones are moderately soft. For fracturing larger and ^ stronger bones the osteoclast is required. The 3 limb is properly adjusted between the arms of c the instrument and the force applied by means of a screw in Grattan's osteoclast, or by levers in that of Thomas. Osteotomy is usually done by Macewen's or Reeves' modified Ogston's method, i. Mace- wen^s operation consists in chiselling through the femur just above the epiphysis, but leaving the posterior surface, which is in contact with the popliteal artery, intact, and snapping this A line of section in across by forciblv bending the bone. 2. In Macewen s ; 1>, in J ■ /-,-., Oeston's; and c, in Recvcs' modification of Oi^stoii s Operation, the stonrope°S"^' internal condyle is fir'st loosened with a chisel, and then made to ;:lide uiiwards on the shaft of the femur by .forcibly straiiditening the leg. The chi.sel is introduced behind the synovial meinbrane and shcnild not be driven so far into the condyle as to endang'T the opening of the joint. The line of incision through the femur in these operations TALIPES OR CLUB-FOOT. 775 is shown in Fig. 369. The incision in the soft tissues, which in either operation should be merely long enough to admit the chisel, may in each be made vertically two fingers' breadth above the patella, and midway between the inner edge of the rectus and the tendon of the adductor magnus. The operations should be performed antiseptically and the limb secured to a long splint, or placed in Bavarian plaster splints in a straight position for about a month, and subsequently kept in an ordinary plaster case for six weeks to two months till sound union has taken place. Genu varum, or bow-legs, is the opposite deformity to genu valgum, and what has been said of the latter as regards pathology, treatment, etc., will apply to it if external be substituted for in- ternal in the phraseology. It is frequently associated with a bow- ing of the shaft of the tibia, either at its upper or its lower third, and sometimes with a bowing of the femur. Genu recurvatum or extrorsum is a condition of over- exten- sion at the knee. It is frequently present in a slight degree in cases of knock-knee. It sometimes occurs as a congenital affection ; the hyper-extension may then be extreme, the feet touching the groins. When it is combined with knock-knee, the irons for the latter affection should have a front stop. In congenital cases di- vision of the quadriceps may be necessary, but continual attempts at flexion and the use of an instrument with a cog-wheel at the knee will usually suffice. Talipes or club-foot is a distorsion in which the relations to the tarsal bones to each other and to the bones of the leg are variously altered, and the bones held in their abnormal position by alteration in the shape of the bones and by the contraction or shortening of certain of the muscles, ligaments, and fasciae attached to the foot. Cause. — Talipes may be either congenital or acquired. The congenital form has been attributed to — i, spastic muscu lar contraction induced by some lesion of the nerve-centres ; 2, malpositions of the foetus in iitero ; 3, structural alteration in the form of some of the tarsal bones. The supporters of the first view maintain that the bones are drawn into their abnormal posi- tion by muscular contraction, and regard any alteration in the shape of the bones as the result and not as the cause of their malposition ; whilst those who uphold the second and third views deny that spastic contraction occurs, as no lesion of the nerve- centres has been found to account for it, and look upon the con- traction of the muscles as merely due to adaptive shortening con- sequent upon the altered position of the bones. The congenital variety is sometimes hereditary, very occasionally occurs in sev- eral members of the same family, and is frequently associated with other congenital malformations, as spina bifida, meningocele, 776 DISEASES OF REGIONS. etc. The acquired form is generally the result of infantile paraly- sis, the bones then either being drawn into their abnormal posi- tions by the contraction of the muscles antagonistic to those paralyzed, or falling into the abnormal positions by the weight of the foot. In either case the weight of the body in standing and walking tends more and more to confirm this faulty position. Amongst other causes may be mentioned long continuance of the foot in the extended position, disease of the ankle or tarsus, yielding of the ligaments, etc. Varieties. — There are five principal forms of club-foot : — Talipes equiniis, varus, calcaneus, valgus, and cavus. But these may be variously combined, producing compound forms, which are then called equino-varus , equino-valgus , calcaneo-valgus, etc. T. Talipes equimis (Figs. 370, 371) is nearly always an ac- quired affection, and generally due to infantile paralysis of the an- terior or extensor muscles ; as a congenital affection it is very rare. I have only seen two cases during the twelve years I have had charge of the orthopoedic department at St. Bartholomew's. The heel is drawn upwards by the tendo Achillis, and the anterior part of the foot is in consequence depressed and held in the ex- tended position. The weight of the body is thus transmitted through the heads of the metatarsal bones, which together with the anterior part of the tarsus are bent down- wards and backwards from the transverse ^'^- 371- tarsal joint and fixed in this position by the adai)tive shortening of the plantar fascia, liga- ments and muscles, thus rendering the sole of Fig. 370. Cun^eniUL Ace/ulrccL Talipes cquinus. (Bryant's Surgery.) Talipes equiniis, with coin])lcte paralysis of the iinlerior muscles. the foot unnaturally concave, a condition known as pes cavus. The patient walks with fatigue and lameness on the balls of hi!> TALIPES OR CLUB-FOOT. 777 toes, (Fig. 370), and if both feet are affected he may be unable to walk at all. When the extensor muscles of the toes are com- pletely paralyzed the toes may be bent under as shown in Fig. 371, and the patient walks on the dorsum of the toes or even on the dorsum of the foot. Corns, and perhaps ulcers, are then formed, rendering walking exceedingly painful or impossible. In long-standing cases, in consequence of the contraction being greater on the inner than on the outer side of the sole, an inward twist is given to the foot {equino-varus). At times the tendo AchiUis is not sufficiently shortened to draw up the heel, but at the same time is so contracted as to prevent the foot being placed beyond a right angle with the leg. This condition is spoken of as right-angled contraction of the tendo Achillis or as rectangular talipes. 2. Talipes varus is the most complicated variety of club-foot, and is the most common of the congenital forms. By some the distortion here described as varus is called equino-varus. I pre- fer, however, to apply the simple term varus to the form under consideration, and equino-varus to cases of equinus in which there is added a secondary twisting inwards of the foot. In varus (Fig. 372), the OS calcis is drawn up by the tendo Achillis, tilting the astragalus partially out of the ankle-joint, and the bones in front of the transverse tarsal joint are drawn inwards and upwards by the tibialis anticus and posticus, so that the scaphoid is placed internal to the astragalus instead of in front of it, whilst its tube- rosity is in close contact with the internal malleolus. The liga- ments on the inner side of the sole and between the tibia and astragalus are shortened, and are often the chief agents holding the bones in their deformed position. In severe cases, how- ever, the astragalus is itself deformed, its head looking almost directly inwards, in- stead of forwards and slightly inwards. Thus, in a well marked case (Fig. 373 a and b), the heel appears drawn up, the anterior part of the foot ad ducted and inverted, the inner border turned upwards or inverted, and the outer border down- wards, so that the sole looks backwards and the dorsum forwards, the long axis of the foot being at the same time shortened and bent upon itself, the sole unnaturally concave, and the plantar fascia tense. In severe cases (Fig. 373c) , the inner border of the foot may be in contact with the leg, and when the foot has been walked upon the sole looks upwards. Fig. 372. Congenital talipes varus. 'St. Bartholomew's Hospital Mu- seum.) 778 DISEASES OF REGIONS. as well as backwards, and the dorsum downwards as well as forwards ; whilst the sole is narrowed by the approximation of the fifth metatarsal bone to the first, and a bursa often forms over the outer border of the dorsum. In the acquired form, which is generally due to infantile paralysis, the history of the case, the wasting, shortening, coldness and passive congestion of the hmb, and often the absence of rig^'dity, will commonly serve to distinguish it from the congenital. 3. Talipes calcaneus is rare. In the congenital variety (Fig. 374) the anterior part of the foot is drawn up and often a little everted or inverted, and generally held rigidly in this position by the contraction of the extensor muscle?. In the acquired form (Fig. 374), which is commonly the result of infantile paralysis of Fig. 373. Congenital varus. Three grades of severity. (Bryant's Surgery.) the calf muscles, the heel is placed first on the ground in walking, but there is no drawing up of the foot by the extensors. The anterior part of the foot drops downwards from the transverse Fig. 374. Acf./i/ir(i^ (.'ox(/r/iilei7. Talipes calcaneus. (Bryant's .Surgery.) tarsal joint, and the tendo y\rhi]lis, instead of standing out tensely as in the normal foot, can often hardly l)e felt. 4. In talipes valgus or flat-foot the longitudinal and transverse arches of the foot are flattened and the anterior part of the foot TALIPES OR CLUB-FOOT. 779 is more or less everted. Though rare as a congenital, it is very common as an acquired deformity, and as such is, perhaps, most often due to the yielding of the ligaments of the sole and the re- laxed state of the muscles which normally support the plantar arches, in consequence of general debility and want of muscular tone, combined with long-standing or carrying heavy weights with the feet abducted. Hence its frequency in growing and under-fed lads, errand-boys, policemen, waiters, housemaids, and the like. Amongst other causes may be mentioned rheumatism, gonorrhoea, rickets, sprains of the plantar ligaments, and spasm or paralysis of certain muscles of the leg. It is also met with in badly-set cases of Pott's fracture. The calcaneo-scaphoid liga- ment and plantar fascia, and to a less extent the other ligaments of the sole, are elongated, and the bones on the inner side of the foot, instead of forming an arch, are depressed and in contact with the ground. The bones in front of the transverse tarsal joint are at the same time more or less abducted and everted, leaving the head of the astragalus, which is itself depressed, partly exposed on the inner side of the foot. In severe, and generally in congenital cases, the heel and front of the foot are drawn up by the tendo Achillis and the anterior muscles respectively, whilst the outer border of the foot is raised from the ground. The acquired form is often productive of so much crippling and pain as to render the sufferer unable to follow any employment which necessitates much standing or walking. The foot (Fig. 375) looks broader and longer than natural, the sole is flat, the inner border in contact with the ground, and the internal malleolus depressed ; whilst two prominences, formed by the tuberosity of the scaphoid and the partially exposed head of the astragalus, can be seen and felt projecting on the inner side Fig. 375. of the foot. In slight cases the foot can be made to assume its "| natural form on manipulation or |, on standing on tip-toe, but in / severe cases it is rigidly fixed in the deformed position. Pain and stiffness of the metatarso- phalangeal joint of the great toe {HaJ/i/x dolorosus) is a com- mon concomitant of flat-foot in boys and young adults. Talipes valgus or flat-foot. (St. Bartholo- 5. In talipes CaVllS the sole is ™<=^^'s Hospital xMuseumt. unnaturally arched and the plan- tar fascia is tense. The toes are often extended at the metalarso- 78p DISEASES OF REGIONS. phalangeal joint, and flexed at the first interphalangeal joints, giving them a clawed appearance (hollotu clazv-foot). This con- dition is said at times to be due to infantile paralysis affecting the interosseous muscles. I have tested the muscles in many cases, but have not found them paralyzed. General treatment of Talipes. — The indications are — i, to restore the deformed foot to its natural position; and 2, to retain it in this position until the normal functions of the joints and muscles have been so far restored that there is no tendency to a relapse. In the congenital and in many of the acquired forms these indications can be successfully fulfilled if appropriate means are taken and sufficient time and care are given to the case. But in the paralytic varieties, where the muscles have undergone com- plete atrophy and degeneration, these, of course, cannot be re- stored, and the foot can only be maintained in the normal posi- tion by the use of instruments. For the fulfilling of the first indi- cation both operative and mechanical or manipulative treatment may be necessary. For the second, the use of mechanical sup- ports and physiological after-treatment should be employed. The operative trea/menf, when this is necessary, will generally consist in the subcutaneous division of certain tendons {tenotomy^, in the division of contracted ligaments {syndesmotomy), and in in- veterate cases in the excision or section of some of the tarsal bones {tarsectomx or /arso/o/iiy), or in the performance of one or other of the following operations : — Phelps' open incision ; Buchanan's sub- cutaneous section ; Fitzgerald's operation ; forcible rectification. Tenotomy is indicated where there is much rigidity and the foot cannot be brought into its natural position by manipulation. Its object is the lengthening of the shortened tendon, not its mere division. The lengthening is effected by the organization of the small-cell-exudation which is poured out between the divided ends of the tendon. Hence the importance of subcutaneous division, that is, of making a mere puncture in the skin and pre- venting the entrance of septic matter, lest suppuration ensue and the tendon become adherent to its sheath or fail to unite. The tendon having been made tense by an assistant, pass the teno- tome beneath it with the blade on the flat ; then whilst the ten- don is slightly relaxed, turn the edge of the tenotome towards the tendon and cut towards the skin, the assistant again making it tense to facilitate the division, but relaxing the moment it is felt to give way, lest the skin be severed and the puncture be con- verted into an open wound. The puncture should be covered with a dossil of antiseptic gauze, and the foot secured to a splint or in a plaster-of- Paris bandage. It was formerly the custom to place the foot in a spHnt in the deformed, or in only a slightly TALIPES OR CLUE-FOOT. 781 improved position for a few days until the puncture had healed and the tendon had united, before beginning mechanical exten- sion to stretch the new material between the divided ends. It was thought that if the foot was at once rectified and the ends of the divided tendon consequently much separated, there was grave risk of the tendon not uniting, or of the uniting material remain- ing weak. I have not, however, found this to be the case ; and I now invariably place the foot immediately after tenotomy in the best position possible, often leaving a gap a quarter of an inch to half an inch, or even more, between the ends of the divided ten- don. By at once rectifying the position of the foot, after divid- ing any contracted ligaments that may still hold the bones in their deformed position, much time is saved and the necessity of expensive extension-apparatus is avoided. In dividing the pos- terior tibial tendon, after a puncture has been made with a sharp- pointed tenotome, a blunt-pointed tenotome should be substituted for it lest the posterior tibial artery be pricked. Should this ves- sel be wounded, all that is necessary is to apply firm pressure to the foot and ankle by a pad and l)andage. On no account should an attempt be made to tie it, as this would convert the subcuta- neous into an open wound. Even where the anterior as well as the posterior tibial artery has been wounded in tenotomy, bleeding has been readily arrested by pressure, and no harm has ensued. In the fat ankle of an infant the posterior border of the tibia, the guide to the tendon of the tibialis posticus, cannot be felt ; the tenotome should then be entered midway between the anterior and posterior border of the leg, and at right angles to the surface. Syndesuwtomy consists in dividing the contracted ligaments which, after tenotomy, are frequently found to hold the foot in the deformed position. It is performed by passing a tenotome deeply into the foot over the situation of the ligaments to be divided, and cutting freely through them whilst they are put on the stretch by an assistant manipulating the foot. The position of the foot should then be rectified by wrenching, and a plaster-of-Paris bandage applied. Tarsectomy has for its object the removal of certain bones or portions of bones from the tarsus, so as to allow the foot to be at once restored to its normal position. It should only be under- taken in inveterate cases after milder measures have failed. The operations most frequently performed are Davy's, or the removal of a wedge-shaped piece of bone from the tarsus, and Lund's, or the excision of the astragalus. Tarsotomy is the operation of dividing the tarsus transversely with a chain saw, and, like tarsectomy, should only be done in inveterate cases. 782 DISEASES OF REGIONS. Phelps^ open incision consists in making an incision through the soft tissues on the inner side of the loot down to the bones. The tibialis anticus and posticus, the abductor haUucis and the cal- caneo-scaphoid ligaments are divided. The wound is then stuffed with aseptic gauze and allowed to granulate from the bottom. Buchanan's subcuiatieoits section. — A tenotomy knife is passed between the skin and the plantar fascia half across the sole of the foot, and all soft parts, the muscles, arteries, nerves, and ligaments, are then divided down to the calcaneo-scaphoid joint. Fitzgerald' s operation consists in dividing subcutaneously with a chisel the neck of the astragalus and the os calcis just behind the posterior articular ficet for the astragalus, and in then drilling the cuboid in several places, breaking up subcutaneously the scaphoid with a chisel and hammering it back into place. Forcible rectification. — This is done by a Thomas wrench or by Grattan's, Redard's, or some other form of osteoclast. The liga- ments preventing reduction are torn across, and sometimes the bones are broken. Mechanical treatment. — Until recently it was usual to keep the foot in the deformed position till the tendons Fi'^s?^- had united, and then bring the foot slowly into its normal position by gradually stretching the divided tendon. The apparatus usually em.ployed was some form of Scarpa's shoe (Fig. 376) or other cog-wheel contrivance. By the majority of Surgeons, however, plaster-of-Paris is now substituted for such expensive apparatus, the foot being secured at once in the plaster in the best possible position. In slight cases divi- sion of the tendon will alone be sufficient to allow of this ; in more severe cases the division Scarpa's shoe. of the ligamciits will also be necessary, whilst in very severe cases removal of a portion of bone will be required. If plaster-of-Paris is used, a cotton-wood bandage should always be employed beneath the plaster to pre- vent injurious pressure on the parts. The mechanical supports necessary after the foot has been rectified will be briefly men- tioned under the treatment of each variety of talipes. Physiological after-treatment is most important for the purpose of restoring the natural movements of the joints and the func- tional activity of the muscles. It consists in active and passive exercises, massage, Faradization, hot and cold sponging, and lastly in teaching the patient the proj^er use of the restored foot. It now remains to mention the special treatment appropriate to each variety of talipes. In talipes equinus, tenotomy of the tendo Achillis is usually all TALIPES OR CLUB-FOOT. 783 Fig. 377. Boot with double leg- irons to above knee, outside iron contin- ued 10 pelvic girdle. that is required ; but if there is much contraction of the sole {talipes cavus), the plantar fascia, or any tense band that can be felt, should first be divided, and when the sole has been straight- ened out by keeping the foot for a fortnight or so in plaster of Paris, the tendo Achillis may then be cut, and the foot again placed in plaster in the restored position for another two or three weeks. A boot with double leg-irons and toe- raising spring must be subsequently worn in par- alytic cases, the irons being carried above the knee and the outer band above the hip to a pelvic band if the flexors or extensors of the leg are also affected (Fig. 377). In talipes vanes, except in slight cases, the tibialis anticus and posticus should first be di- vided, and the inversion of the foot overcome by some form of varus sphnt, or plaster of Paris. VVhen this has been thoroughly done, the tendo Achillis should be cut, and the heel brought down as in equinus. Where there is much contraction of the sole, the plantar fascia, or other tense band, should be divided after the tibials, but before the tendo Achillis. A similar instrument to that described for equinus should then be worn for six months to a year or more, or as long as any tendency is shown to relapse. In paralytic cases, where the whole leg tends to twist inwards from the hip-joint, the outer iron should be carried to the pelvis. In very severe cases the ligaments on the inner side of the sole and the posterior ligament of the ankle may be divided subcu- taneously, as suggested by Mr. R. W. Parker {syndesmotomy); or, if this is not enough, the whole of the soft tissues on the inner side of the sole may be divided subcutaneously down to the bone {Bitchanan'' s operation), or the contracted tendons and ligaments below and in front of the internal malleolus may be divided by an open incision (^Phelps' operation), or as a last resource a wedge-shaped piece from the transverse tarsal joint, or the astra- galus, may be removed. In talipes calcaneus, the extensor tendons, in the congenital form, must be divided if the foot cannot be rectified by plaster of Paris alone. In the acquired form a boot and irons, similar to that used in equinus but with a toe- depressing spring, may be worn. In paralytic cases the tendo Achillis may in some in- stances be shortened by removing half an inch or more and splic- ing the divided ends, or the peronei may be sutured to the tendo Achillis so as to take the place of the paralyzed calf muscles {NicolodonPs operation) . 784 DISEASES OF REGIONS. In talipes valgus or flat-foot, such, exercises as alternately raising the body on tip-toe, or walking on the outer Fig. 378. edge of the foot, will in slight cases of the ac- quired variety when combined with the use of a valgus pad and a properly shaped boot, gener- ally be successful. In severer cases a boot with outside leg-iron and rubber band to brace up the sunken arch (Fig. 378), should be worn; whilst where there is much rigidity, the foot should be wrenched into position with the pa- tient under an anaesthetic and placed in plaster of Paris for a month. The wrenching may be repeated if necessary, and the boot above de- , , , ^ , „ scribed subsequentlv worn. In very severe Author s boot for flat- .. r r^i ' ■, ■ • /^i foot. cases excision 01 Lhopart s jomt {Ogston s oper- ation), the removal of a wedge-shaped piece of the neck of the astragalus, and osteotomy of the tibia just above the ankle, have been performed, and are said to be attended with success. I have on only one occasion had to do Ogston's oper- ation, having always found wrenching sufficient. By some Sur- geons division of the peronei tendons is recommended, a pro- cedure which in my opinion is quite unnecessary, and contrary to the principles which should guide us in the treatment of the deformity. Hallux valgus is the dislocation of the great toe inwards at the metatarso-phalangeal joint. It is frequently connected with an enlarged bunion over the inner side of the joint. In the way of treatment a sock with a separate stall for the big toe should be worn, and the boots should be straight along the inner edge and square at the toe. Krohne's lever. Bigg's bunion spring, or Holden's toe-post in the boot, will be found useful in correcting the inward displacement. If the toe-post is used a gloved stock- ing must be worn. For advanced cases, excision of the head of the metatarsal bone is attended with the best results. Hammer toe is a condition in which usually the second toe is hyperextended at the metatarso-phalangeal joint and flexed at the first interphalangeal joint. It is due to contraction of the lateral ligaments and glenoid plate (not to contraction of the tendons), the result in probably the majority of cases of wearing too short or badly-shaped boots. It is sometimes hereditary, however, and Mr. Anderson regards it as due to a physiological contraction of the ligaments, and only in a remote sense to the use of ill-formed boots. Treatment. — Wrenching the toe, dividing the ligaments subcutaneously, excising the joint, or am]nitating the toe, accord- ing to the degree of the deformity, is the proper treatment. APPENDIX. AMPUTATIONS. Amputations. — The objects that should be kept in view in performing an amputation are : i. To remove the whole of the injured or diseased part that is beyond the reach of recovery, with as little sacrifice of the healthy tissues as possible. 2. To prevent all unnecessary haemorrhage. 3. To secure a sufficient covering for the end of the bone. 4. To avoid adhesion of the cicatrix to the bone. 5. To divide the large blood-vessels and nerves transversely, and leave their cut ends in such a part of the stump that they may be Httle exposed to pressure. 6. To ensure an efficient drain and aseptic condition of the wound. Amputations may be performed by the circular or by t\\t flap method. In the circular method the integuments are first divided by a circular incision round the entire circumference of the limb. They are then retracted, and the muscles divided higher up the limb by a similar circular sweep of the knife. The muscles are next in their turn retracted, and the periosteum is divided still higher up the bone, which is finally sawn through at that spot. This method possesses the advantages that the vessels and nerves are divided transversely, and that the wound is of moderate dimensions ; but the cicatrix is opposite the end of the bone, the coverings for the latter are apt to be deficient, and the stump is liable to assume a conical shape. The circular method is now seldom employed, except for amputation of the arm. In iht flap me/hod, double flaps, or a single anterior or posterior flap, are provided for the covering of the bone. The flap or flaps may consist of integuments alone, or of more or less of the mus- cular and other soft tissues as well. In the former case the flaps are cut and reflected, and the muscles and other soft parts are then divided at the level of the base of the flaps in a circular manner down to the bone, which is sawn through a little higher up. By this method most of the advantages of the circular ampu- tation are secured, without its disadvantages. When, on the other hand, the muscles are included in the flaps, the vessels and nerves are Hable to be split, or notched, or 'divided obliquely instead of transversely, whilst the mass of muscle in the flap tends to prolong the healing of the wound. These muscular flaps may be cut either 2>Z* ( 785 ) 786 APPENDIX. from without inwards, /. e., from the circumference towards the bone, or from within outwards, /. e., by the method of transfixion. In whichever way the flaps are cut, and whether they consist of integimients only, or of integuments and muscle, they may as re- gards position be antero-posterior or lateral, or one may be antero- external and the other postero-internal, or vice versa. As regards length they may be equal, or one may be long, the other short ; and as regards breadth they should be half the circumference of the limb. As a rule they should be cut square, but with rounded angles. The following modifications of the flap operation may be briefly mentioned. Teak's method consists in making a long and short rectangular flap (Fig. 379). The long flap, which is generally anterior, or Fig. 379. Tealc's amputation. (Bryant's Surgery.) antero-external, is quadrilateral in shape, and its length and breadth each equal to half the circumference of the limb; it includes all the soft parts down to the bone. The short flap is posterior, or postero-internal ; its length is one-fourth the anterior, and its breadth equal to half the circumference of the limb ; it also includes all the soft parts down to the bone, and contains the large vessels and nerves. When the operation is completed and the wound closed, the stump presents the appearance shown in the lower half of Fig. 379. The advantages claimed for Teale's method are : i. Freedom from tension. 2. A complete covering for the bone, free of large vessels and nerves ; and 3. A dependent position of the wound. It is applirable to amputations through the leg, arm, forearm and lower third of the thigh. Garden's 7nelhod, designed for amputating through the con- SPECIAL AMPUTATIONS. 787 dyles of the femur, consists in reflecting a semi-oval flap of integ- uments, half the circumference of the limb in length and breadth, from the front of the knee-joint, dividing everything else down to the bone by a circular sweep of the knife and sawing the bones across slightly above the plane of the divided muscles. Special amputations. — Amputation at the shoulder-joint may be performed either by the flap or by the oval method. In either case the subclavian artery should be compressed above the clav- icle, or in some instances the axillary tied before the amputation is begun. The flap method. — A large flap consisting of integu- ments and deltoid muscle is usually taken from the outer aspect of the joint, either by transfixion or better by cutting from with- out inwards. In transfixion, the deltoid having been grasped and raised by the Surgeon's left hand, the knife should be made to transfix the limb on its upper and outer aspect just below the acromion, and a flap formed with rounded angles about four inches long. The flap is turned back, the head of the bone freed from its connections, and the knife passed behind it, and made to cut its way out towards the axilla, the axillary artery being seized as it is divided. In cutting a flap from without inwards, the in- cision is made from a point just external to the coracoid process and carried in a circular sweep downwards as low as the insertion I of the deltoid, and then upwards to the posterior fold of the ' axilla just behind and below the acromion. In the oval method {Spence's niodification), an incision is made from just external to the coracoid vertically downwards as in excising the joint, "through the clavicular fibres of the deltoid and pectoralis major" to the humeral attachment of the latter muscle, which is then divided. The incision is next carried with a gentle curve through the lower fibres of the deltoid towards the posterior border of the axilla. A second incision is then made through the skin and fat only, from the point where the straight incision ter- minated across the inside of the arm, to meet the incision at the outer part. The outer flap is next dissected up with the trunk of the posterior circumflex artery, the head freed from its connections, disarticulated, and the remaining soft parts cut through on the axillary aspect, the axillary artery being divided last of all. Amputations of the arm and forearm are usually performed by double skin-flaps and circular division of the muscles. The cir- cular method, however, or amputation by single or double trans- fixion or by Teale's method, may be employed. Amputation at the wrist may be performed by two short flaps, by a long palmar flap, or by an external flap taken from the thumb. In the double-flap method the incision is commenced half an inch above the styloid process of the radius or ulna. The flaps should 788 APPENDIX. be cut square, with rounded angles, and about two inches in length. The joint should be opened on the dorsal aspect, and on the completion of the disarticulation the styloid processes of the radius and ulna sawn off. The thumb at the carpo-metacarpal joint may be amputated by transfixion or by an oval incision. In the transfixion method the point of the knife in operating on the right side is entered at the web of skin between the first and second metacarpal bones, and made to emerge on the palmar aspect of the carpo-metacarpal joint. A palmar flap is then cut from the tissues forming the ball of the thumb, and the knife drawn obliquely across the back of the thumb from one extremity of the flap to the other. In ope- rating on the left side, the oblique incision across the back of the thumb is first made, then the point of the knife is thrust down through the web and made to transfix as on the right side. In the oval 528. needles, 528, 529. Snake-bites, 118. Snellen's test-types, 484. Snuffles, 74. Sounding fcir stone, 686. Spasm of the osso])hagus, 556. of the urethra, 706. Spasmodic stricture, 706. Specula, aural, 468. Spernialic cord, diseases of, 737. Iiydroccle of, 737. torsion of, 739. tumors of, 739. varicocele of, 737. Sphacelus, 52. Sphenoidal sinus, catarrh of, 553. S[)ica bandage, 623. Spina bilida, 591. INDEX. 8ll Spinal cord, injuries of, 363. Spine, caries of, 584. concussion of, 368. curvature, angular, of, 584. lateral, of, 580. diseases of, 580. dislocation of, 363. extension of, 367. fracture-dislocation of, 364. fractures of, 363. injuries of, 362. Pott's disease of, 584. railway, 368. sprains of, 362. trephining, 367. wounds of, 363. Spleen, extirpation of, 619. rupture of, 378. wound of, 381. Splenectomy, 619. Splint, box, 460. Bryant's, 450. Cline's, 458. Dupuytren's, 459. Liston's, 449. Manning's, 454. Roughton's, 459. Splints, 174. Bavarian, 174. Spongy gums, 533. Spontaneous aneurysm, 270. Sprains, 186, 403, 429. Spreading traumatic gangrene, 56. Squint, 507. Staphyloma, 491, 506. Staphylorrhaphy, 528. Staphylococcus pyogenes aureus, 38. Stasis in inflammation, 19. Sterno-mastoid muscle, contraction of, 772. division of, 773. Sternum, dislocation of, 369. fracture of, 369. Stiff-joint, 254. Stings of insects, 118. Stomach, rupture of, 378. dilatation of the cardiac and pyloric ends of, 618. opening the, 559. wound of, 381. Stomatitis, 515. Stone, (5d'i-5o CAMERON. Oils and Varnishes. With Illustrations, Formulse, Tables, etc. ^2.25 CAMERON. Soap and Candles. 54 Illustrations. $2.00 CLOWES AND COLEMAN. Elementary Practical Chem- istry and Qualitative Analysis. Adapted for Use in the Labora- tories of Schools and Colleges. Illustrated. ?i-2S GARDNER. The Brewer, Distiller, and 'Wine Manufac- turer. A Hand-Book for all Interested in the Manufacture and Trade of Alcohol and Its Compounds. Illustrated. Ji-So GARDNER. Bleaching, Dyeing, and Calico Printing. With Formulae. Illustrated. |i-5o GROVES AND THORP. Chemical Technology. The Appli- cation of Chemistry to the Arts and Manufactures. 8 Volumes, with numerous Illustrations. Vol. I. Fuel and Its Applications. 607 Illustrations and 4 Plates. Cloth, J5.00; Half Morocco, $6.50 Vol.11. Lighting. Illustrated. Cloth, ^4.00; Half Morocco, ^5.50 Vol. III. Lighting — Continued. In Press. HOLLAND. The Urine, the Gastric Contents, the Common Poisons, and the Milk. Memoranda, Chemical and Microscopi- cal, for Laboratory Use. sth Ed. Illustrated and interleaved, Ji. 00 LEFFMANN. Compend of Medical Chemistry, Inorganic and Organic. Including Urine Analysis. 4th Edition, Rewritten and Revised. .80; Interleaved, Ji. 25 LEFFMANN. Progressive Exercises in Practical Chemis- try. Illustrated. 2d Edition. $1.00 LEFFMANN. Analysis of Milk and Milk Products. Arranged to Suit the Needs of Analytical Chemists, Dairymen, and Milk Inspec- tors. 2d Edition. Enlarged, Illustrated. t^-'^S LEFFMANN. Water Analysis. Illustrated. 3d Edition. Jx.25 LEFFMANN. Structural Formulae. Including 180 Structural and Stereo-Chemical Formulae. i2mo. Interleaved. Ji.oo MUTER. Practical and Analytical Chemistry. 4th Edition. Revised to meet the requirements of American Medical Colleges by Claude C. Hamilton, m.d. 51 Illustrations. ^1.25 OETTEL. Practical Exercises in Electro-Chemistry. Illus- trated. .75 OETTEL. Introduction to Electro-Chemical Experiments. Illustrated. .75 RICHTER. Inorganic Chemistry. 4th American, from 6th Ger- man Edition. Authorized translation by Edgar F. Smith, m.a., PH.D. 89 Illustrations and a Colored Plate. ^1-75 RICHTER. Organic Chemistry. 3d American Edition. Trans, from the last German by Edgar F. Smith. Illustrated. In Press. SMITH. Electro-Chemical Analysis. 2d Edition, Revised. 28 Illustrations. |i-2S SMITH AND KELLER. Experiments. Arranged for Students in General Chemistry. 3d Edition. Illustrated. .60 STAMMER. Chemical Problems. With Answers. ,50 SUBJECT CATALOGUE. SUTTON. Volumetric Analysis. A Systematic Handbook for the Quantitative Estimation of Chemical Substances by Measure, Applied to Liquids, Solids, and Gases. 7th Edition, Revised. 112 Illustrations. ^4.50 SYMONDS. Manual of Chemistry, for Medical Students. 2d Edition. J2.00 WOODY. Essentials of Chemistry and Urinalysis. 4th Edition. Illustrated. In Press. *** Special Catalogue of Books on Chemistry free ufon application. CHILDREN. CAUTLIE. Feeding of Infants and Young Children by Nat- ural and Artificial Methods, fust Ready. J2.00 HALE. On the Management of Children in Health and Dis- ease. .50 HATFIELD. Compend of Diseases of Children. With a Colored Plate. 2d Edition. .80; Interleaved, |i. 25 IRELAND. Mental Affections of Children. Idiocy, Imbe- cility, etc. In Press. MEIGS. Infant Feeding and Milk Analysis. The Examination of Human and Cow's Milk, Cream, Condensed Milk, etc., and Directions as to the Diet of Young Infants. .50 MONEY. Treatment of Diseases in Children. Including the Outlines of Diagnosis and the Chief Pathological Differences Between Children and Adults, ad Edition. $2.50 PO'WER. Surgical Diseases of Children and their Treat- ment by Modern Methods. Illustrated. $^-So STARR. The Digestive Organs in Childhood. The Diseases of the Digestive Organs in Infancy and Childhood. With Chapters on the Investigation of Disease and the Management of Children. 2d Edition, Enlarged. Illustrated by two Colored Plates and numerous Wood Engravings. ^2,00 STARR. Hygiene of the Nursery. Including the General Regi- men and Feeding of Infants and Children, and the Domestic Manage- ment of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. Just Ready. fi.oo TAYLOR AND "WELLS. The Diseases of Children. Illus- trated. A New Text-Book. Nearly Ready. CLINICAL CHARTS. GRIFFITH. Graphic Clinical Chart for Recording Temper- ature, Respiration, Pulse, Day of Disease, Date, Age, Sex, Occupation, Name, etc. Printed in three colors. Sample copies free. Put up in loose packages of fifty, .50. Price to Hospitals, 500 copies, J4.00; 1000 copies, $7.50. With name of Hospital printed on, .50 extra. KEEN'S CLINICAL CHARTS. Seven Outline Drawings of the Body, on which may be marked the Course of Disease, Fractures, Operations, etc. Pads of fifty, Ji.co. Each Drawing may also be had separately, twenty-five to pad, 25 cents. SCHREINER. Diet Lists. Arranged in the form of a chart. Pads of 50. .75 MEDICAL BOOKS. DEFORMITIES. REEVES. Bodily Deformities and Their Treatment. A Hand-Book of Practical Orthopedics. 228 Illustrations. Ji-TS HEATH. Injuries and Diseases of the Jaws. 187 Illustrations. 4th Edition. Cloth, $4.50 DENTISTRY. special Catalogite 0/ Dental Books sent free upon application. BARRETT. Dental Surgery for General Practitioners and Students of Medicine and Dentistry. Extraction of Teeth, etc. 3d Edition. Illustrated. Nearly Ready. BLODGETT. Dental Pathology. By Albert N. Blodgktt, M.D., late Professor of Pathology and Therapeutics, Boston Dental College. 33 Illustrations. ?i-2S FLAGG. Plastics and Plastic Filling, as Pertaining to the Filling of Cavities in Teeth of all Grades of Structure. 4th Edition. J4.00 FILLEBROWN. A Text-Book of Operative Dentistry. Written by invitation of the National Association of Dental Facul- ties. Illustrated. $2.25 QORGAS. Dental Medicine. A Manual of Materia Medica and Therapeutics. 6th Edition, Revised. Cloth, J4.00; Sheep, J5.00 HARRIS. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery, and Mechanism. 13th Edition. Revised by F. J. S. Gorgas, m.d., D.D.s. 1250 Illustrations. Cloth, J6.00; Leather, $7.00 HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 5th Edition. Revised and Enlarged by Fer- dinand F. S. Gorgas, m.d., d.d.s. Cloth, J4.50 ; Leather, $5.50 HEATH. Injuries and Diseases of the Jaws. 4th Edition. 187 Illustrations. J4.50 HEATH. Lectures on Certain Diseases of the Jaws. 64 Illustrations. Boards, .50 RICHARDSON. Mechanical Dentistry. 7th Edition. Thor- oughly Revised and Enlarged by Dr. Geo. W. Warren. 691 Illus- trations. Cloth, ^5.00; Leather, ^6.00 SEWELL. Dental Surgery. Including Special Anatomy and Surgery. 3d Edition, with 200 Illustrations. $2.00 TAFT. Operative Dentistry. A Practical Treatise. 5th Edition. 100 Illustrations. In Press. TAFT. Index of Dental Periodical Literature. fi.oo TALBOT. Irregularities of the Teeth and Their Treatment. 2d Edition. 234 Illustrations. $300 TOMES. Dental Anatomy. Human and Comparative. 263 Illus- trations. 5th Edition. Just Ready. ^4.co TOMES. Dental Surgery. 3d Edition. 292 Illustrations. ^4.00 WARREN. Compend of Dental Pathology and Dental Medi- cine. With a Chapter on Emergencies. 3d Edition. Illustrated. Jxtst Ready. .80; Interleaved, $1.25 WARREN. Dental Prosthesis and Metallurgy. 129 Ills. J1.25 WHITE. The Mouth and Teeth. Illustrated. .40 %* Special Catalogue of Dental Books free upon application. SUBJECT CATALOGUE. DICTIONARIES. GOULD. The Illustrated Dictionary of Medicine, Biology, and Allied Sciences. 'Being an Exhaustive Lexicon oi Medicine and those Sciences Collateral to it: Biology (Zoology and Botany), Chemistry, Dentistry, Parmacology, Microscopy, etc., with many usefiil Tables and numerous fine Illustrations. 1633 pages. 3d Ed. Sheep or Half Dark Green Leather, ;fio.oo; Thumb Index, Jii.oo Half Russia, Thumb Index, J12. 00 GOULD. The Medical Student's Dictionary. Including all the Words and Phrases Generally Used in Medicine, with their Proper Pronunciation and Definition, Based on Recent Medical Literature. With Tables of the Bacilli, Micrococci, Mineral Springs, etc., of the Arteries, Muscles, Nerves, Ganglia, and Plexuses, etc. loth Edition. Rewritten and Enlarged. Completely reset from new type. 700 pp. Half Dark Leather, $3.25 ; Half Morocco, Thumb Index, $4.00 GOULD. The Pocket Pronouncing Medical Lexicon. (12,000 Medical Words Pronounced and Defined.) Containing all the Words, their Definition and Pronunciation, that the Medical, Dental, or Pharmaceutical Student Generally Comes in Contact With ; also Elaborate Tables of the Arteries, Muscles, Nerves, Bacilli, etc., etc., a Dose List in both English and Metric System, etc.. Arranged in a Most Convenient form for Reference and Memorizing. Full Limp Leather, Gilt Edges, Ji.oo ; Thumb Index, J1.25 70,000 Copies of Gould's Dictionaries Have Been Sold. *^* Sample Pages and Illustrations and Descriptive Circulars of Gould's Dictionaries sent free upon application. HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 5th Edition. Revised and Enlarged by Ferdinand J. S. Gorcas, m.d., d.d.s. Cloth, I4.50; Leather, J5.50 LONGLEY. Pocket Medical Dictionary. With an Appendix, containing Poisons and their Antidotes, Abbreviations used in Pre- scriptions, etc. Cloth, .75 ; Tucks and Pocket, |i.oo MAXWELL. Terminologia Medica Polyglotta. By Dr. Theodore Maxwell, Assisted by Others. J3.00 The object of this work is to assist the medical men of any nationality in reading medical literature written in a langiiage not their own. Each term is usually given in seven languages, viz. : English, French, German, Italian, Spanish, Russian, and Latin. TREVES AND LANG. German-English Medical Dictionary. Half Russia, ^3.25 EAR (see also Throat and Nose). HOVELL. Diseases of the Ear and Naso-Pharjrnx. Includ- ing Anatomy and Physiology of the Organ, together with the Treat- ment of the Affections of the Nose and Pharynx which Conduce to Aural Disease. 122 Illustrations. IS-oo BURNETT. Hearing and How to Keep It. Illustrated. .40 DALBY. Diseases and Injuries of the Ear. 4th Edition. 38 Wood Engravings and 8 Colored Plates. $'^■5° PRITCHARD. Diseases of the Ear. 3d Edition, Enlarged. Many llhistrations and Formulae. j^i.SO WOAKES. Deafness, Giddiness, and Noises in the Head. 4th Edition. Illustrated. Ja.oo MEDICAL BOOKS. ELECTRICITY. BIGELOV^. Plain Talks on Medical Electricity and Bat- teries. With a Therapeutic Index and a Glossary. 43 Illustra- tions. 2d Edition. $1.00 JONES. Medical Electricity. 2d Edition. 112 Illustrations. $2.50 MASON. Electricity ; Its Medical and Surgical Uses. Numer- ous Illustrations. .75 EYE. A Special Circular 0/ Books on the Eye sent free upon application. ARLT. Diseases of the Eye. Clinical Studies on Diseases of the Eye. Translation by Lyman Ware, m.d. Illustrated. J'-zs DONDERS. Aphorisms upon Refraction and Their Results. 8vo. In Press. PICK. Diseases of the Eye and Ophthalmoscopy. Trans- lated by A. B. Hale, m. d. 157 Illustrations, many of which are in colors, and a glossary. Cloth, 54.50; Sheep, J5.50 GOULD AND PYLE. Compend of Diseases of the Eye and Refraction. Including Treatment and Operations, and a Section on Local Therapeutics. With Formulae, Useful Tables, a Glossary, and III Illustrations, several of which are in colors. Just Ready. Cloth, .80 ; Interleaved, ^1.25 GOAVERS. Medical Ophthalmoscopy. A Manual and Atlas with Colored Autotype and Lithographic Plates and Wood-cuts, Comprising Original Illustrations of the Changes of the Eye in Dis- eases of the Brain, Kidney, etc. 3d Edition. I4.00 HARLAN. Eyesight, and How to Care for It. Illus. .40 HARTRIDGE. Refraction. 96 Illustrations and Test Types. 8th Edition, Enlarged. $1.50 HARTRIDGE. On the Ophthalmoscope. 3d Edition. With 72 Colored Plates and many Wood-cuts. Ji-5o HANSELL AND BELL. Clinical Ophthalmology. Colored Plate of Normal Fundus and 120 Illustrations. ^i-So MORTON. Refraction of the Eye. Its Diagnosis and the Cor- rection of its Errors. With Chapter on Keratoscopy and Test Types. 6th Edition. Ji 00 OHLEMANN. Ocular Therapeutics. Authorized Translation, and Edited by Dr. Charles A. Oliver. In Press. PHILLIPS. Spectacles and Eyeglasses. Their Prescription and Adjustment. 2d Edition. 49 Illustrations. $1.00 SWANZY. Diseases of the Eye and Their Treatment. 6th Edition, Revised and Enlarged. 158 Illustrations, i Plain Plate, and a Zephyr Test Card. ' J3.00 THORINGTON. Retinoscopy, ■zA'&A. \\\n%. Just Ready. Ji.oo WALKER. Students' Aid in Ophthalmology. Colored Plate and 40 other Illustrations and Glossary. ^i-5o FEVERS. COLLIE. On Fevers. Their History, Etiology, Diagnosis, Prog- nosis, and Treatment. Colored Plates. J2.00 GOODALL AND WASHBOURN. Fevers and Their Treat- ment. Illustrated. 93-oo 10 SUBJECT CATALOGUE. GOUT AND RHEUMATISM. DUCK'WORTH. A Treatise on Gout. With Chromo-lithographs and Engravings. Cloth, ^6.00 GARROD. On Rheumatism. A Treatise on Rheumatism and Rheumatic Arthritis. Cloth, $5.00 HAIG. Causation of Disease by Uric Acid. A Contribution to the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. fe-oo HEADACHES. DAY. On Headaches. The Nature, Causes, and Treatment ot Headaches. 4th Edition. Illustrated. Ji.oo HEALTH AND DOMESTIC MEDI- CINE (see also Hygiene and Nursing). BUCKLEY. The Skin in Health and Disease. lUus. ,40 BURNETT. Hearing and How to Keep It. Illustrated. .40 COHEN. The Throat and Voice. Illustrated. .40 DULLES. Emergencies. 4th Edition. Illustrated. Ji.oo HARLAN. Eyesight and How to Care for It. Illustrated. .40 HARTSHORNE. Our Homes. Illustrated. .40 OSGOOD. The Winter and its Dangers. .40 PACKARD. Sea Air and Bathing. .40 PARKES. The Elements of Health. J1.35 RICHARDSON. Long Life and How to Reach It. .40 WESTLAND. The Wife and Mother. $1.50 WHITE. The Mouth and Teeth. Illustrated. .40 ■WILSON. The Summer and its Diseases. .40 ■WOOD. Brain Work and Overwork. .40 STARR. Hygiene of the Nursery. 5th Edition. ^i.oo CANFIELD. Hygiene of the Sick-Room. J1.25 HEART. SANSOM. Diseases of the Heart. The Diagnosis and Pathology of Diseases of the Heart and Thoracic Aorta. With Plates and other Illustrations. ^6.00 HISTOLOGY. STIRLING. Outlines of Practical Histology. 368 Illustrations. 2d Edition, Revised and Enlarged. With new Illustrations. ^2.00 STOHR. Histology and Microscopical Anatomy. Translated and Edited by A. bcHAPBR, M.D., Harvard Medical School. 268 Illustrations. • ^3-o° MEDICAL BOOKS. HYGIENE AND WATER ANALYSIS. special Catalogue of Books on Hygiene sent free upon application. CANFIELD. Hygiene of the Sick-Room. A Book for Nurses and Others. Being a Brief Consideration of Asepsis, Antisepsis, Dis- infection, Bacteriology, Immunity, Heating and Ventilation, and Kindred Subjects. |i.2S COPLIN AND BEVAN. Practical Hygiene. A Complete American Text-Book. 138 Illustrations. Cloth, J3. 25 ; Sheep, J4. 25 FOX. 'Water, Air, and Food. Sanitary Examinations of Water, Air, and Food. 100 Engravings. 2d Edition, Revised. %'i-V^ KENWOOD. Public Health Laboratory Work. 116 Illustra- tions and 3 Plates. J2.00 LEFFMANN. Examination of Water for Sanitary and Technical Purposes. 3d Edition. Illustrated. Ji.zs LEFFMANN. Analysis of Milk and Milk Products. Illus- trated. fi.zS LINCOLN. School and Industrial Hygiene. .40 MACDONALD. Microscopical Examinations of 'Water and Air. 25 Lithographic Plates, Reference Tables, etc. 2d Ed. $2.50 McNEILL. The Prevention of Epidemics and the Construc- tion and Management of Isolation Hospitals. Numerous Plans and Illustrations. fo-SO NOTTER AND FIRTH. The Theory and Practice of Hygiene. (Being the 9th Edition of Parkes' Practical Hygiene, rewritten and brought up to date.) 10 Plates and 135 other Illustrations. 1034 pages. 8vo. J7.00 PARKES. Hygiene and Public Health. By Louis C. Parkes, M.D. 5th Edition. Enlarged. Illustrated. 552.50 PARKES. Popular Hygiene. The Elements of Health. A Book for Lay Readers. Illustrated. Ji.*5 STARR. The Hygiene of the Nursery. Including the General Regimen and Feeding of Infants and Children, and the Domestic Management of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. Ji.oo STEVENSON AND MURPHY. A Treatise on Hygiene. By Various Authors. In Three Octave Volumes. Illustrated. Vol. I, J6.00; Vol. II, J6.oo; Vol. Ill, I5.00 *»* Each Volume sold separately. Special Circular upon application. ■WILSON. Hand-Bock of Hygiene and Sanitary Science. With Illustrations. 8th Edition. Preparing: \yEVL. Sanitary Relations of the Coal-Tar Colors. Author- ized Translation by Henry LeFFMANN, M.D., PH.D. J1.25 *** Special Catalogue of Books on Hygiene free upon application. LUNGS AND PLEUR-ffi. HARRIS AND BEALE. Treatment of Pulmonary Consump- tion. I2.50 POWELL. Diseases of the Lungs and Pleurae, including Consumption. Colored Plates and other lUus. 4th Ed. I4.00 TUSSEY. High Altitudes in the Treatment of Consumption. Just Ready. Ji.So SUBJECT CATALOGUE. MASSAGE. KLEEN. Hand-Book of Massage. Authorized translation by MussBY Hartwell, M.D., PH.D. With an Introduction by Dr. S. Weir Mitchell. Illustrated by a series of Photographs Made Especially by Dr. Kleen for the American Edition. ^2.25 MURRELL. Massotherapeutics. Massage as a Mode of Treat- ment. 6th Edition. In Press. OSTROM. Massage and the Original Swedish Move- ments. Their Application to Various Diseases of the Body. A Manual for Students, Nurses, and Physicians. Third Edition, En- larged. 94 Wood Engravings, many of which are original. ^i.oo WARD. Notes on Massage. Interleaved. Paper cover, gi. 00 MATERIA MEDICA AND THERA- PEUTICS. ALLEN, HARLAN, HARTE, VAN HARLINGEN. A Hand-Book of Local Therapeutics, Beinga Practical Description of all those Agents Used in the Local Treatment of Diseases of the Eye, Ear, Nose and Throat, Mouth, Skin, Vagina, Rectum, etc., such as Ointments, Plasters, Powders, Lotions, Inhalations, Supposi- tories, Bougies, Tampons, and the Proper Methods of Preparing and Applying Them. Cloth, $3.00 ; Sheep, J4.00 BIDDLE. Materia Medica and Therapeutics. Including Dose List, Dietary for the Sick, Table of Parasites, and Memoranda of New Remedies. 13th Edition, Thoroughly Revised in accord- ance with the new U. S. P. 64 Illustrations and a Clinical Index. Cloth, J4.00; Sheep, J5.00 BRACKEN. Outlines of Materia Medica and Pharmacology. J2.75 DAVIS. Materia Medica and Prescription ^A^riting. I1.50 FIELD. Evacuant Medication. Cathartics and Emetics, I1.75 GORQAS. Dental Medicine. A Manual of Materia Medica and Therapeutics. 6th Edition, Revised. Just Ready. ^400 GROFF. Materia Medica for Nurses. In Press. HELLER. Essentials of Materia Medica, Pharmacy, and Prescription Writing. Ji.oo MAYS. Theine in the Treatment of Neuralgia. % bound, .50 NAPHEYS. Modern Therapeutics. Qth Revised Edition, En- larged and Improved. In two handsome volumes. Edited by Allen J. Smith, m.d., and J. Aubrey Davis, m.d. Vol. I. General Medicine and Diseases of Children. J4.00 Vol. II. General Surgery, Obstetrics, and Diseases of Women. I4.Q0 POTTER. Hand-Book of Materia Medica, Pharmacy, and Therapeutics, including the Action of Medicines, Special Therapeu- tics, Pharmacology, etc., including over 600 Prescriptions and For- mulae. 6th Edition, Revised and Enlarged. With Thumb Index in each copy. Cloth, J4. 50; Sheep, ;gs. 50 POTTER. Compend of Materia Medica, Therapeutics, and Prescription Writing, with Special Reference to the Physiologi- cal Action of Drugs. 6tri Revised and Improved Edition, based upon the U. S. P. i8go .80; Interleaved, J1.25 MEDICAL BOOKS. 13 SAYRE. Organic Materia Medica and Pharmacognosy. An Introduction to the Study of the Vegetable Kingdom and the Vege- table and Animal Drugs. Comprising the Botanical and Physical Characteristics, Source, Constituents, and Pharmacopeial Prepara- tions. With chapters on Synthetic Organic Remedies, Insects In- jurious to Drugs, and Pharmacal Botany. A Glossary and 543 Illus- trations, many of which are original. I4.00 ■WARING. Practical Therapeutics. 4th Edition, Revised and Rearranged. Cloth, J2.00; Leather, J3.00 WHITE AND WILCOX. Materia Medica, Pharmacy, Phar- macology, and Therapeutics. 3d American Edition, Revised by Rbynold W. Wilcox, m.a., m.d., ll.d. Clo., J2.75; Lea., ^3.25 MEDICAL JURISPRUDENCE AND TOXICOLOGY. REESE. Medical Jurisprudence and Toxicology. A Text-Book for Medical and Legal Practitioners and Students. 5th Edition. Revised by HenrT Lkffmann, m.d. Clo.,j3.oo; Leather, I3.50 " To the student of medical jurisprudence and toxicology it is in- valuable, as it is concise, clear, and thorough in every respect." — The American Journal of the Medical Sciences. MANN. Forensic Medicine and Toxicology. Illus. $6.50 MURRELL. What to Do in Cases of Poisoning. 7th Edition, Enlarged. Ji.oo TANNER. Memoranda of Poisons. Their Antidotes and Tests. 7th Edition. .75 MICROSCOPY. BEALE. The Use of the Microscope in Practical Medicine. For Students and Practitioners,with Full Directions for Examining the Various Secretions, etc., by the Microscope. 4th Ed. 500 Illus. $6.50 BEALE. How to Work with the Microscope. A Complete Manual of Microscopical Manipulation, containing a Full Description of many New Processes of Investigation, with Directions for Examin- ing Objects Under the Highest Powers, and for Taking Photographs of Microscopic Objects. 5th Edition. 400 Illustrations, many of them colored. J6.50 CARPENTER. The Microscope and Its Revelations. 7th Edition. 800 Illustrations and many Lithographs. $5-5o LEE. The Microtomist's Vade Mecum. A Hand-Book of Methods of Microscopical Anatomy. 887 Articles. 4th Edition, Enlarged. Just Ready. tA-°° MACDONALD. Microscopical Examinations of Water and Air. 25 Lithographic Plates, Reference Tables, etc. 2d Edition. J2.50 REEVES. Medical Microscopy, including Chapters on Bacteri- ology, Neoplasms, Urinary Examination, etc. Numerous Illus- trations, some of which are printed in colors. ^250 WETHERED. Medical Microscopy. A Guide tojthe Use of the Microscope in Practical Medicine. 100 Illustrations. J2.00 SUBJECT CATALOGUE. MISCELLANEOUS. BLACK. Micro-Organisms. The Formation of Poisons. A Biological Study of the Germ Theory of Disease. .75 BURNETT. Foods and Dietaries. A Manual of Clinical Diet- etics. 2d Edition. #1.50 GOULD. Borderland Studies. Miscellaneous Addresses and Essays. lamo. ^2.00 GOWERS. The Dynamics of Life. .75 HAIG. Causation of Disease by Uric Acid. A Contribution to the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. J3.00 HARE. Mediastinal Disease. Illustrated by six Plates. J2.00 HEMMETER. Diseases of the Stomach. Their Special Path- ology, Diagnosis, and Treatment. With Sections on Anatomy, Dieti etics. Surgery, etc. Illustrated. Clo.J6.oo; Sh. J7.00 HENRY. A Practical Treatise on Anemia. Half Cloth, .50 LEFFMANN. The Coal-Tar Colors. With Special Reference to their Injurious Qualities and the Restrictions of their Use. A Trans- lation of Thbodore Weyl's Monograph. $1-25 MARSHALL. History of Woman's Medical College of Penn- sylvania. J1.50 NEW SYDENHAM SOCIETY'S PUBLICATIONS. Circulars upon application. Per Annum, }8.oo TREVES. Physical Education : Its Effects, Methods, Etc. .75 LIZARS. The Use and Abuse of Tobacco. .40 PARRISH. Alcoholic Inebriety. |x.oo ST. CLAIR. Medical Latin. Ji.oo SCHREINER. Diet Lists. Pads of 50. .75 NERVOUS DISEASES. BEEVOR. Diseases of the Nervous System and their Treat- ment. 1^2 50 GORDINIER. The Gross and Minute Anatomy of the Cen- tral Nervous System. With many original Illustrations. Preparing. GOAVERS. Manual of Diseases of the Nervous System. A Complete Text-Book. 2d Edition, Revised, Enlarged, and in many parts Rewritten. With many new Illustrations. Two volumes. Vol. I. Diseases of the Nerves and Spinal Cord. Clo. $3.00 ; Sh. J4.00 Vol. II. Diseases of the Brain and Cranial Nerves; General and Functional Disease. Cloth, J4.00; Sheep, Js.co GOWERS. Syphilis and the Nervous System. Ji.oo GOWERS. Diagnosis of Diseases of the Brain. 2d Edition. Illustrated. |i.50 GOWERS. Clinical Lectures. A New Volume of Essays on the Diagnosis, Treatment, etc., of Diseases of the Nervous System. J2.00 GOWERS. Epilepsy and Other Chronic Convulsive Diseases. 2d Edition. In Press HORSLEY. The Brain and Spinal Cord. The Structure and Functions of. Numerous Illustrations. $2.50 OBERSTEINER. The Anatomy of the Central Nervous Or- gans. A Guide to the Study of their Structure in Health and Dis- ease. 198 Illustrations. ^S-So MEDICAL BOOKS. 15 ORMEROD. Diseases of the Nervous System. 66 Wood En- gravings. Ji.oo OSLER. Cerebral Palsies of Children. A Clinical Study. J2.00 OSLER. Chorea and Choreiform Affections. $2.00 PRESTON. Hysteria and Certain Allied Conditions. Their Nature and Treatment. Illustrated. Just Ready. %2.. WATSON. Concussions. An Experimental Study of Lesions Aris- ing from Severe Concussions. Paper cover^ Ji.oo WOOD. Brain Work and Overwork. .40 NURSING. special Catalogue of Books for Nurses sent free upon application. •BROWN. Elementary Physiology for Nurses. .75 CANFIELD. Hygiene of the Sick-Room. A Book for Nurses and Others. Being a Briet Consideration of Asepsis, Antisepsis, Disinfec- tion, Bacteriology, Immunity, Heating and Ventilation, and Kindred Subjects for the Use of Nurses and Other Intelligent Women. |i.2s CULLINGW^ORTH. A Manual of Nursing, Medical and Sur- gical. 3d Edition with Illustrations. .75 CULLINGWORTH. A Manual for Monthly Nurses. 3d Ed. .40 CUFF. Lectures to Nurses on Medicine. New Ed. /« Pi-ess. DOMVILLE. Manual for Nurses and Others Engaged in At- tending the Sick. 8th Edition. With Recipes for Sick-room Cook- ery, etc. -75 FULLERTON. Obstetric Nursing. 40 Ills. 4th Ed. $1.00 FULLERTON. Nursing in Abdominal Surgery and Diseases of Women. Comprising the Regular Course of Instruction at the Training-School of the Women's Hospital, Philadelphia. 2d Edition. 70 Illustrations. $1.50 GROFF. Materia Medica for Nurses. In Press. HUMPHREY. A Manual for Nurses. Including General Anatomy and Physiology, Management of the Sick Room, etc, 15th Ed. Illustrated. $1.00 SHAWE. Notes for Visiting Nurses, and all those Interested in the Working and Organization of District, Visiting, or Parochial Nurse Societies. With an Appendix Explaining the Organization and Working of Various Visiting and District Nurse So- cieties, by Helen C. Jenks, of Philadelphia. Ji.oo STARR. The Hygiene of the Nursery. Including the General Regimen and Feeding of Infants and Children, and the Domestic Man- agement of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. Just Ready. Ji.oo TEMPERATURE AND CLINICAL CHARTS. See page 6. VOSWINKEL. Surgical Nursing, iii Illustrations. Ji.oo WARD. Notes on Massage. Interleaved. Paper cover, Ji.oo *** Special Catalogue of Books on Nursing fre€ upon application. OBSTETRICS. BAR. Antiseptic Midwifery. The Principles of Antiseptic Meth- ods Applied to Obstetric Practice. Authorized Translation by Henry D. Fry, m.d. , with an Appendix by the Author. Ji.oo 16 SUBJECT CATALOGUE. CAZEAUX AND TARNIER. Midwifery. With Appendix by Mund6. The Theory and Practice of Obstetrics, including the Dis- eases of Pregnancy and Parturition, Obstetrical Operations, etc. 8th Edition. Illustrated by Chromo- Lithographs, Lithographs, and other full-page Plates, seven of which are beautifully colored, and numerous Wood Engravings. Cloth, I4.S0 ; Full Leather, J5.50 DAVIS. A Manual of Obstetrics. Being a Complete Manual for Physicians and Students. 2d Edition. 16 Colored and other Plates and 134 other Illustrations. ^2.00 JELLETT. The Practice of Midwifery. Illustrated. J1.7S LANDIS. Compend of Obstetrics, sth Edition, Revised by Wm. H. Wells, Assistant Demonstrator of Clinical Obstetrics, Jefferson Medical College. With many Illustrations, .80 ; Interleaved, $1.25. SCHULTZE. Obstetrical Diagrams. Being a series of 20 Col- ored Lithograph Charts, Imperial Map Size, of Pregnancy and Mid-« wifery, with accompanying explanatory (German) text illustrated by Wood Cuts. 2d Revised Edition. Price in Sheets, $26.00; Mounted on Rollers, Muslin Backs, J36.00 STRAHAN. Extra-Uterine Pregnancy. The Diagnosis and Treatment of Extra-Uterine Pregnancy. .75 WINCKEL. Text-Book of Obstetrics, Including the Pathol- ogy and Therapeutics of the Puerperal State. Authorized Translation by J. Clifton Edgar, a.m., m.d. With nearly 200 Illus- trations. Cloth, $5.00; Leather, J6.00 FULLERTON. Obstetric Nursing. 4th Ed. Illustrated. Ji.oo SHIBATA. Obstetrical Pocket-Phantom with Movable Child and Pelvis. Letter Press and Illustrations. $1.00 PATHOLOGY. BARLOW. General Pathology. 795 pages. 8vo. J5.00 BLACKBURN. Autopsies. A Manual of Autopsies Designed for the Use of Hospitals for the Insane and other Public Institutions. Ten full-page Plates and other Illustrations. Ji-^S BLODGETT. Dental Pathology. By Albert N. Blodgbtt, M.D., late Professor of Pathology and Therapeutics, Boston Dental College. 33 Illustrations. |i-2S COPLIN. Manual of Pathology. Including Bacteriology, Technic of Post-Mortems, Methods of Pathologic Research, etc. 265 Illus- trations, many of which are original. i2mo. 1J3.00 GILLIAM. Pathology. A Hand-Book for Students. 47 IIlus. .75 HALL. Compend of General Pathology and Morbid Anatomy. 91 very fine Illustrations. .80; Interleaved, Ji. 25 VIRCHOW. Post-Mortem Examinations. A Description and Explanation of the Method of Performing Them in the Dead House of the Berlin Charity Hospital, with Special Reference to Medico- Legal Practice. 3d Edition, with Additions. .75 WHITACRE. Laboratory Text-Book of Pathology. With 121 Illustrations. Just Ready. fi-So PHARMACY. special Catalogue 0/ Books on Pharmacy sent free upon application'. COBLENTZ. Manual of Pharmacy. A New and Complete Text-Book by the Professor in the New York College of Pharmacy. 2d Edition, Revised and Enlarged. 437 lUus. Cloth,|3.so; Sh.,14.50 MEDICAL BOOKS. 17 BEASLEY. Book of 3100 Prescriptions. Collected from the Practice of the Most Eminent Physicians and Surgeons — English, French, and American. A Compendious History ot the Materia Medica, Lists of the Doses of all the Officinal and Established Pre- parations, an Index of Diseases and their Remedies. 7th Ed. $2.00 BEASLEY. Druggists' General Receipt Book. Comprising a Copious Veterinary Formulary, Recipes in Patent and Proprietary Medicines, Druggists' Nostrums, etc. ; Perfumery and Cosmetics, Beverages, Dietetic Articles and Condiments, Trade Chemicals, Scientific Processes, and an Appendix of Useful Tables. loth Edi- tion, Revised. $2.00 BEASLEY. Pocket Formulary. A Synopsis of the British and Foreign Pharmacopoeias. Comprising Standard and Approved Formulae for the Preparations and Compounds Employed in Medical Practice. 12th Edition. Ik Press. i»ROCTOR. Practical Pharmacy. Lectures on Practical Phar- macy. With Wood Engravings and 32 Lithographic Fac-simile Prescriptions. 3d Edition, Revised, and with Elaborate Tables of Chemical Solubilities, etc. $300 ROBINSON. Latin Grammar of Pharmacy and Medicine. 2d Edition. With elaborate Vocabularies. ^i-75 SAYRE. Organic Materia Medica and Pharmacognosy. An Introduction to the Study of the Vegetable Kinedom and the Vege- table and Animal Drugs. Comprising the Botanical and Physical Characteristics, Source, Constituents, and Pharmacopeia! Prepar- ations. With Chapters on Synthetic Organic Remedies, Insects Injurious to Drugs, and Pharmacal Botany. A Glossary and 543 Illustrations, many of which are original. Cloth, J4.00; Sheep, J5.00 SCOVILLE. The Art of Compounding. Second Edition, Re- vised and Enlarged. Just Ready. Cloth, J2.50 ; Sheep, $3.50 STEWART. Compend of Pharmacy. Based upon " Reming- ton's Text-Book of Pharmacy." 5th Edition, Revised in Accord- ance with the U. S. Pharmacopoeia, 1890. Complete Tables of Metric and English Weights and Measures. .80; Interleaved, J1.25 UNITED STATES PHARMACOPCEIA. 1890. 7th Decennial Revision. Cloth, $2.50 (postpaid, ^2.77); Sheep, $3.00 (postpaid, J3.27) ; Interleaved, $4.00 (postpaid, $4.50); Printed on one side ot page only, unbound, I3.50 (postpaid, $3.90). Select Tables from the U. S. P. (1890). Being Nine of the Most Important and Useful Tables, Printed on Separate Sheets. Care- fully put up in patent envelope. .25 POTTER. Hand-Book of Materia Medica, Pharmacy, and Therapeutics. 600 Prescriptions and Formulae. 6th Edition. Cloth, $4.50; Sheep, $5.50 *#* Special Catalogue of Books on Pharmacy free upon application. PHYSICAL DIAGNOSIS. BROWN. Medical Diagnosis. A Manual of Clinical Methods. 4th Ed. 112 Illnstrations. Just Ready. Cloth, ^e. 25 FENWICK. Medical Diagnosis. 8th Edition. Rewritten and very much Enlarged. 135 Illustrations. Cloth, J2.50 TYSON. Hand-Book of Physical Diagnosis. For Studenu and Physicians. By the Professor of Clinical Medicine in the University of Pennsylvania. Illus. 3d Ed., Improved and Enlarged. In Press. MEMMINGER. Diagnosis by the Urine. 23 Illus. Ji.oo 2 18 SUBJECT ICATALOGUB. PHYSIOLOGY. BRUBAKER. Compend of Physiology, 8th Edition, Revised and Enlarged. Illustrated. .80; Interleaved, ^1.25 KIRKE. Physiology. (14th Authorized Edition. Dark-Red Cloth.) A Hand-Book of Physiology. 14th Edition, Revised and Enlarged. By Prof. W. D Halliburton, of Kings College, London. 661 Illustrations, some of which are printed in colors. Cloth, J3.00; Leather, ^3.25 LANDOIS. A Text-Book of Human Physiology, Including Histology and Microscopical Anatomy, with Special Reference to the Requirements of Practical Medicine, sth American, translated from the 9th German Edition, with Additions by Wm. Stirling, M.D.,D.sc. 845 Illus., many of which are printed in colors. In Press. STARLING. Elements of Human Physiology. 100 Ills. $1.00 STIRLING. Outlines of Practical Physiology. Including Chemical and Experimental Physiology, with Special Reference to Practical Medicine. 3d Edition. 289 Illustrations. ^2.00 TYSON. Cell Doctrine. Its History and Present State. $1.50 YEO. Manual of Physiology. A Text-Book for Students of Medicine. By Gerald F. Yko, m.d., f.r.c.s. 6th Edition. 254 Illustrations and a Glossary. Cloth, J2. 50 ; Leather, J3.00 PRACTICE. BEALE. On Slight Ailments; their Nature and Treatment. 2d Edition, Enlarged and Illustrated. ^1-25 CHARTERIS. Practice of Medicine. 6th Edition. $1.00 FOAVLER. Dictionary of Practical Medicine. By various writers. An Encyclopsedia of Medicine. Clo.,$3.oo; Half Mor. J4.00 HUGHES. Compend of the Practice of Medicine, sth Edition, Revised and Enlarged. Part I. Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kid- neys, etc., and General Diseases, etc. Part II. Diseases of the Respiratory System, Circulatory System, and Nervous System; Diseases of the Blood, etc. Price of each part, .80; Interleaved, $1.25 Physician's Edition. In one volume, including the above two parts, a Section on Skin Diseases, and an Index. 5th Revised, Enlarged Edition. 568 pp. Full Morocco, Gilt Edge, ^2.25 ROBERTS. The Theory and Practice of Medicine. The Sections on Treatment are especially exhaustive. 9th Edition, with Illustrations. Cloth, I4. 50; Leather, ^5.50 TAYLOR. Practice of Medicine. Cloth, J2.00; Sheep, $2.50 TYSON. The Practice of Medicine. By James Tyson, m.d.. Professor of Clinical Medicine in the University of Pennsylvania. A Complete Systematic Text-book with Special Reference to Diag- nosis and Treatment. Illustrated. 8vo. Cloth, ^5.50 ; Leather, J6.50 ; Half Russia, $7.50 PRESCRIPTION BOOKS. BEASLEY. Book of 3100 Prescriptions. Collected from the Practice of the Most Eminent Physicians and Surgeons — English, French, and American. A Compendious History of the Materia, Medica, Lists of the Doses of all Officinal and Established Prepara- tions, and an Index of Diseases and their Remedies. 7th Ed. ^3.00 MEDICAL BOOKS. 19 BEASLEY. Druggists' General Receipt Book. Comprising a Copious Veterinary Formulary, Recipes m Patent and Proprie- tary Medicines, Druggists' Nostrums, etc. ; Perfumery and Cos- metics, Beverages, Dietetic Articles and Condiments, Trade Chem- icals, Scientific Processes, and an Appendix of Useful Tables, loth Edition, Revised. J2.00 BEASLEY. Pocket Formulary. A Synopsis of the British and Foreign Pharmacopoeias. Comprising Standard Formulae for the various Preparations and Compounds, nth Edition. Cloth, |2. 00 PEREIRA. Prescription Book. Containing Lists of Phrases and Abbreviations Used in Prescriptions, Grammatical Construction of Prescriptions, etc. i6th Edition. Cloth, .75 ; Tucks, ^i.oo ■WYTHE. Dose and Symptom Book. Containing the Doses and Uses of all the Principal Articles of the Materia Medica. 17th Ed. Cloth, .75 ; Leather, with Tucks and Pocket, $1.00 SKIN. BULKLEY. The Skin in Health and Disease. Illustrated. .40 CROCKER. Diseases of the Skin. Their Description, Pathol- ogy, Diagnosis, and Treatment, with Special Reference to the Skin Eruptions of Children, gz Illus. zd Edition. Cloth,j4.50; Sh., J5.50 IMPEY. Leprosy. 37 Plates. 8vo. J3.50 SCHAMBERG. Diseases of the Skin. Illustrated. Being No. 16 ? Quiz-Compend? Series. Cloth, .80; Interleaved, gi. 25 VAN HARLINGEN. On Skin Diseases. A Practical Manual of Diagnosis and Treatment, with special reference to Differential Diagnosis. 3d Edition, Revised and Enlarged. With Formulae and 60 Illustrations, some of which are printed in colors. $2.75 SURGERY AND SURGICAL DIS- EASES. CAIRD AND CATHCART. Surgical Hand-Book. 5th Edition, Revised. 188 Illustrations. Full Red Morocco, ^z.50 DEAVER. Appendicitis, Its Symptoms, Diagnosis, Pathol- 0£y> Treatment, and Complications. Elaborately Illustrated with Colored Plates and other Illustrations. Cloth, ^3.50 DEAVER. Surgical Anatomy. With 200 Illustrations, Drawn by a Special Artist from Directions made for the Purpose. In Preparation. DULLES. What to Do First in Accidents and Poisoning. 5th Edition. New Illustrations. Ji.oo HACKER. Antiseptic Treatment of Wounds, According to the Method in Use at Professor Billroth's Clinic, Vienna. .50 HAMILTON. Lectures on Tumors, from a Clinical Stand- point. Third Edition, Revised, with New Illustrations. In Press. HEATH. Minor Surgery and Bandaging, loth Ed., Revised and Enlarged. 158 Illustrations, 62 Formulae, Diet List, etc. $1.25 HEATH. Injuries and Diseases of the Jaws. 4th Edition. 187 Illustrations. ^4-5° HEATH. Lectures on Certain Diseases of the Jaws. 64 Illus- trations. Boards, .50 HORWITZ. Compend of Surgery and Bandaging, including Minor Surgery, Amputations, Fractures, Dislocations, Surgical Dis- eases, and the Latest Antiseptic Rules, etc., with Differential Diagno- sis and Treatment. 5th Edition, very much Enlarged and Rear- ranged. 167 Illustrations, 98 Formulae. Clo.,.8o; Interleaved, Ji. 25 JO SUBJECT CATALOGUE. JACOBSON. Operations of Surgery. Over 200 Illustrations. Cloth, J3. 00; Leather, ^4.00 JACOBSON. Diseases of the Male Organs of Generation. 88 Illustrations. ^6.00 MACREADY. A Treatise on Ruptures. 24 Full-page Litho- graphed Plates and Numerous Wood Engravings. Cloth, ^6.00 MAYLARD. Surgery of the Alimentary Canal. 134 lllus. I7.50 MOULLIN. Text-Book of Surgery. With Special Reference to Treatment. 3d 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. 623 Illustrations, over 200 of which are original, and many of which are printed in colors. Handsome Cloth, J6. 00; Leather, $7.00 " 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." — The American Journal of Medical Science. ROBERTS. Fractures of the Radius. A Clinical and Patho- logical Study. 33 Illustrations. Ji.oo SMITH. Abdominal Surgery. Being a Systematic Description ot all the Principal Operations. 224 lUus. 6th Ed. 2 Vols. Clo., Jio.oo SWAIN. Surgical Emergencies. Fifth Edition. Cloth, Ji. 75 VOSWINKEL. Surgical Nursing, iii Illustrations. |i.oo WALSHAM. Manual of Practical Surgery. 5th Ed., Re- vised and Enlarged. With 380 Engravings. Clo., ^2.00; Lea., ^2.50 W^ATSON. On Amputations of the Extremities and Their Complications. 250 Illustrations. %Si° THROAT AND NOSE (see also Ear). COHEN. The Throat and Voice. Illustrated. .40 HALL. Diseases of the Nose and Throat. Two Colored Plates and 59 Illustrations. $2:50 HOLLOPETER. Hay Fever. In Press. HUTCHINSON. The Nose and Throat. Including the Nose, Naso-Pharynx, Pharynx, and Larynx. Illustrated by Lithograph Plates and 40 other Illustrations. 2d Edition. In Press, MACKENZIE. Pharmacopoeia of the London Hospital for Dis. of the Throat. 5th Ed., Revised by Dr. F. G. Harvey. $1.00 McBRIDE. Diseases of the Throat, Nose, and Ear. A Clinical Manual. With colored lUus. from original drawings. 2d Ed. f6.oo POTTER. Speech and its Defects. Considered Physiologically, Pathologically, and Remedially. Ji.oo ^A^OAKES. Post-Nasal Catarrh and Diseases of the Nose Causing Deafness. 26 Illustrations. fi.oo URINE AND URINARY ORGANS. ACTON. The Functions and Disorders of the Reproductive Organs in Childhood, Youth, Adult Age, and Advanced Life, Considered in their Physiological, Social, and Moral Relations. 8th Edition. $1.75 ALLEN. Albuminous and Diabetic Urine. lUus. P'-^S MEDICAL BOOKS. 21 BROCKBANK. Gall Stones. J2.25 BEALE. One Hundred Urinary Deposits. On eight sheets, for the Hospital, Laboratory, or Surgery. Paper, J2.00 HOLLAND. The Urine, the Gastric Contents, the Common Poisons, and the Milk. Memoranda, Chemical and Microscopi- cal, for Laboratory Use. Illustrated and Interleaved. 5th Ed. Ji.oo MEMMINGER. Diagnosis by the Urine. 23 lUus. Ji.oo MOULLIN. Enlargement of the Prostate. Its Treatment and Radical Cure. 2d Edition. Illustrated. In Press. THOMPSON. Diseases of the Urinary Organs. 8th Ed. $3.00 TYSON. Guide to Examination of the Urine. For the Use of Physicians and Students. With Colored Plate and Numerous Illus- trations engraved on wood. 9th Edition, Revised. $1-25 VAN NUYS. Chemical Analysis of Healthy and Diseased Urine, Qualitative and Quantitative. 39 Illustrations. Ji.oo VENEREAL DISEASES. COOPER. Syphilis. 2d Edition, Enlarged and Illustrated with 20 full-page Plates. >S-oo GOWERS. Syphilis and the Nervous System, i.oo JACOBSON. Diseases of the Male Organs of Generation. 88 Illustrations. J6.00 VETERINARY. ARMATAGE. The Veterinarian's Pocket Remembrancer. Being Concise Directions for the Treatment of Urgent or Rare Cases, Embracing Semeiology, Diagnosis, Prognosis, Surgery, Treatment, etc. 2d Edition. Boards, Ji. 00 BALLOU. Veterinary Anatomy and Physiology. 29 Graphic Illustrations. .80; Interleaved, Ji. 25 TUSON. Veterinary Pharmacopoeia. Including the Outlines of Materia Medica and Therapeutics. 5th Edition. ^2.25 WOMEN, DISEASES OF. BYFORD (H. T.). Manual of Gynecology. Second Edition, Revised and Enlarged by 100 pages. With 341 Illustrations, many of which are from original drawings. Just Ready. I300 BYFORD (W. H.). Diseases of Women. 4th Edition. 306 Illustrations. Cloth, ^2.00 DUHRSSEN. A Manual of Gynecological Practice. 105 Illustrations. Ji-SO LEWERS. Diseases of Women. 146 lUus. sth Ed. $2.50 WELLS. Compend of Gynecology. lUus. .80; Interleaved, |i. 25 FULLERTON, Nursing in Abdominal Surgery and Diseases of 'Women. 2d Edition. 70 Illustrations. |i'5o SUBJECT CATALOGUE. COMPENDS. From The Southern Clinic. " We know of no series of books issued by any house that so fully meets our approval as these ? Quiz-CompendsT. They are well ar- ranged, full, and concise, and are really the best line of text-books that could be found for either student or practitioner." BLAKISTON'S ?QUIZ-COMPENDS? The Best Series of Manuals for the TJse of Students. Price of each, Cloth, .80. Interleaved, for taking Notes, $1.25. fl^ These Corapends are based on the most popular text-books and the lectures of prominent professors, and are kept constantly re- vised, so that they may thoroughly represent the present state of the subjects upon which they treat. 4®" The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. j8®~ They are arranged in the most approved form, thorough and concise, containing over 6oo fine illustrations, inserted wherever they could be used to advantage. >9^ Can be used by students ot any college. >9^ They contain information nowhere else collected in such a condensed, practical shape. Illustrated Circular free. No. I. POTTER. HUMAN ANATOMY. Fifth Revised and Enlarged Edition. Including Visceral Anatomy. Can be used with either Morris's or Gray's Anatomy. 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. By Samuel O. L. Potter, m.d., Professor of the Practice of Medicine, Cooper Medical College, San Francisco ; late A. A. Surgeon, U. S. Army. No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Fifth Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., Physician-in-Chief, Philadelphia Hospital, late Demonstrator ot Clinical Medicine, JeflFerson Medical College, Phila. No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. Fifth Edition, Revised and Improved. Same author as No. 2. No. 4. BRUBAKER. PHYSIOLOGY. Eighth Edition with new Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Brubaker, m.d.. Professor of Physiology and General Pathology in the Pennsylvania College of Dental Surgery ; Demonstrator of Physiology, Jefferson Medical College, Philadelphia. No. 5. LANDIS. OBSTETRICS. Fifth Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., Assistant Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. Enlarged. 47 Illustrations. No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revised Edition (U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of Practice, Cooper Medical College, San Francisco ; late A. A. Sur- geon, U. S. Army. MEDICAL BOOKS. PQUIZ-COMPENDS ?— Continued. No, 7. WELLS. GYNECOLOGY. A New Book. By Wm. H. Wells, M.D., Assistant Demonstrator of Obstetrics, Jefferson College, Philadelphia. 150 Illustrations. No. 8. GOULD AND PYLE. DISEASES OF THE EYE AND REFRACTION. A New Book. Including Treatment and Surgery, and a Section on Local Therapeutics. By George M. Gould, m.d., and W. L. Pylh, m.d. With Formulae, Glossary, Tables, and iii Illustrations, several of which are Colored. No. 9. HOR"WITZ. SURGERY, Minor Surgery, and Bandag- ing. Fifth Edition, Enlarged and Improved. By Grvillb HoRWiTZ, B. S-, M.D., Clinical Professor of Genito-Urinary Surgery and Venereal Diseases in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth Edition. Including Urinalysis, Animal Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, M.D., Professor of Chemistry in Pennsylvania College of Dental Surgery and in the Woman's Medical College, Philadelphia. No. II. STEWART. PHARMACY. Fifth Edition. Based upon Prof Remington's Text-Book of Pharmacy. By F. E. Stewart, M.D., PH.G., late Quiz-Master in Pharmacy and Chemistry, Phila- delphia College of Pharmacy ; Lecturer at Jefferson Medical College. Carefully revised in accordance with the new U. S. P. No. 12. BALLOU. VETERINARY ANATOMY AND PHY- SIOLOGY. Illustrated. By Wm. R. Ballou, m.d.. Professor of Equine Anatomy at New York College of Veterinary Surgeons ; Physician to Bellevue Dispensary, etc. 29 graphic Illustrations. No. 13. ^VARREN. DENTAL PATHOLOGY AND DEN- TAL MEDICINE. Third Edition, Illustrated. Containing a Section on Emergencies. By Geo. W. Warren, d.d.s.. Chief of Clinical Staff, Pennsylvania College of Dental Surgery. No. 14. HATFIELD, DISEASES OF CHILDREN. Second Edition. Colored Plate. By Marcus P. Hatfield, Profes- sor of Diseases of Children, Chicago Medical College. No. 15. HALL. GENERAL PATHOLOGY AND MORBID ANATOMY. 91 Illustrations. By H. Newberry Hall, ph. g., M.D., late Professor of Pathology, Chicago Post-Graduate Medi- cal School. No. 16. DISEASES OF THE SKIN. By Jay T. Schamberg, M.D., Instructor in Skin Diseases, Philadelphia Polyclinic. With many Viandsome Illustrations. Price, each, Cloth, .80. Interleaved, for taking Notes, $1,25. In preparing, revising, and improving Blakiston's ? Quiz-Com- pends ? the particular wants of the student have always been kept in mind. Careful attention has been given to the construction of each sentence, and while the books will be found to contain an immense amount of knowledge in small space, they will likewise be found easy reading ; there is no stilted repetition of words ; the style is clear, lucid, and dis- tinct. The arrangement of subjects is systematic and thorough ; there is a reason for every word. They contain over 600 illustrations. Tyson's Practice of Medicine. With Many Illustrations. Text-Book of the Practice of Medi- cine. With Special Reference to Diagnosis and Treatment. By James Tyson, m. d., Professor of Clinical Medicine in the Univer- sity of Pennsylvania; Physician to the Hos- pital of the University and to the Philadelphia Hospital ; Fellow of the College of Physicians of Philadelphia, etc. With Many Useful Illustrations. Octavo. 1 1 80 Pages. Cloth, $5.50; Sheep, $6.50; Half Russia, $7.50. Extracts from a Review in the American Journal of Medical Sciences, March, 1897: " Externally it is the largest and handsomest single volume on the practice of medicine." "Clinical features are usually described in a masterly way." "The directions (for treatment) are full and clear, and as a rule, eminently judicious and conservative." " Dr. Tyson's style is already so well known in medical literature that it is only necessary to say the present work is one of the best examples." "We welcome Dr. Tyson's Practice as a most valuable addition to medical literature." ^Descriptive circular and sample pages upon application. x>^ ^^^ \%^^ ^\>rao<>^^*>*— Surgery, Its theory and practice / 2002189143